CARE HOMES FOR OLDER PEOPLE
South Haven Lodge 69-73 Portsmouth Road Woolston Southampton Hampshire SO19 9BE Lead Inspector
Clare Hall Unannounced Inspection 15 November 2005 10:00a 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 Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 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 Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service South Haven Lodge Address 69-73 Portsmouth Road Woolston Southampton Hampshire SO19 9BE 023 8068 5606 023 8044 9092 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) New Century Care (Southampton) Ltd Mr Maximillian A H Whatman Care Home 45 Category(ies) of Dementia (45), Dementia - over 65 years of age registration, with number (45), Old age, not falling within any other of places category (45) South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Service users in the category of dementia (DE) must be at least 55 years of age. The home is not registered to take patients detained under the Mental Health Act 1983 - as amended. The home may accommodate up to 45 male and female service users in the categories DE, DE (E) and OP at any one time. 13th June 2005 Date of last inspection Brief Description of the Service: South Haven Lodge is a care home providing nursing care and accommodation to 45 people who require care through old age or a diagnosis of dementia. It was bought in May 2004 and is now owned by New Century Care (Southampton) Ltd. The home is located in the residential area of Woolston and has good links to public transport systems. Local shops and community facilities are easily accessible. South Haven Lodge has accommodation over two floors connected by two stairways and two passenger lifts. There is a mixture of single and double bedrooms. At the rear of the property is an extensive well-maintained garden, which is accessible to the service users. Car parking is available at the front of the home. South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The manager was available throughout the inspection, which was conducted over a two-day period. The first day of the inspection was carried out unannounced and undertaken by one inspector. Staff and service users and their relatives were spoken with and a full tour of the premises undertaken in view of the current refurbishments being undertaken. Two inspectors conducted the second day and the area manager joined the manager. Issues of concern regarding the management of challenging behaviour were raised and investigated as part of the inspection process and outcomes are noted in the report. The inspection process also addressed the home’s proposal to vary its current registration to include mental disorder. The inspection process included the review of records and observation of practice and staff intervention and support given to clients. Discussions with staff and residents were undertaken on a group and individual basis and the inspector, with co-operation of the homes manager, sought the views of every client by providing comment cards to all service users and their representatives prior to the inspection. What the service does well: What has improved since the last inspection?
South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 6 New Century Care Ltd continues to undertake an extensive refurbishment and redecoration throughout the home. A further eight rooms have been redecorated, making a total of sixteen which have been refurbished in the preceding eighteen months and the downstairs sitting room and dining area have been decorated and a new ceiling with light fittings provided. On the day of the inspection the first load of new room furnishings arrived and this process will continue over the forthcoming weeks as the home is replacing the majority of the furnitures for the bedrooms and communal areas. A further improvement since the last inspection is that the staff have been provided with an alternative smoking area, changing and meal break facilities. Also the staff have reviewed the procedures regarding the previous practice of crushing prescribed medications and for the covert administration of medications. The provision for regular staff meetings has been addressed. Night staffing levels have been reviewed and an additional trained member of staff has been employed on twilight duties to support staff between the hours of five and 10pm. Of the seven requirements raised at the last inspection, six have been fully met and one remains outstanding. It was observed that the one remaining requirement in respect of the environment is currently being addressed and a meeting will be held with an additional visit undertaken in March 2006 to tour the home and to discuss changes and improvements being made. The home’s proposal to make changes to the bathrooms and to provide an extra service user bedroom from a current downstairs bathroom will also be discussed at this time. What they could do better:
The home is undergoing extensive redecoration and refurbishment including the replacement of flooring and additional building works to bathrooms and toilets. Consideration must be made to ensuring the safety of residents during this time and also to ensure the needs of the service users with regards to bathing toileting and hairdressing can be continued and managed safely despite the building works being undertaken. Further attention must be paid to the management of odours, though it is recognised that with the forthcoming change of flooring this will help alleviate part of the problem which has been a concern due to the age and wear of the carpets. A plan outlining the proposed dates for completion of renovations, redecoration was not provide to the commission following the last inspection and it has been
