Inspection on 27/02/07 for South Haven Lodge

This inspection was carried out on 27th February 2007.

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 Haven Lodge 15/11/05

South Haven Lodge 13/06/05

South Haven Lodge 22/02/05

South Haven Lodge 12/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE South Haven Lodge South Haven Lodge 69-73 Portsmouth Road Woolston Southampton Hampshire SO19 9BE Lead Inspector Susan Hall Unannounced Inspection 09:40 27 February 2007 th 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.V319442.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. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Haven Lodge Address South Haven Lodge 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), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (10), Old age, not falling within any other category (45) South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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. A maximum of 10 service users within the category of MD(E) Date of last inspection 15th November 2005 Brief Description of the Service: South Haven Lodge is situated in the residential area of Woolston, within easy reach of local shops and facilities. There are good links to local transport systems. The home provides nursing care for older people, who may also have a diagnosis of dementia or mental disorder. It is owned by New Century Care (Southampton Ltd.), a company who have care homes in different parts of the country. Accommodation is provided in single and double rooms on two floors - ground and first floor. Some of these have en-suite toilet facilities. There are two passenger lifts for easy access between floors. The home has large, well maintained gardens at the rear of the property, and ample car parking at the front. The home has benefitted from extensive refurbishment during 2006-7, so that it provides a pleasant environment for service users. Fees range from £430.50 to £800.00 per week, depending on the dependency levels and assessed needs of service users. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key Inspection, which included assessing information compiled by the CSCI office since the previous inspection in November 2005, as well as a visit to the home. Information which was obtained included notifications regarding different events, regulatory activity, and any complaints or allegations made to CSCI. A “Random” Inspection was carried out in July 2006, in response to information that the first floor of the home was excessively hot, and could affect service users’ health. An Inspector visited the home, and gave two requirements about ensuring that service users had sufficient drinks given to them; and to ensure that reasonable measures were taken to ensure a comfortable temperature in individual rooms. The manager ensured that these requirements were met, and purchased some cooling fans for service users who were confined to bed. One allegation had been made about standards of care, but after due investigation by the Social Services department, this was dismissed, as it was unfounded. Pre-inspection documentation was completed by the manager at the end of December 2006; and questionnaires were completed by some service users and relatives. The Inspector received six replies, and found this helpful information in confirming her findings when she visited the home. The visit lasted for 6.5 hours, and during that time she had conversations with eight service users, three relatives and ten staff, as well as the manager. The Inspector received very positive comments about the home; for example, relatives said “you couldn’t fault the care here”; “you couldn’t get anywhere better” and “ I am very lucky to have my relative here”. Conversations with service users were sometimes quite muddled, but the sense was clear in that they were content living in the home, think the staff are very kind and caring, and they enjoy the food and activities. What the service does well: The home provides good standards of personal and health care, with attention paid to service users’ specific needs. There are a good variety of activities; and opportunities for relatives and visitors to stay for meals, and take part in the life of the home. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 6 The home maintains good staffing levels, which ensure that there are sufficient numbers of staff to carry out effective care. There is an excellent staff training programme, covering all mandatory subjects and additional training. What has improved since the last inspection? What they could do better: The home’s statement of purpose had been revised, but still had some required points missing. Medication Administration Records (MAR charts) had sticky labels from the Pharmacy for new prescriptions during the month. These labels are no longer acceptable, as they can peel off, or cover over other information. Additional entries should be carefully handwritten and signed by two nurses. The kitchen had not been refurbished, and some cupboard doors are damaged. There are no fly screens at the windows. Staffing facilities are of poor quality. There is one room used for staff to change, and to eat meals in. Application forms for recruitment, should specify that a full employment history is required from applicants (not five or ten years). The NICEIC electrical certificate had not been updated since 2001. (NB: The Inspector spoke to the manager four days after the inspection visit, and was informed that action had already been taken on most of these issues). South Haven Lodge DS0000059970.V319442.