Inspection on 17/08/06 for Sidegate Lane Nursing Home

This inspection was carried out on 17th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sidegate Lane Nursing Home 13/08/07

Sidegate Lane Nursing Home 02/11/05

Sidegate Lane Nursing Home 07/02/05

Sidegate Lane Nursing Home 10/11/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sidegate Lane Nursing Home 248 Sidegate Lane Ipswich Suffolk IP4 3DH Lead Inspector Jane Higham Unannounced Inspection 17 and 29 August 2006 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sidegate Lane Nursing Home Address 248 Sidegate Lane Ipswich Suffolk IP4 3DH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01473 274141 01473 715245 Orbit Housing Association Mrs Michelle Webster Care Home 24 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24), Mental disorder, excluding learning of places disability or dementia (4), Mental Disorder, excluding learning disability or dementia - over 65 years of age (4) Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2005 Brief Description of the Service: 248 Sidegate Lane is a purpose built, 24 bedded care home with nursing which offers accommodation to people over the age of 55 who suffer from severe mental infirmity. The home also offers four beds for the care of people over the age of 55 with enduring functional mental health needs. The home is owned by the Orbit Housing Association and is situated in a residential area of Ipswich, close to local amenities and a short bus or car journey from Ipswich town centre. The home was first registered in 1993 and in 1998 was registered to accommodate somewhat younger adults, over the age of 55, thus recognising the incidence of dementia in the younger age group and looking to meet their needs. In October 2005, the registration of the home was again amended to include four beds for people with functional mental health needs. Orbit Housing Association is a non profit making organisation run by voluntary committees and provides a cross section of housing throughout the country. The home is operated in conjunction with social care services and as such admission can only be accessed via this agency. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection of 248 Sidegate Lane, a twenty-four bedded care home with nursing accommodating people over the age of 55 who suffer from severe mental frailty (dementia) and/or long term functional mental health needs. The home is owned and administered by Orbit Housing Association in conjunction with Social Care Services and is sited in a residential area of Ipswich, within easy reach of the town centre and all its facilities and resources. The Inspection was carried out on 17 August 2006 over a period of 7 hours and continued on 29 August 2006 for a further period of 2 hours 15 minutes. The key inspection focused on the care standards relating to Homes for Older People. The report has been written using accumulated evidence gathered prior to and during the inspection. Prior to the inspection, the home was provided with both service user and relative/visitors questionnaires for distribution. At the time of writing no questionnaires had been returned to the Commission. The National Minimum Standards and Care Homes Regulations are referred to throughout this report and any compliance identified. All key standards were assessed as part of this inspection. The Registered Manager of the home was present throughout the inspection and assisted with the inspection process. The Inspector had the opportunity to talk to both residents and staff. Unfortunately on the day of the inspection, no family members or visitors were available to provide feedback to the Inspector. What the service does well: The home continues to offer residents a very spacious and unrestricted environment which is homely and provides a good standard of accommodation offering residents maximum privacy. Good overall healthcare is provided and clinical guidance is derived from the qualified nursing staff who are on duty throughout the day. Additionally the home ensures that residents are able to access community health resources. The home places a strong emphasis on the provision of meaningful activity and tailors that provision to the needs and abilities of individual residents. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: As in the previous inspections, some shortfalls in relation to the recording of the individual administration of resident medication were identified. It is of concern that staff members responsible for the administration of medication continue to make omissions, preventing an appropriate audit trail of administered medications to be established. The home must establish robust procedures to monitor the safety and accuracy of medication systems. As in the previous inspection, it was again identified that whilst the home seeks to offer a specialist service for people suffering from severe mental infirmity, inclusive of such organic illnesses such as dementia, no structured and consistent training package is provided to care staff. The owning organisation needs to ensure that a training package is produced or purchased for each staff member to ensure that they have a basic understanding of dementia and its causes and consequences and that they are appropriately able to meet the individual needs of service users. It was difficult for the home to evidence that all staff receive appropriate training due to the lack of an overall training record. The Inspector was also advised by the Manager that the home had not been allocated a training budget for the forthcoming financial year. Whilst in general, judgements of the outcome groups identified in the report range from adequate to good, it is of some concern that the home has 17 requirements and is only achieving a 55 compliance with CSCIs key standards. Whilst three of the requirements contained within this report relate to training and staff competencies there are other key areas which the home must focus on to bring standards up to a good level of compliance. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Residents and/or their representatives can expect to be provided with sufficient information on which to base a decision about whether they would wish to live at the home. Residents can also expect to receive a full assessment of their individual needs, prior to admission and thereafter to be issued with a placement contract which includes the terms and conditions. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home was able to evidence that it has a comprehensive Statement of Purpose and Service User Guide which provides detailed information to service users and their families as to the services and facilities provided. All information as required by regulation is included in this document. It was noted however, that Section 1 of the Statement of Purpose states that the home is registered to accommodate 24 people over the age of 55 who suffer from severe dementia or mental disorder. The home’s registration currently Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 10 allows four service users under the category of mental disorder to be accommodated and therefore the Statement of Purpose needs to be amended to accurately reflect this condition of registration. The Manager confirmed that the Statement of Purpose was not routinely sent out to residents and their families but was available on request. The Inspector suggested that a copy of this document be made available in the foyer of the building, thus being accessible to any visitor to the home. For the purposes of the inspection, the three most recently admitted residents were selected for the purposes of case tracking. In two cases, the home was able to evidence that a detailed pre-admission needs assessment had been completed by social care services and submitted to the home, prior to any decision about admission taking place. In the case of the third resident, no pre-admission assessment either carried out by the home or social care services could be located. Pre-admission assessments seen, were detailed in their content and gave sufficient information to allow the home to make a decision on whether the needs of the prospective resident could be met. In the case of two of the residents, additional information had been provided by hospital services on discharge. All three residents selected for the purposes of case tracking had been issued with a placement contract both by social services and the owning organisation, which gave additional information on terms and conditions. The maximum fee rate at the time of the inspection was £385. The home does not offer an intermediate care service. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Residents living at the home can expect to be provided with an individual plan of care based on their assessed needs. Residents could not necessarily be assured that these care plans were being reviewed on a regular basis. Service users health and emotional needs were being met and residents could be assured that their privacy and dignity would be protected. Practices employed for the administration of medication did not totally ensure the safety of residents. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: For the purposes of the inspection, the Inspector examined the care plans for the three most recently admitted residents. Two of the three residents selected for the purposes of case tracking had been provided with a detailed individual plan of care. Both documents were based on a living and needs assessment and included information on the likes, dislikes and preferences of the resident. In both care plans, assessed needs were identified and objectives set to ensure that these needs were being met. Clear Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 12 guidance was provided on the levels of intervention and support required. In the case of the third resident, who had only been at the home a short time, a basic care plan was in place, although did not contain sufficient information on the likes, dislikes and preferences of the person or any information on preferred activity. All three care plans included a moving and handling assessment and a pressure area assessment. In the case of one of the resident who spoke little English, it was clear that much effort had been made to facilitate communication and their care plan included a basic phrase sheet in their native tongue. In the case of two of the care plans, there was little or no evidence to show that these had been reviewed on a monthly basis and amendments made where necessary. Whilst the home was able to evidence that risk assessments in relation to daily living had been produced for two of the residents, selected for the purposes of case tracking, no such assessment had been completed in relation to physical aggression, which had been identified as part of the pre-admission assessment in relation to one of the three residents. This was identified as a shortfall during the previous inspection which took place on 02 November 2005. Care Plans and daily notes evidenced that the physical and emotional health needs of residents are monitored and met, either by nursing staff working within the home or via community health services such as GP and hospital resources. On the day of the inspection, one resident was attending an outpatient appointment at Ipswich Hospital and was accompanied by a member of the nursing staff. A care plan seen indicated that one resident had an identified weight problem and that actions had been put in place to support them to lose weight by a controlled diet. As part of the inspection process, the Inspector examined the procedures and practices for the safe storage and administration of resident medication. Each of the three living units has its own secure fit for purpose medication trolley and medication is administered via a monitored dosage blister pack system. In general medication was stored both securely and appropriately, although it was noted that one pack of medication (chewable tablets) stored in the trolley had expired some four months ago and needed to be disposed of in line with the home’s procedures. The home maintained an appropriate and secure system for the storage and administration of controlled drugs. Medication administered to residents on an individual basis was recorded appropriately on the Medication Administration Records, although gaps in recording were identified where no code had been entered. This shortfall was highlighted as part of the previous inspection which took place on 02 November 2005. All residents are provided with their own room which includes ensuite toilet facilities thus promoting maximum privacy. All bedroom doors are fitted with a privacy lock, although these can be overridden by staff in the case of an emergency. It was clear from meeting residents that attention had been paid to support with personal grooming and to assisting residents in making choices about what they would like to wear etc. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 13 Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Residents living at the home can expect to be offered a range of meaningful activities and supported to follow their chosen interests. Residents can also expect to be supported to maintain contact with family and friends and to access community leisure and recreational facilities. Service Users, through individual care planning, will be supported to make choices around their every day lives. Residents could not necessarily expect to be offered a choice of meals. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home was able to evidence that it places a high priority on offering residents meaningful activities. An activities co-ordinator is employed on a five day a week basis for five hours per day and provides activities on a general basis as well as targeting them to the differing needs of residents living on each unit. The Inspector was advised that four residents had recently printed their own t-shirts. As well as the services offered by the activities co-ordinator care staff will support residents with individual activities and on the day of the inspection, one resident had been to Woodbridge, supported by a staff Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 15 member. The Inspector was advised that another resident was growing their own tomatoes in the home’s garden. Activities on offer are advertised on a white board in the home’s main lounge, although on the day of the inspection, the activities co-ordinator was on annual leave. On the day of the inspection, the Inspector had the opportunity to speak to several residents. One resident had been able to bring his electronic organ with him which had been adapted to play using computer discs. They advised the Inspector that they loved to play the organ and sometimes entertained staff members and other residents. Another resident who had just returned from a day out with their family, showed the Inspector their wide range paintings and drawings of churches which adorned their room. They had enjoyed their day and also reported that they liked going to the local pub for lunch accompanied by staff members. Craft work completed by residents as part of the activities programme was also on display. On the day of the inspection, staff on one unit were busy decorating the lounge ready to celebrate the birthday of one of the residents. The home has an open visiting policy, although on the day of the inspection, no visitors were seen by the Inspector. Care Plans seen at the time of the inspection evidenced that residents were supported to make choices around their daily lives, to follow their interests and to spend their time how and where they wished. On the day of the inspection however, it was noted that in the lounge of Zone 3, the radio had been turned on by a staff member and was playing modern rock and pop music. Staff must ensure that individual care plans reflect the preferred tastes of residents and that their preferences are catered for. As part of the inspection process, the Inspector undertook a tour of the home’s kitchen and looked at meal provision in general. It was identified during the previous inspection, which took place on 02 November 2005, that whilst meal provision was of a relatively good standard, a limited choice of options was available to residents. The Inspector was advised by the Chef that the menu was at that time being amended to include more choice. At the time of this inspection, there was no evidence to suggest that that had been progressed. The kitchen premises were well equipped and there was a good provision of fresh fruit and vegetables. A four-week planned menu was in use which whilst evidencing that a nutritious diet was available, residents were still only offered one choice. The Chef had prepared home-baked cakes for the evening meal when ham and tomato quiche would be served. One resident described the meals as “ok” and another commented that the meals were pretty boring with “ a lot of minced stuff”. It was noted that the one resident who had come to live at the home from abroad was stated as having a normal diet but no evidence was available to confirm that any research had been carried out in relation to culturally appropriate or preferred food. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents and their families can expect to be provided with sufficient information to enable them to make a complaint or raise a concern. Policies and procedures employed at the home protect residents from the risk of abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home was able to evidence that it had a complaints procedure which was displayed within the home and also included as part of the Statement of Purpose and Service User Guide. Additionally, residents and their families also receive a copy of a resident handbook which also contains information on how to make a complaint or raise a concern. The home was also able to evidence that it maintains a log of all complaints received. Since the previous inspection, the Commission has received no complaints in relation to this service. The home was able to evidence that it has a clear procedure on the protection of vulnerable adults and the owning organisation provide all staff with training on the recognition and reporting of abuse. Staff personnel records seen at the time of the inspection evidenced that prospective employees are subject to both a POVA Check and Enhanced Disclosure via the Criminal Records Bureau. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 Residents living at the home can expect to be provided with accommodation which is fit for purpose and maintained to a good standard of decorative order and repair and provides a homely and domestic style environment. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Accommodation at the home is divided into three living units two on the ground floor and one on the first, each with eight bedrooms and its own living, dining, kitchen and communal bathroom accommodation. All bedrooms are for single occupancy and have the benefit of ensuite shower and toilet facilities. The front entrance leads into a large reception area which is comfortably furnished and provides a pleasant area where residents can spend time if they wish watching the “comings and goings” of the home. In addition to the lounge facilities located on each unit there is a large communal lounge sited centrally, Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 18 which again is furnished in a domestic style and has an attractive conservatory leading off. As part of the inspection process, the Inspector undertook a tour of the building. Since the previous inspection a new “rise and fall” assisted bath had been installed on Zone 4 with an overhead shower unit and a new dining room table had also been purchased for Zone 3. As in previous inspections all areas of the home were maintained to a good standard of decorative order and repair. Attractive and comfortable furniture was provided in all areas and the environment had been made to look very homely with pictures, ornaments etc. It was noted that the settee sited in the corridor area of the home was torn. A selection of resident bedrooms was also examined. These were very spacious and good use had been made of attractive soft furnishings. All bedrooms had ensuite shower and toilet facilities which were wheelchair accessible and provided maximum privacy. Many of the bedrooms had been made to look very personal by the occupant with the addition of personal belongings, paintings, flowers, photographs and small items of furniture from previous accommodation. In general the home was maintained to an acceptable standard of cleanliness and hygiene, although it was noted there was an unpleasant odour in one of the bedrooms located on Zone 4 and in the same room a commode pot had not been emptied and the lid left off. All areas of the home were provided with appropriate aids and adaptations such as handrails, grab rails and hoists. A passenger lift provided level access to the first floor of the building. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Residents living at the home can expect to be supported by an appropriate number of staff. However, residents could not necessarily expect care staff to have received the appropriate training to ensure that their individual and complex needs are met. Residents are not wholly protected by the home’s recruitment procedures. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: On the day of the inspection, the home was able to evidence that it provided an appropriate level of staffing throughout the waking day and night. During the morning period, residents are supported by two registered nurses and six members of care staff. The level of registered nurses on duty decreases to one in the afternoon and evening, although six care staff remain on duty. During the night period there is one registered nurse on duty supported by three members of care staff. The home employs a total of 34 care staff (excluding registered nurses) 52 of which hold an NVQ Level 2 qualification or above. For the purposes of the inspection, the Inspector examined the personnel files of two randomly selected staff members. Whilst evidence was available to confirm that prior to commencing duties both staff members were subject to a Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 20 POVA check and Enhanced Disclosure via the Criminal Records Bureau, in both cases only one written reference had been secured. At the time of the inspection, the home was unable to provide an overall training record which “tracked” what training had been undertaken by each staff member. However, the home kept a log of training provided and since the last inspection there had been two moving and handling training days, fire training and training on working with challenging behaviour. Certificates were available to confirm that ten members of staff had undertaken training in moving and handling but there was no evidence to confirm whether, if any, staff had undertaken refresher training on a planned basis. At the time of the inspection, two staff members were accredited trainers for moving and handling. The home was able to evidence that newly employed staff are provided with an in-house induction programme which includes health and safety training. It would appear that since the previous inspection, the home’s training budget had been considerably cut and any training outside of mandatory areas is not being offered. The Inspector was advised that three staff members were funding themselves in order to undertake training in infection control. The home provides a specialist residential service for people over the age of 55 who suffer from severe mental frailty and the majority of residents accommodated suffer from advanced stage dementia. Whilst the registered manager of the home has undertaken some training in the care of older people with dementia, the owning organisation does not provide a formal training package to staff on dementia care. In order to ensure that the home is able to meet the needs of this service user group, who have been assessed as requiring psychiatric nursing input, it is of utmost importance that care staff undertake this training. A requirement for care staff to undertake training in the care of older people with dementia was made as part of the previous inspection which took place on 02/11/06 and thus far remains unaddressed. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Residents living at the home can expect it to be managed and administered in an effective and competent manner and with their best interests to the fore. Residents are protected against financial abuse by the homes procedures and systems for the administration and safe keeping of their finances. The home is unable to fully evidence that it provides a safe environment for service users. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The current Manager of the home, Ms. Michelle Webster has been in post since December 2003 and was registered with the Commission in January 2005. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 22 She is a Registered Mental Health Nurse and since taking up her post has undertaken training in the care of older people with dementia. The Inspector was notified that the Manager had recently returned to work after a 7-week period of sick leave. The Commission was not informed of this absence as required by Regulation 38 of the Care Homes Regulations 2001. Quality assurance visits to the home are carried out by a representative of the owning organisation in compliance with Regulation 26 of the Care Homes Regulations 2001. At the time of the inspection, the home did not hold resident meetings, but a satisfaction questionnaire is sent out to resident’s representatives and their representatives on an annual basis by the owning organisation. The next questionnaire was due to be distributed in December of this year. For the purposes of the inspection, the Inspector examined the systems used for the safekeeping and administration of resident finances. Procedures used evidenced that residents and/or their representatives had a choice about whether they wished to hold cash themselves or leave it in the safe-keeping of the home’s administration. Resident monies were securely held in separate folders and all transactions made on behalf of the resident were recorded and tallied with corresponding retained receipts. In general the home provided a safe environment for service users, whilst electrical and gas safety checks had been carried out, certificates were not held at the home to evidence this. The home was able to evidence that it documents all accidents and deaths occurring in the home and notifications are submitted to the Commission under Regulation 37 of the Care Homes Regulations 2001. During the tour of the building it was noted that two residents manoeuvred themselves around the building in a wheelchair. Whilst in the case of one of the residents, a risk assessment had been produced to confirm that they should wear a lap strap when mobilizing in the wheelchair, a risk assessment for the second resident could not be found as part of the care planning documentation. Appropriate fire safety records were maintained which evidenced that fire alarms, fire fighting equipment and emergency secondary lighting were tested at a frequency as recommended by the Suffolk Fire and Rescue Service. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Sch.1 Requirement The Registered Persons must ensure that the homes Statement of Purpose correctly reflects the number of residents accommodated under each category of registration. The Registered Persons must ensure that the home is able to evidence that a detailed assessment has been carried out in relation to the needs of any prospective service user. The Registered Persons must ensure that evidence is available to show that resident care plans are reviewed on a regular basis. The Registered Persons must ensure that out of date medication is disposed in line with the homes procedure. The Registered Persons must ensure that the Medication Administration Records are completed whenever prescribed medication is administered to a resident. This is a repeat requirement from 02 November 2005. Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 25 Timescale for action 14/10/06 2 OP3 14(1) 20/08/06 3 OP7 15(2)(b) 14/10/06 4 OP9 13(2) 20/08/06 5 OP9 13(2) 20/08/06 6 OP14 12(3) 7 8 OP15 OP19 16(2)(i) 23(2)(c) 9 OP26 16(2)(k) 10 OP26 13(3) 11 OP29 Sch.2 12 OP30 Sch.2 13 OP30 13(3) & 18(c)(i) 18(c)(i) 14 OP30 The Registered Persons must ensure that the preferences and tastes of service users are taken into account in relation to their daily life at the home. The Registered Persons must ensure that residents are offered a choice of options at mealtimes. The Registered Persons must ensure that the torn settee sited in the corridor area is either replaced or repaired. The Registered Persons must ensure that the unpleasant odour located in a bedroom on Zone 4 is identified and eliminated. The Registered Persons must ensure that commode pots are covered and emptied following use. The Registered Persons must ensure that two satisfactory written references are obtained prior to any prospective staff member commencing duties. The Registered Persons must ensure that documentary evidence is available which confirms what training has been undertaken by each staff member and on what date. The Registered Persons must ensure that care staff receive training on infection control procedures. The Registered Persons must ensure that all care staff are provided with a planned training programme on the care of older people with dementia. The home must be able to evidence the content of this programme. This is a repeat requirement from 02 November 2006. The Registered Persons must ensure that the Commission are DS0000024487.V305728.R01.S.doc 20/08/06 14/10/06 27/10/06 20/08/06 20/08/06 20/08/06 27/10/06 27/10/06 27/10/06 15 OP31 38 20/08/06 Page 26 Sidegate Lane Nursing Home Version 5.2 16 OP38 13(4) 17 OP38 13(4) notified in writing where the Registered Manager is absent from the home for any period in excess of 28 days. The Registered Persons must ensure that Risk Assessments are completed in relation to all risks identified as part of a preadmission assessment. The Registered Persons must ensure that the home is able to evidence that mandatory safety checks on gas and electrical wiring and equipment has been carried out within the appropriate timescales. 14/10/06 14/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The Registered Persons should ensure that a copy of the home’s Statement of Purpose and Service User Guide is readily available to residents, their representatives and visitors to the home. The Registered Persons should ensure that care plans contain sufficient information in relation to the likes, dislikes and preferences of the service user. The Registered Persons should endeavour to ensure that residents from ethnic minorities are offered culturally appropriate food. 2 3 OP7 OP15 Sidegate Lane Nursing Home DS0000024487.V305728.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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