South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 7 agreed that a further visit to view on going works will be undertaken in March 2006 to monitor developments. The home’s documentation needs to be further expanded to include more details on the mental health needs of service users and a record made regarding individual users capacity to consent. It was also discussed with the manager that the care staff need to be more actively involved in the reassessment and documentation of the care provided and use the care plans as working documents. A concern, which needs to be monitored, is the provision for toileting and bathing facilities. One of the service users toilets upstairs is now a male staff toilet and changing area and one bathroom downstairs is being used as a store room for wheelchairs and an upstairs bathroom is out of order and has been so since August 2005. The provision of bathing and toilet facilities provided at the initial point of registration must be maintained and fully functional. The home currently accommodates 35 wheelchair users and has one seat assisted bath and one parker bath. There are no showers. Additionally there is limited hoist accessible /disabled toilets. The current renovations appear to be making changes to address this and these plans need to be monitored. No formal plans or proposal has been submitted to the Commission in respect of these changes. It has been discussed that staff must adhere to the home’s infection control procedures as their were concerns related to practice raised as an outcome to this inspection. 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 Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 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 South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 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 Information regarding the service is easily available and service users have the necessary information pertaining to conditions of residence. The home has submitted an application to the commission to apply for a variation in its current registration so as to be able to provide services to clients with a mental disorder. EVIDENCE: The home has a very comprehensive information folder, statement of purpose and service user guide for service users and their relatives. There is extensive information regarding the home available in each of the service user’s rooms and in the main hallway. This includes information regarding the training undertaken by the staff. One service user was found at the last inspection to be outside of the home’s category for registration. Since then an application for variation in respect of the service has been received. The additional proposed category of mental disorder (MD) to the homes registration was considered as part of the inspection process and will be discussed throughout the report. The inspectors audited the supporting
South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 10 documentation in respect of this application and therefore audited the Homes provision and support of this category by investigating the homes provision for providing adequate numbers of qualified and experienced staff, the environment, the support provided by the community healthcare team, the operational policies and procedures in the home and the further provision for training. Consideration was also given to the current registration of the home. South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 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): 7,8,9,10 Documentation is of a good standard but this needs to be expanded. The safe administration of medications has improved since the last inspection and done in accordance with appropriate professional guidance and in a risk assessment framework. EVIDENCE: Three service users records and care documents were viewed during the inspection, two current files and one archived file. Some of the documents were comprehensive, detailed and care plans indicated a date of the identified need with a review date when completed. These plans demonstrated the current needs of the service users including expected outcome, goals and actions. Care plan evaluations when completed were detailed. Records indicated food profiles, falls risk assessment, night care plan, dependency assessment form, continence assessment, waterlow, manual handling risk assessment, oral assessment, nutritional risk assessment monthly observations, life histories and wishes upon death. Not all plans had the signatures of the resident/representative.
South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 12 Discussions with staff indicated that the care staff are not fully aware of the recorded care plan and issues identified on that plan. Care staff also informed the inspector that they do not complete the daily records or refer to the care plan to seek guidance of the service users needs and record their interventions but that the trained staff undertakes this. Care staff complete a task related checklist, which records areas such as skin, wash, bath, hair, nails etc. Staff stated these records are archived so they couldn’t audit care recorded such as when a bath was last provided to a service user. This should be addressed. It was noted and discussed that the home’s current proforma for the assessment and details relating to the service users needs requires further expansion especially in respect of the home’s application for the MD category. Currently the proforma does not include enough details on the mental health assessment of the service user. It was also identified that the current manual handling risk assessment does not guide staff on how to appropriately handle clients. The area manager demonstrated a new proforma which will be undertaken to improve the information. The manager agreed to address this with staff and ensure that staff adhered to the details on the risk assessment. This will be looked at in more detail at the next inspection. Four service users spoken with said they were very happy with the care provided. One service user explained that she was able to make choices regarding the time she got up, what she wore and how she spent her day. Another service user explained how she had been in the home for a long time and felt safe and supported by staff. One gentleman stated he was able to access his walking aid and was free to mobilise. All service users observed in the lounges and dining area were seated in chairs which allowed the freedom of movement and those using specialist reclining chairs had a medical need and were not able bodied due to an element of physical