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. The summary of this inspection report can be made available in other formats on request. South Haven Lodge DS0000059970.V319442.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 South Haven Lodge DS0000059970.V319442.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with suitable information before admission; and detailed pre-admission assessments are completed. EVIDENCE: The statement of purpose had been updated by the company, and arrived at the home on the previous day. The manager had not yet had time to check the contents. The provider and manager details had been correctly amended, and most other points - including the aims and objectives, and the schedule of accommodation - were included. However, the Inspector noted that two points had been omitted, regarding fire precautions and associated emergency procedures, and the arrangements for service users to attend the religious services of their choice. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 10 The Inspector noted that while the layout was easy to read, if the layout had been set out according to the requirements of Standard 1 and Schedule 1 of the Regulations, it would have been obvious that these points had been overlooked. The service users’ guide is suitably worded, and includes clear details regarding admission, terms and conditions of residency, and the complaints procedure. However, service users’ views are not included, and this means that the company is missing a good opportunity to share some of the service users’ comments. Three pre-admission assessments were viewed. These are carried out by the manager or deputy. They are very comprehensive, and include detailed information regarding care needs such as: allergies, medication, condition of pressure areas, communication ability, appetite & diet, personal hygiene needs – and condition of feet, toes, mouth, teeth etc.; continence needs, mental health – including wandering, confusion, any night problems. The service user’s perception of their own condition is included; and details of members of the multi-disciplinary team involved in their care, and family involvement. A separate mental health assessment is carried out at the same time. The mental state examination includes the past psychiatric history, appearance, rapport with staff, preoccupying thoughts, family networks, medication, social skills, spiritual needs, and sight & hearing needs. A mini mental test is carried out if appropriate. Joint assessments are obtained, and as much information as possible from family. All service users and next of kin/advocate are supplied with a contract from the home, which includes terms and conditions of residency. This is in addition to social service contracts. Service users are admitted for a trial visit, with a review after 4 weeks to check the suitability of the placement. Some service users may be admitted for respite care if a bed is available. This may later lead to a permanent stay in the home – which is clearly beneficial if the service user has some previous knowledge and memory of the home. Emergency admissions are not usually indicated. Service users are not admitted for rehabilitation/convalescent care, so standard 6 is not applicable in this home. South Haven Lodge DS0000059970.V319442.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good standards of nursing care, and health needs are appropriately met. EVIDENCE: The Inspector assessed 3 care plans. These include a page to indicate that the plan has been discussed with the service user or their next of kin as appropriate. As most service users have limited mental capacity, it is usually relatives who have involvement in the care planning. Care plans are reviewed monthly. There is a named nurse and key worker system. The named nurses have the responsibility for ensuring that care plans are kept up to date. The plans are well set out in individual A4 folders, and are indexed for easy access of information. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 12 Care plan assessments are completed on admission and reviewed monthly. These cover aspects of care such as: personal hygiene needs; a moving and handling assessment; skin and pressure area risk assessment; nutritional risk assessment; continence assessment; pain assessment, and a night care plan assessment. These were seen to be carefully completed with sufficient details. For example, moving and handling assessments included details of the service user’s mobility, if they need a wheelchair or hoist, and if one or two care staff are needed for transfers. Other equipment which may be needed, such as bed rails and “bumpers”, is also assessed. Night care plan assessments show when the service user likes to go to bed, if they like a hot drink, light on/off, and if they need repositioning every two hours. Care plans are formulated from the original assessments. These have detailed information, and are set out as the need, goal, action & review. Care plans for specific needs were seen, such as diabetes, or wound care, and clearly specified the ongoing evaluations, and if the care was meeting the need. For example, wound care plans show that the wound is reevaluated every time the dressing is changed, and how the wound is progressing. Care plans include records of appropriate intervention from health professionals, such as dietician, chiropodist, GP, physiotherapist and dentist. The Consultant Psychiatrist visits the home every four weeks, and carries out reviews as arranged with the manager. There