Inspection on 15/08/05 for South Bebside Nursing Home

This inspection was carried out on 15th August 2005.

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

South Bebside Nursing Home 19/07/07

South Bebside Nursing Home 23/08/06

South Bebside Nursing Home 09/01/06

South Bebside Nursing Home 02/12/04

South Bebside Nursing Home 21/05/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE South Bebside Nursing Home Patterdale Road Blyth Northumberland NE24 4JU Lead Inspector Suzanne McKean Unannounced 15 August 2005 09:30 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 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. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service South Bebside Nursing Home Address Patterdale Road Blyth Northumberland NE24 4JU 01670 364881 01670 351986 south.bebside@fshc.co.uk Ringdane Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr John S Anderson CRH 38 Category(ies) of OP Old Age (36) registration, with number PD Physical Disability(2) of places South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd and 17th December 2004 Brief Description of the Service: South Bebside is a purpose built home providing care for thirty-eight service users. The home was first registered in July 1998. It is a modern traditional brick building and has an open aspect into the car park. The service users have access to the area to the front to offer the opportunity to sit out. The building has an entrance area, which there are usually service users sitting followed by the nurse’s station, and the open area from which the lounge and the bedroom corridors are accessed. The home is situated in an area of predominantly domestic housing although it is close to public services and shopping facilities. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a period of 5 hours on one day by the inspector, who has visited the home on a number of previous occasions. The manager was on duty allowing the examination of records being stored securely in line with the homes policy on confidentiality. twelve residents were spoken to during the visit and six relatives and the inspector also spoke to seven of the staff the in process of the inspection visits. During the inspection the records examined included, four care plans, the training records, as well as complaints and accident records. The inspector also viewed three staff files including the process for their recruitment and selection. What the service does well: What has improved since the last inspection? At the last inspection seven requirements were identified only two of which are outstanding at this one. The Manager has ensured that the standard of decoration has continued to improve resulting in the current redecoration requirements being at a level which falls within the general annual programme. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 6 What they could do better: 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. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 8 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 standard(s) 3, 6 The Manager ensures that the residents being admitted to the home can have their needs met and that the equipment and or staff skills are present before admission. EVIDENCE: The home is provided with an assessment prior to admission from the Care Manager. These were available in the care plans for those service users, which were case tracked (detailed examination of specific residents care plans and discussion with the service users and named Key Worker/Nurse). The home carries out a comprehensive assessment of the prospective service users needs prior to admission for both planned placement and more urgent admissions. The admission assessment for the service users who’s care plans were examined were detailed and contained the necessary information on which to base a plan of care. The home is not registered for and therefore does not offer intermediate care. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7, 8, 10 Individual care planning is undertaken and the care is being delivered in line with these plans. The residents are having their needs met and the staff are aware of the need to maintain residents privacy are doing so as part of their delivery of care. EVIDENCE: Each resident has an individual plan of care, which is based on the admission assessment and is then added to during the placement. Five care plans were examined and they were completed to a good standard. There was evidence that relevant risk assessments are available for the prevention of falls, nutrition, wound care, moving and assisting, continence promotion and mental health status. The plans showed that they are regularly reviewed and updated and that reviews are regularly held with residents and their representatives. The care plans showed that the residents have access to all NHS services and facilities. There was a good range of pressure relieving mattresses in use for the prevention of pressure sores. However it was noted that there a number of residents who have complex moving and handling needs who are being cared for on divan beds, this is a potential risk for the resident and the staff caring for them and must be reviewed. A number of the beds in the home are in a poor state and must be replaced, it would therefore be prudent to provide South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 10 suitable “nursing type” beds in a programme of replacement. The recording of the nursing action taken for wound care was satisfactory with evaluations being dated and signed. Residents interviewed confirmed that the staff treat them with respect and contacts between staff and residents through the day was judged to be polite and courteous but friendly. A resident interviewed on the day said “staff are lovely, really nice” and another said “staff always knock before coming in, even the bedroom not just the bathrooms”. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 11 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 standard(s) 15 The food being served is being prepared safely by knowledgeable staff and offers choice to the residents. The home offers the resident a balanced diet and there is sufficient quantity of both food and fluids to meet their needs. Staff are aware of the importance of a balanced diet and the way it is served. EVIDENCE: The kitchen was clean and well organised, the recording of food, fridge, and freezer temperatures were in place and completed appropriately. There was an ample supply of frozen, tinned, dried and fresh food available all of which was appropriately stored. The kitchen staff were aware of residents specialist needs including how to fortify foods for those who have poor appetites or those who have lost weight. The residents are offered a choice of three meals a day and residents on the day were seen eating heartily one asked said that the “food is lovely” and there is “always plenty to eat, sometimes too much”. The meal being served was ample portion size, hot and well presented. Residents were offered assistance in a discreet manner. Residents were offered second helpings and alternatives to the main and dessert course were available. A variety of cold drinks were available throughout the meal and hot, cold drinks and biscuits were available throughout the day. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16, 18 The home ensures that the residents and relatives are made aware of the complaints policy. There is a system for managing and dealing with complaints, which makes it possible for them to be investigated and action taken to address any issues identified. The residents are protected by ensuring that the staff are given Protection of Vulnerable Adults training and whistle-blowing as well as reporting concerns to the Manager. EVIDENCE: The complaints procedure is available in the service users guide and a copy is available at the front entrance as well as being displayed in the home. The records of the complaints made to the home was examined, there have been no complaints recorded for this year. Two of the residents who were interviewed during the visit were asked about the way in which they would have any problems dealt with, each were able to identify the way this would be done. Three relatives who were visiting the home were aware of the complaints procedure but had not needed to use it. Written guidance is in place regarding the protection of vulnerable adults. Staff confirmed that they knew about the guidance and could identify the action they would take if they were made aware of or had any concerns regarding this issue. It is recommended that the Manager undertake the Protection of Vulnerable Adults training as planned. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19, 20, 21, 22, 23, 24, 26 The home is generally well decorated and safe, it is being maintained in a satisfactory way and there is a programme in place to ensure that the redecoration and maintenance is undertaken. The bedrooms are all single occupancy and are decorated and equipped in a homely and personalised way. There are suitable well equipped toilets and bathrooms and specialist equipment is provided when required using external advice as necessary. Control of infection is being compromised by the absence of a sluice disinfector on both floor. EVIDENCE: A tour of the home was conducted both with staff and alone to assess the general condition of the home. It is tidy and organised in such a way to make sure that the residents are able to use the home safely. It is purpose built and is well maintained and there is evidence of some refurbishment and redecoration-taking place as necessary including the bedroom areas which are being redecorated as part of the ongoing schedule. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 14 The laundry was well organised with racks and individual baskets for clean clothing. The equipment consists of three commercial type washing machines, two dryers a domestic iron and a rotary iron. It was noted that although there has been a new sluice disinfector fitted this is only appropriate to be used on the floor on which it is sited, it therefore requires a similar facility on the other floor. This is outstanding from previous inspections. Generally the standards of cleanliness in the home are good and the domestic staff work hard to maintain the standard. The residents’ bedrooms were personalised reflecting individual choices and preferences and three residents asked about their bedrooms said they were happy with the decoration and that they were kept clean by the staff. The bedrooms are all single occupancy and are decorated and equipped in a homely and personalised way and although some of the bedrooms are. During the visit the residents were sitting outside at the front of the building and were enjoying the pleasant weather, chatting and enjoying a visit from the mobile ice cream van. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The home is staffed with appropriate numbers of staff and there are qualified nurses on duty in sufficient numbers to meet the needs of the residents. EVIDENCE: Staffing rotas showed that the Manager is ensuring that enough staff are on duty to meet the staffing levels set down prior to the change to the CSCI without reduction. It was noted that when sickness and staff holidays occur these occasions are being covered by home staff. However when this is not possible agency staff can be used, late reporting does occasionally result in fewer staff being on duty for short periods. The staffing levels are adjusted to take into account the occupancy level and this is monitored by the Manager. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35 The Registered Manager, ensures that systems are in place to ensure effective management taking into account the needs and wishes of the residents. He continues to consult the residents, staff and other interested parties to review the service provided and manage the staff in a way to improve care delivered. The management of the personal allowances of the residents is detailed and effectively managed and audited. EVIDENCE: South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 17 The Manager Mr Anderson is in the process of undertaking the Registered Managers Award. His management approach was discussed with him and he described strategies for ensuring that the home operates in an open, positive and inclusive atmosphere. This includes regular staff meetings for which minutes were available, an “open door” policy as well as using periods in which he is involved in the delivery of care to have less formal discussions with all of the staff and the resdients. During the inspection the staff were observed communicating with the manager in a friendly but respectful way and seeking his advice as necessary on both clinical and management issues. The personal records kept in the home of residents who are receiving assistance to manage their finances were examined. The record of financial transactions was found to be detailed, logical and appropriate. Receipts were in place for purchases made on behalf of service users and signatures of either two members of staff or one and the service user were in place for all of the records examined. The Manager is not either an agent of appointee for any service users. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 3 x 3 x x x South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 19 yes Are there any outstanding requirements from the last inspection? 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 2 Regulation 5 (b) (c) Requirement Timescale for action 01.11.05 2. 26 23 (2) (k) 3. 8 16 (2) The Registered Individual must provide residents with a statement of terms and conditions on it being introduced. OUTSTANDING The home must provide 01.11.05 adequate sluicing facilities to meet the needs of the service users in this category of care. OUTSTANDING The home must provide 01.11.05 adequate and appropriate beds to meet the needs of the service resdient and allow care to be provided in a safe way. 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. 2. Refer to Standard 28 31 Good Practice Recommendations It is recommended that the Manager undertake the local Social Services Protection of Vulnerable Adults training to ensure that he remains familiar with the joint procedures. The Manager should continue the NVQ level 4 Management Training so that it is achieved within the required timescale. B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 20 South Bebside Nursing Home 3. 18 It is recommended that the Manager undertake the local Social Services Protection of Vulnerable Adults training as planned. South Bebside Nursing Home B53-B03 S503 South Bebside V232911 150805 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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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