disability. Two healthcare specialists who regularly visit the home stated they had no concerns with regards to the homes practices and one professional stated he felt the staff are more aware of policies and standards of care and this is observed in their practice. During discussion with staff it was identified that improvements have been made for the safe administration of medicines and that staff are no longer crushing medication and do not administer medicines covertly. More medicines are being ordered in liquid form and the home has contracted services to deal with medication returns. South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 13 Staff explained the new procedure for the disposal of controlled drugs to the inspector. Records for the storage of controlled drugs and recording of medicines given were correct. One written comment card response from a relative to the Commission stated, “Staff are very kind dedicated and caring. Nothing is too much trouble. Mum is kept very clean and warm and this home is managed with a very happy atmosphere”. South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 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): 13,15 Residents have choice in respect of food provided and has improved the dining facilities. The home has an open visiting policy. EVIDENCE: Visitors were observed freely throughout the two days. Staff were observed interacting with them and visitors were seen participating in the days events and meal times, supporting clients and chatting. Records also indicated who was on the premises at any time and there are notice boards situated around the home giving information and seeking the views of visitors, and showing photos of recent events held by the home. The menu provided in the home shows a varied and nutritious diet, including the use of fresh vegetables and alternatives to the meal. Each service user is offered three full meals each day, two of which are cooked, at intervals of not more than five hours. Hot and cold drinks and snacks were reported to be available and trollies with a selection of cold drinks were seen being offered and provided to residents. South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 15 The menu now identifies that a snack meal is offered in the evening and the interval between this and breakfast the following morning is no more than 12 hours. The home’s menu gives a clear indication of what food is and can be provided at breakfast, lunch and evening mealtimes and informs relatives and residents of what is offered. Four service users were very complimentary regarding the food provided and one service user was observed requesting a cup of tea at the kitchen hatch and being provided with one. Staff have reported to the inspector that the cooker needs replacing as the main oven does not heat up adequately and the staff have difficulties lighting the gas. The cooker does look very old and worn and is rusted. Relatives reported that, “on the whole the care is good” and one relative stated “the care is better than it was, the home also feels better and the staff are lovely”. South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 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): 16,18 The home’s procedures and practices protect service users from abuse but the home needs to improve the recording of valuables held in the safe. South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 17 EVIDENCE: There has been one issue of concern made to the Commission since the last inspection regarding placing a service user on the floor on a duvet to ensure they were safe. Following review of the clients care records, risk assessments and daily care records and observations throughout this two day period the inspectors were satisfied that appropriate measures had been taken in respect of handling clients with challenging behaviour. One general practitioner also commented on having observed staff dealing with some very difficult situations and stated she felt the staff had handled the situations very well. The inspectors did not observe any inappropriate practices or interventions. The homes policies and procedures regarding challenging behaviour and interventions were reviewed and were satisfactory and staff described appropriate measures for dealing with people who wish to wander. One comment card received in respect of the service stated ”Staff are very friendly and always make time if you have a concern. They are usually aware of any problems and have informed doctor. Very good and caring with elderly occupants.” Four service users stated in their questionnaires that they were not aware of the homes complaints procedures. All necessary information including the complaints procedure was seen and is accessible in service users’ rooms and in the main hallway. Discussions and records indicated that the home holds small sums of money on the service users behalf. Records identify inventories are made of personal items but there were valuable items in the homes safe which are not recorded in a property book or equivalent. Records had only been made on the envelope to state whom the item belonged to. The manager and area manager agreed to address this. South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 18 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): 19,20,21,22,23,24,25,26 New Century Care has been undertaking ongoing improvements in the redecoration and refurbishment of its current facilities at South Haven Lodge. Improvements have been made but require further clarification for the proposed timescale for completing all outstanding work. The homes heating and thermostatic control system needs to be discussed at the meeting. EVIDENCE: Redecoration and refurbishment is ongoing at South Haven Lodge. During a tour of the premises the inspector was shown the newly decorated service user’s rooms. The rooms refurbished are of a good standard and particular thought has been taken to ensure a homely décor is achieved by covering hospital bed heads with floral coverings. It was stated by the manager that the home has invested £60,000 in the home furnishings and all rooms have Kings Fund height adjustable beds.