is one nurse on duty for each floor throughout the day, and they carry the responsibility for that floor for medicine administration, dressings, supervision of other staff, and writing daily reports. Feedback is given at handovers at shift changes. Medication is stored in a large clinical room which was seen to be clean and orderly. The room and drugs fridge temperatures are recorded daily. There is an air conditioning unit in the room for when the room temperature is getting to the maximum level (25 degrees). There are a suitable number of locked cupboards. These were seen to be in good order. Creams and lotions are stored separately from internal medication. There is no oxygen stored on the premises. The suction machine (and other equipment) is checked and cleaned monthly. Medication is administered via a monitored dosage system. Liquid medication is used wherever possible for service users who have difficulty swallowing. Medication is only crushed with the express written permission of the GP, there is no other alternative, and it does not affect the efficacy of the medicine South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 13 concerned. No medication was found out of date. There was no overstocking, and there are good procedures in place for receipt and disposal of medication. The controlled drugs cupboard is sufficiently large and meets specified requirements. There are two medicine trolleys – one for each floor. The Inspector examined the ground floor trolley and Medication Administration Records (MAR charts) for this floor. These had been well completed. The Inspector highlighted a concern that some had sticky pharmacy labels on them for additional medication prescribed during the month. This practice is no longer acceptable as these can come off, or be used to cover up other information. Any additional entries should be clearly handwritten, and checked and signed by two nurses. The Inspector observed that service users were well groomed and dressed, and that attention is paid to caring for them with privacy and dignity. Staff were gentle and caring in their approaches to service users, and explained what they were doing. There are sufficient staff for service users not to feel rushed. Care plans contain remarks regarding any wishes service users have expressed about dying. The home’s policy is to keep service users in the home where they know staff and feel at home, whenever possible. The deputy manager stated that the subject of palliative care has been included in the training programme. South Haven Lodge DS0000059970.V319442.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a varied programme of activities. Care is taken to ensure that nutritional needs are properly met. EVIDENCE: The home employs an activities co-ordinator, who is very proactive in assessing what activities are suitable for different service users, and how to motivate service users to take part. She assesses the mental state of service users on the day, to check if they are able to take part in group activities. When there is a new admission, she allows the service user time to settle into the home, and obtains as much feedback as possible from relatives and friends. She will then discuss the range of activities with them to find out what they would like to do. An individual record is kept for each service user in an activities folder. This includes their life history, as well as information about physical and mental limitations. Different activities may include reminiscence, crafts, drawing/painting, films, music etc. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 15 The co-ordinator was currently arranging men’s afternoons, where they would sit together to watch a suitable film with a non-alcoholic beer – and ladies film afternoons. On the day of the inspection the ladies were watching Ice Age 2. One-to-one time is arranged as needed, and may include manicures, hand massage or foot spas, giving an opportunity to chat. She is looking to develop more sensory items Outside entertainers are booked once or twice per month, and every day in the week before Christmas. These include a range of entertainment, such as Line Dancers; Marionettes; Singers (various types); and a Dance Troupe. A Residents’ Fund has been commenced in order to raise money for additional entertainment programmes and specific items, as well as the monthly amount provided for entertainment by the company. There is a monthly “Bric-a-Brac” stall, and a summer garden party. She has been able to purchase DVD machines for the lounges (set on the walls on brackets), and radios for service users confined to their bedrooms. Service users are assessed for their suitability for dial-a-ride buses, so that they can be taken out. The coordinator also arranges service users’ dental visits, hospital visits and GP visits, and acts as their escort; and oversees all the arrangements for wheelchairs to be kept in good condition, serviced appropriately, and new ones provided. The home has lovely gardens at the rear, and service users enjoy going into the garden in good weather. Home visits are arranged if the service user has been assessed as suitable for this, and relatives can manage their care during this time. Children from the school next door visit on an arranged basis, and after singing, stay for tea and to chat with service users. The local Air Training Corps cadets take part in helping with the summer fetes/garden parties. There is a large white board in the dining room which is used to show the day and date and weather. Menus are displayed on each dining