Inspection on 09/01/06 for South Bebside Nursing Home

This inspection was carried out on 9th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

South Bebside Nursing Home 19/07/07

South Bebside Nursing Home 23/08/06

South Bebside Nursing Home 15/08/05

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 Inspection 9th January 2006 09:30 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 South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 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. South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service South Bebside Nursing Home Address Patterdale Road Blyth Northumberland NE24 4JU 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) 01670 - 364881 01670 351986 south.bebside@fshc.co.uk Ringdane Ltd Mr John Stephen Anderson Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (2) of places South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2005 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 nurses 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 DS0000000503.V275881.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over 4 hours. This is the second unannounced inspection the home has had in this year. All of the core standards have been examined over the two inspections. It is therefore suggested that both reports are looked at to get the full picture of the home. Fourteen residents, three relatives and three staff were spoken to directly although more were chatted to briefly. Four care plans, training records and the records for medication, staff files and training, health and safety records were examined. There were three requirements identified during the last inspection two of which were clearly met. The one for the provision of a hot was disinfector for bed cleaning of bedpans was not met. However, following discussion with the company representative it was agreed that an external report would be sought to give advice of the need for this. What the service does well: What has improved since the last inspection? Two of the three requirements, which were identified at the last inspection, were clearly met. The third requirement to provide a hot wash steriliser for cleaning bedpans and commode pots it to be assessed by an external advisor. The recommendations to provide formal Protection of vulnerable adults training is being undertaken although not completed as yet. Also the manager has almost completed the Registered Managers Award. South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 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 DS0000000503.V275881.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 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 the following standard(s): 2,3,6 The Manager ensures that residents being admitted can have their needs met and that the equipment and staff skills are present before admission. All residents are given a written contract / statement at the time of admission. The home is not registered for therefore does not provide intermediate care. EVIDENCE: South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 9 The home is given an assessment before admission by 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). Following the reintroduction of the company contract / statement of contract all residents have been issued with a copy, only a few relatives / residents have not yet signed and returned them. These are now being contacted so that they can be assisted to do this. 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 DS0000000503.V275881.R01.S.doc Version 5.1 Page 10 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 Individual care planning is undertaken and the care is being delivered in line with these plans. The residents are having their needs met. Residents are confident that the staff treat them with respect and maintain their privacy so far as possible when delivering care and throughout their daily life. The residents received their prescribed medication in line with safe working practices. The medicines in the home are well managed and safely disposed of as necessary. 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 South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 11 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. A number of the specialist nursing type beds have now been purchased and there is a programme in place to replace more of the divan type beds. 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, really nice” and another said, “staff are always very kind”. South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 12 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 Residents are satisfied with the flexibility of their routines for daily living and activities, which are appropriate to meet their cultural, social, religious and recreational interests and needs. Arrangements for residents to maintain contact with their family and friends and the local community are suited to each individual’s needs and vary accordingly. EVIDENCE: Residents spoken to confirmed that they are encouraged to take control of their daily routines in simple but important ways including the time they get up, what and when they eat and how they spend their time. They also confirmed that they are able to make choices about how they spend their day and said they were satisfied with the activities available. Some organised activities are available and staff said that residents are able to choose whether or not they are involved. The residents’ bedrooms were personalised reflecting individual choices and preferences and three residents asked about their bedrooms said they were happy with the decoration. South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 13 Residents have visitors at any time and are able to use their own rooms, the small lounges or the larger, busier lounges to receive them. Four relatives spoken to on the day confirmed that they are welcomed to the home. Relatives are given information within the residents’ guide about visiting arrangements. Residents said they were satisfied with the arrangements for visitors and that staff welcome them. South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 14 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): These standards were examined during the last inspection. EVIDENCE: South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 15 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): 26 The infection control measures in the home are generally good and the home is clean, pleasant and is odour free. An independent audit will identify the need for additional equipment or strategies for reducing the risk of cross infection. EVIDENCE: 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. As the company have questioned the need for this it has been agreed that an audit be undertaken by the Communicable Disease Nurse to determine the action necessary. Generally the standards of cleanliness in the home are good and the domestic staff work hard to maintain the standard. South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 16 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): 29, 30 The staff are recruited and selected using a system, which ensures that they are able to care for the residents and have not been identified as posing a risk to their welfare through Criminal Record Bureau and the Protection of Vulnerable Adults List. The training programme is not up to date for all staff for moving and handling although a significant amount of training is being given to the staff. EVIDENCE: Staff records examined was completed in line with the company policies and procedures, including two references and a completed application form. The requirement to have a CRB and POVA check in place is applied to all of the staff in the home. There is a record of the interview kept so that the Manager is able to demonstrate the process is done in a fair and consistent way. The training records maintained by the Manager to allow him to plan for training was examined, it was very clearly maintained and offered a good system. However, although there is evidence of a significant amount of training in both statutory and clinical areas of practice not all staff are receiving training in line with the company policy and statutory requirements for fire training a plan is in place to address this. South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 17 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): 38 The Registered Manager, Mr Anderson, ensures that he has systems in place to make sure that the home is managed effectively taking into account the needs and wishes of the residents. He is continuing to ensure safe working practices in the home in line with the company policies and procedures with the exception of the need to provide fire training for the staff. EVIDENCE: There are clear lines of accountability both in the home and within the company. The records to support the Managers confirmation that he ensures safe working practices in relation to first aid, food hygiene, moving and handling and infection control were in place and on examination were satisfactory. Fire training is not up to date at present and there is a plan to address this. There was evidence that the home manager takes the necessary action to ensure the health and safety of the service users through regular tours of the South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 18 building, risk assessments and recording of action taken to respond to hazards. The staff are aware of the need to maintain a safe environment in the home. This is supported by the policies and procedures examined and by discussion with the Manager. South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 19 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 South Bebside Nursing Home DS0000000503.V275881.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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 OP26 Regulation 23(2)(K) Requirement Timescale for action 31/03/06 2. OP30 23(4)(d) The home must have a full control of infection audit by an external Communicable Disease Nurse to ensure that they are working in line with current best practice to meet the needs of the service users in this category of care. The staff must receive fire 28/02/06 training at intervals in line with current guidance from the Regional Fire Brigade. 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 OP28 OP31 Good Practice Recommendations It is recommended that the Manager implement the training for staff according to the local Social Services Protection of Vulnerable Adults joint procedures. The Manager should continue the NVQ level 4 Management Training so that it is achieved within the required timescale. DS0000000503.V275881.R01.S.doc Version 5.1 Page 21 South Bebside Nursing Home Commission for Social Care Inspection Cramlington Area Office 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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