South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 19 The ceilings to the lounges have now had new lighting. The main corridors, flooring, skirting and doors especially near the kitchen are soiled, tired, chipped and worn. The manager confirmed all the areas were incorporated in the programme of refurbishment. The bathrooms and toilets on the lower floor are not suitable for the client group and in a poor state, except for the bathroom providing a Parker bath. The inspector was informed at the last two inspections that these would be refurbished but no work has yet been undertaken. A requirement was raised following the last inspection seeking the full programme for refurbishment, with timescales but this has not been provided in full. Staff confirmed that a number of the current bathrooms are not practical and are not being used, as they are not suitable. One area of the home, which provides a room for hairdressing, three cubicle toilets and one bathroom, was stated to be under discussion to renovate into two disabled toilets and a service users room. No plans or discussions have yet taken place with the Commission formally regarding these changes. Since the last inspection the manager has reviewed the outside smoking/seating area for staff as this was situated outside a service users’ room on the ground floor. Smoke and conversations emanated through to this service user’s room. The smoking area has now been moved to the back of the garden. A male changing area has now been provided in one of the communal toilets upstairs and a female changing and toilet facilities provided downstairs. Visitors commented to the inspector about the odours present in some areas of the home. A number of service users’ rooms have odours and again the manager reiterated that with the replacement of the old carpets, which do not respond to regular cleaning, this problem should be alleviated. The inspector was informed previously that service users and their relatives have complained about the temperature of the rooms on the ground floor. Following discussion it had been established that a group of rooms have set temperatures from a thermostat located in the hall and for room temperatures to be changed the maintenance man needs to get into the room remove the panel and adjust the thermometer accordingly. Residents are not able to control the temperacture themselves. This will require further discussion with CSCI. During this visit the inspector was concerned regarding the number of accessible toilets for service users, considering thirty five are wheelchair
South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 20 bound. One has been out of order since August 2005 and only one other is hoist accessible. A full review of what toileting and bathing facilities are provided against the needs of the client group will be reviewed with the proposals for the bathrooms and toilets by CSCI to ensure current refurbishments are appropriate in view of the homes stated purpose. An area of concern raised during the inspection was that where a storage unit has been removed in the dining room there remains a hole in the floor, which constitutes a risk to staff and service users. It was identified during a tour of the grounds that once in the back garden access through the side of the building is not possible which is considered a concern if there was a fire. The manager agreed to get the locks moved to the inside of the gate. Two relatives of service users reported that they took the service users’ underwear home to wash because white clothing washed in the home laundry comes back grey. Discussions with laundry staff identified that the home has three small washing machines as well as an industrial machine, which have broken soap feeders, and the homes quilts are a tight fit to get into these small machines. The sheer volume of laundry was stated to be difficult to manage due to the size of the machines and on viewing white items of clothing were mixed in with dark. One-service users relative commented, ”I am always happy to visit in such a friendly atmosphere and regularly witness the little acts of kindness, that mean so much to the service users and visitors alike. The ongoing improvements to the fabric of the care home are noticeable very time I visit.” South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 21 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 Staff feedback was positive but the manager must continue to ensure appropriate numbers of staff are employed to meet the needs of the service and that staff are given the opportunity to meet regularly. New Century Care provides good opportunities for staff development. EVIDENCE: One area of concern raised previously was that there was only one member of trained staff on night duty in charge of the shift, responsible for supervising all residents and staff. The manager has now employed a trained member of staff to work a twilight shift covering the hours of five until 10pm so assistance can be given during the busy evening period and evening medication round. This will need to be monitored further especially in view of the application to vary condition. Mixed reviews were given in respect of staffing. Only two of the forty five comment cards sent out and received stated that there didn’t always appear to be enough staff on duty and comments received from relatives stated there appeared to be plenty of staff on duty. In support of this change in the home’s registration the inspectors monitored the homes provision for training. It was established that three registered mental health qualified nurses, which provide a total of 117hours cover a