table. Permission is obtained from relatives for taking photos of service users taking part in activities, or for medical reasons. The co-ordinator was currently fixing up a display of small photographs in each service user’s bedroom, (unless they refuse), showing the names and photos of care staff, and their named nurse and key worker. There are pictures/signs on doors and in rooms showing bathrooms etc. and these are helpful signs and tastefully done. Visitors are allowed to visit any time, and said they are always made to feel welcome. They can stay and have meals for a small price, and two relatives said they really value this, and the food is very good. Advocacy is arranged when needed, usually via Help The Aged or Age Concern. The main cook has been working at the home for nine years. She arranges the menus, and gets to know service users likes and dislikes. A kitchen assistant South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 16 works alongside her until 4.30pm. A second cook is on duty in the afternoons/evenings to provide teas/suppers. The menus were viewed and looked excellent. There is always a good alternative choice of menu. Most service users cannot remember what they have ordered, and may forget their likes/dislikes, so it is important that the kitchen staff are aware of their nutritional needs and are able to meet these. A large number of service users needed soft or pureed/blended diets, and these are set out as attractively as possible in individual portions. The cooks make fresh home made cakes every day. The kitchen is quite small for the number of residents, and only works because of good organisation. There is only one upright freezer, and discussions with the cook showed clearly that this is insufficient for the food storage for these numbers – especially if there are events/Christmas etc. An additional freezer is needed. There are no fly screens at the windows, and these should be provided. Care staff wear green tabards when they are dealing with food. A carer was seen giving a mid-morning drink to a service user in bed and was carrying this out very carefully and gently. Care staff ensure that service users have sufficient drinks given to them when they cannot feed themselves, and fluid charts confirmed this. There are always snacks and drinks available, any time of the day or night. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and are well handled. Service users are protected from abuse. EVIDENCE: Complaints are logged in a hardback records book, showing the nature of the complaint, and how it has been resolved. The details of complaints – including letters, interviews, and investigations – are retained in separate files. The complaints procedure is on display in the entrance hall, and contains the correct information. Service users and relatives feel able to voice concerns and know that they will be dealt with. One relative said “she knows that if she has any concerns, they will be seen to straight away”. There had been three complaints logged since the last inspection, and the records showed that these had been properly addressed. One of these had been substantiated, and two were not. Staff are trained in recognition and prevention of different types of abuse. The excellent staff training matrixes confirmed that all staff receive this training. Hampshire Council Adult Protection policies and procedures are available in the Nurses’ office. Staff files show confirmation of POVA First checks prior to South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 18 commencement of work, and all staff have had Criminal Record Bureau (CRB) checks done through the home. The disclosure reference numbers and outcomes are retained. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The refurbishment has considerably enhanced the premises, and provides a pleasant environment for service users. EVIDENCE: The Inspector was pleased to find that the home’s refurbishment is almost complete. All communal areas, bathrooms, toilets, and bedrooms have been redecorated, re-carpeted (or new flooring) and have new soft furnishings. Corridors have been fitted with Perspex covering below the dado rail, so that wheelchairs and other equipment does not damage the new wallpaper. Bedrooms have been tastefully decorated with colour co-ordinated soft furnishings, wallpaper and carpets. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 20 The lounges are spacious, and homely, and the large dining room has been fitted with sensible laminate flooring which can be easily cleaned after each meal. New dining tables and chairs were in evidence, and all the communal rooms are pleasant to sit in. There is a small interview room at the front of the building, and this and the offices, are yet to be refurbished. However, the manager has been given a date in March 2007 for this work to commence. All bedrooms were viewed on the first floor, and many bedrooms on the ground floor. There are four bathrooms and one shower room (which is a wet room), and these have all been refurbished. Most baths are fitted with integral hoists. One does not have a hoist, but can be used by a small number of service users who have sufficient mobility to get in and out of the bath without help. The nursing staff stated that there are sufficient hoisting facilities, and are pleased that another stand-aid has been purchased and is due for delivery. This will enable them to have a stand-aid on each floor, without waiting for it to be transported in the lift. The home has two lifts – a large lift suitable for equipment as well as