South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 22 week, staff the home. The home also employs registered general nurses and the total trained nurse hours provided is 252 per week. (Percentage of weekly hrs covered by RMN hrs – 46.4 ) With respect to Teaching/Assessing qualifications held, the home manager holds the, RMN cert, ENB 998 and the lead clinical nurse is an RGN, Dip He, Bsc (Hons), with a 7307 Teaching Certificate, and a D32/33 assessor’s award. Also the senior night sister holds RGN, RM, RHV, and ENB 997/998. Other trainers within the home are a Senior Care assistant who is a Health & Safety Trainer, an RN, Moving & Handling Trainer and a First Aid Trainer. The area manager stated that there are five Moving & Handling trainers, three Health & Safety trainers, two Tissue Viability Specialist trainers, one Food Hygiene trainer and two Fire Safety Awareness trainers. It was stated that all the above mentioned trainers have been put through training courses by New Century Care and in February they propose to train a further two First Aid trainers, two Food Hygiene trainers and anticipate another Fire Safety Awareness trainer. Records held and training matrix identify that the teaching and training sessions held at South Haven Lodge in 2004 (August) of which updates are being arranged were, • • • • • • • • Confusion in the Elderly The Wandering & Confused Person Schizophrenia Depression Parkinson’s Disease Epilepsy Our Vision of Care Giving in Dementia Rehabilitation in the Older Person Teaching/Training sessions held at South Haven Lodge during 2005 • • • • • • • • • • • Fire Safety Awareness Food Hygiene Adult Protection Health & Safety/COSHH First Aid Moving & Handling Death, Dying & Bereavement Malnutrition in the Care Setting Infection Control MRSA Managing Challenging Behaviour
DS0000059970.V254949.R02.S.doc Version 5.0 Page 23 South Haven Lodge • •
• • • • Promotion of Continence Role of the Care Worker Optical Awareness Venepuncture – RN’s Male Catheterisation – RN’s Supervision & Mentorship – RN’s and Senior C/A’s Other Courses undertaken at South Haven Lodge • • • Formal Induction/Foundations NVQ level 2 in Care Lead Clinical Nurse commencing RMA South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 24 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): 33,35 The home has a good quality-monitoring tool, which last sought service users opinions in June 2005 and now needs to be undertaken again. The home maintains good financial records in respect of holding service users monies. EVIDENCE: An up to date employers liability insurance certificate was seen in the entrance area. Monies held by the home on behalf of service users were audited and correct. A concern has been raised with the Commission following the last inspection when a friend of a service user raised concerns in respect of the home applying a 25 administrative charge for handling money of the residents. Following an investigation and response from the company, it was stated that the 25 charge is not for handling residents personal money, but an
South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 25 administration charge from their Head office, for invoicing out such extras as chiropody, hairdressing and other private services provided. The home had stated in the response that in anticipation of the introduction of the handling charge, formal notification was sent to each individual representative with monetary responsibility in the form of a letter, of which copies were demonstrated. Alternative arrangements were offered as stated in the letter and that this was put in place for those who requested it. The area manager stated that many of the service users were happy with the arrangements made and anyone who was not happy regarding this had been encouraged speak to the administrator about the alternative arrangements available, as the company stated “they are always happy to hear people’s concerns and work towards an amicable resolution”. The company conducted a full quality audit in November 2004. An audit has not been conducted this year with exception of a food audit having been conducted earlier this year. The manager and area manager agreed to undertake one. One comment card received from a general practitioner did raise some concerns, which were discussed with the manager, and it was agreed that the home would contact visiting healthcare professionals regularly and seek their opinions and address any concerns raised. The concerns raised on this occasion were that improvement is necessary for the assessment of the needs of the service users, referring pressure ulcers for further clinical management and intervention and issues relating to the management of medications. These concerns were raised by one visiting healthcare professional and two others spoken with did not have the same concerns. South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 26 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 2 3 3 2 2 STAFFING Standard No Score 27 X 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 27 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 2. Standard OP19 OP19 Regulation 23(2) b 23(1)(2) 12(1) 16(1) Requirement The uneven dining room floor must be made safe. The registered person must submit a detailed plan of the proposed refurbishment and redecoration to include all communal areas kitchen and bathrooms, subject also to the recommendations given by the fire authority and to address the homes heating provision and odours. This was raised at the last inspection and will be discussed with the area manager and manager The homes infection control procedures must be improved. Waste must be disposed of in appropriate bags. Soap and hand towels must be available at all sink points. Odours in the home must be managed. Bathrooms must be repaired and functional. Timescale for action 30/11/05 10/03/06 3 OP26 23 10/03/05 4 OP21 23(2) j 30/11/05 South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations South Haven Lodge DS0000059970.V254949.R02.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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