staff and service users, and a smaller lift. Additional equipment is purchased as needed. All rooms have nursing beds, and the home has twenty airflow mattresses (to date). All rooms are fitted with call bells, but the manager said that currently only five service users could use these properly. Frequent checks (usually half-hourly) are carried out for service users who are in their bedrooms. The kitchen needs a second freezer and fly screens at the windows. This has already been mentioned in standard 15. The staff are rather let down by their facilities. There is one room for hanging their outdoor clothes, and is the only space for changing in. It is also the place where staff eat their meals. The only alternative for them is to change in a small staff toilet, which is not really sufficient. The maintenance man checks the hot and cold water temperatures every week, and also checks bed rails – to see they fit properly and are not damaged; window restrictors, the grounds, and equipment in each room. The inspector viewed these records, and they were neat and up to date. The maintenance man also carries out a monthly check of each room for the premises, and a monthly carpet/flooring check. Radiators have low surface temperatures. All hot water outlets are fitted with individual thermostatic valves. All bedroom doors are fitted with Dorguard devices which close in the event of fire; and all bedroom doors are fitted with locks for any service user who wishes to have a lock and is capable of managing this. Fire alarm checks are carried out weekly. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 21 The home was clean in all areas, and there were no offensive smells. There are three cleaners employed for most days, and sometimes four for management of additional cleaning tasks. The maintenance man and/or domestic staff shampoo carpets on a daily basis as needed. There are large gardens at the rear, with lawns and flowerbeds. These were well maintained and attractive. There are pathways suitable for wheelchair users to access. The laundry room is situated on the ground floor and has been fitted with two new commercial sized washing machines, and two commercial tumble dryers. The washing machines have a sluicing facility. A red alginate bag system is used for the management of soiled items. The laundry was very well organised, and the laundry assistant keeps a check on the quality of sheets and towels. Linen cupboards were very tidy and well organised. Staff ensure that service users clothes are suitably labelled, and ensure they wear their own clothes at all times. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing numbers are kept at levels to ensure service users’ assessed needs can be met. There are excellent training programmes in place. EVIDENCE: The manager ensures that there are sufficient numbers of staff to provide effective care. These were currently set up as: 2 nurses and 8-9 care staff in the mornings; (the manager’s hours are extra to this); 2 nurses and 5-6 carers in the afternoons and evenings; 1 nurse and 4 carers at night. There is an additional nurse on duty for a “twilight” shift from 4-10pm. The manager and one other nurse are RMN trained, and they will check any concerns regarding dementia/mental health. One of these is on call for any advice needed regarding mental health concerns. The other nurses are RGN. The staff are divided into groups of named nurses, key workers and care staff for different service users, so that they know their areas of responsibility. The manager is assisted by a deputy manager who oversees all the training in the South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 23 home and has set up the training matrixes; and by an administrator who oversees the staffing files (as well as many other duties). The care staff are supported by a wide range of ancillary staff, including an activities coordinator, 3-4 cleaning staff per day, a maintenance man, cooks and kitchen assistant, and a laundry assistant each day. The home also employs a bed maker, who strips each nursing bed each day, checks the airflow mattresses and other equipment, disinfects the beds, and remakes them. There is one volunteer in the home, who carries out 15 hours per week. She has been CRB checked, and is not allowed to do any personal care. The home has a bank system and flexi staff for covering shortages. NVQ training is encouraged. The numbers of care staff with NVQ 2 or above were 11 out of 23 on the day (so just below 50 ), and there were 6 more studying for NVQ 2, and 4 doing NVQ 3. This will put the level well above 50 . Staff recruitment procedures were checked by examining four staff files. These had been well compiled in indexed folders. POVA first and CRB checks were evidenced for all of them, and two satisfactory references. The Inspector pointed out that application forms varied, asking for a record of employment stretching back five years or ten years. She pointed out that both of these are incorrect, as the amendments to the Care Homes Regulations 2003 specify that a full employment history must be obtained. Otherwise the recruitment files showed that sound procedures are in place. Interview records and medical histories are retained. All staff have a copy of the GSCC code of conduct, a contract, and a job description. Nurses PIN numbers are checked. The first day induction record is comprehensive, and other induction papers were seen, showing that competencies are checked before being signed by a nurse. The manager said that a new induction programme (which meets Skills for Care specifications) is being commenced by the company. The staff training records are excellent, with a separate training matrix for trained staff, care staff, and domestic staff. These clearly show when training is due. Trained staff are enabled to keep their training updated with training sessions arranged for items such as nutrition, diabetes, and managing challenging behaviour. The Deputy Manager was arranging for some training in palliative care. Most training is carried out by in-house trainers from the company. Fire training, moving and handling, and other mandatory training was seen to be kept up to date. Mandatory training could be confirmed for all ancillary staff as well as care staff. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31-38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and administration of all aspects of the home is reliably carried out, giving service users and relatives confidence in the level of care which is being provided. EVIDENCE: The manager is trained as an RMN, and has been approved as a Registered Manager. He has worked for this company for two and a half years, and has many years of experience in caring for older people. He is ably assisted by a Deputy Manager, who is RGN, and is the lead clinical nurse. The manager South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 25 takes responsibility for mental health and dementia concerns, and gives a good lead to staff in the home. Staff are clearly aware of their areas of responsibility, and said they are well supported. Staff meetings are held at regular intervals, and (as one carer said) “anyone can share what they want to”. The meetings are recorded for staff who are unable to attend. One to one supervision is carried out, and yearly appraisals. Some of these were viewed, and showed detailed consideration for comments raised by staff. The manager ensures that he retains a visible presence on the floor, and relatives and service users are able to express any concerns and know that these will be dealt with. Relatives can stay for as long as they wish, and are invited to take part in activities, to share in outings, and to stay for meals. There is a “Relatives Forum” every three to four months, and service users are able to share in meetings with the activities co-ordinator to discuss the ongoing activities programmes. A newsletter is produced twice per year. The company sends out questionnaires annually, and the results of these are analysed and audited at the Head Office. The company have demonstrated financial viability by the obvious expenditure on the home for décor and equipment. The Inspector did not request to view business plans. Residents can have pocket monies retained in a safe place in the home, and there is careful administration to ensure that all purchases, payments and credits are entered in individual records, and receipts are retained. Policies and procedures were viewed briefly. These are stored in the nurses’ office allowing easy access for staff. They are all reviewed yearly, and were last reviewed in April 2006. The Inspector observed that records are well maintained and kept up to date. Confidentiality of service users’ details is retained, with care plans stored in locked filing cabinets. The maintenance man keeps good records to confirm that health and safety checks are carried out. These include fire alarm checks, water temperature checks, bed rail checks, monthly inspection of the premises and carpets, and window restrictor checks. Fire extinguishers had been inspected by a registered company and were in date. The home’s insurance certificate is on display and was dated up to April 2007. Water chlorination tests had been carried out on the previous day, and PAT testing for individual electrical items had been booked. The electrical NICEIC certificate was dated for 2001, and is therefore out of date. This comes under Electricity at Work regulations 1989, and there is a recommendation to comply with this legislation. South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 4 Requirement The statement of purpose should be further amended to ensure that all points listed in Schedule 1 of the Care Home Regulations have been included. Medication Administration Records (MAR charts) should not have sticky labels from the pharmacy on them. Additional entries should be clearly handwritten and signed by two nurses. An additional freezer is needed for kitchen storage; and measures should be put in place to prevent the entry of flies into the kitchen through the window (e.g. fly screens). The staffing facilities should be reviewed to ensure that they meet the assessed staffing needs. Timescale for action 30/04/07 2 OP9 13 (2) 31/03/07 3 OP19 16 (1) (g) 30/04/07 4 OP19 23 (3) (a) 31/05/07 South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 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. 1 Refer to Standard OP19 Good Practice Recommendations To review the condition of the kitchen cupboards, and ensure that these are in suitable condition for proper cleaning and promotion of good infection control. To ensure that the application forms are amended to request a full employment history from applicants. To comply with other relevant legislation, namely to update the NICEIC electrical certificate. 2 3 OP29 OP38 South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. Extracts may not be used or reproduced without the express permission of CSCI South Haven Lodge DS0000059970.V319442.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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