Inspection on 03/04/07 for South Wold Nursing Home

This inspection was carried out on 3rd April 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 Wold Nursing Home 08/04/08

South Wold Nursing Home 05/04/06

South Wold Nursing Home 07/12/05

South Wold Nursing Home 08/12/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE South Wold Nursing Home South Road Tetford Horncastle Lincolnshire LN9 6QB Lead Inspector Key Unannounced Inspection 3rd April 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address South Wold Nursing Home DS0000061987.V333769.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 Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Wold Nursing Home Address South Road Tetford Horncastle Lincolnshire LN9 6QB 01507 533393 01507 533311 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) shailenm7@aol.com Mr S Munnien Mrs Satiavanee Munnien Mr S Munnien Care Home 16 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (16) of places South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of Service Users in the home with Nursing needs must not exceed 13. 3rd August 2006 Date of last inspection Brief Description of the Service: Southwold is situated in the village of Tetford, which is approximately 5 miles from the A158. The village lies between the market towns of Horncastle and Alford. The home is a purpose built annexe attached to the rear of a detached property and lies well back from the main road through the village. The annexe is single storey and provides 12 single bedrooms and 2 double bedrooms. To the rear of the home there is a large well-maintained garden with views overlooking the surrounding countryside. The home is registered to provide care for 16 people, including those with dementia. The owners have a statement of purpose, which states their philosophy of care and the services they provide. The current scale of fees are £400.00 - £450.00 South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place during April 2007 and the visit to the home was carried out over approximately 6 hours on one day. This is the second visit to the home in a year, the first of which took place in August 2006. Outcomes from the visit will be referred to in this report. The care received by three residents was followed in detail. Residents spoke about the experience of living at the home; and their personal records, general house records and staff records were looked at. Staff and the registered manager were spoken to and the care being provided was observed. Information already held by the commission was also used as part of the inspection process. Comments made by residents and staff during the visit can be seen in the main body of the report. What the service does well: What has improved since the last inspection? Since the last inspection visit the attention to health and safety issues has improved, for example there are now risk assessments in place for the use of bedrails and unprotected radiators; patio doors in the lounge and a residents bedroom have been repaired, as well as a crack in the patio flooring. Many areas of the home have been decorated and new carpets have been fitted through the hallway and lounges. A new air freshening system has also been fitted. A clear induction programme is now completed with all new staff and a copy of the record is kept in their files. Staff now receive regular, recorded supervision sessions; and there is a wide range of training provided for them. Notifications of event in the home are now being sent to the commission. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 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 Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents have some information to help them make a choice of where to live. However there is inconsistent information about their individual contracts for the placement. Residents benefit from a thorough assessment process, and they are assured that their needs can be met. EVIDENCE: A statement of purpose and service user guide is available within the home, and the registered manager said that a copy of the service user guide is given to prospective residents and/or their representatives when he carries out the pre admission assessment. There was no evidence to support this on the day of the visit, and a recommendation is made to keep a record of when the service user guide is given to people. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 9 A recommendation was made at the previous visit to the home, for contract/terms and conditions to be provided. The registered manager said that some contracts had been put in place but not every one has them. Pre admission assessments are contained in individual files and form the basis of the on-going assessments that start when the person is admitted to the home. The assessments cover areas such as nutrition, emotional needs, social needs, personal care, skin integrity, communication and moving and handling. They also contain information about respect and dignity for the resident. Monthly reviews of the assessments are recorded, and the previous visit to the home identified that people are informed in writing that their needs can be met within the home There are clear admission details recorded for each person, including their end of life arrangements. Intermediate care is not provided at the home. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents have comprehensive and detailed care plans, which means that they are at risk of not having their needs met. EVIDENCE: Care plans are in place for all residents and they contain information about maintaining privacy, dignity and choice, but some files do not contain information about all of the assessed needs. Needs such as personal hygiene, mobility and pressure area care (see also Standards 12-15) are covered in the care plans and staff were observed to be providing for all needs. There is evidence in the records that the care plans are reviewed regularly, however as highlighted at the previous visit there is still not enough detail on what the staff have to do to support the resident. For example, care plans state that a resident needs help to bathe but do not clarify how to provide this help. This means that any new staff or those employed through an agency would not South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 11 have enough information to provide a good standard of care. The registered manager provided evidence that he is currently developing core care plans with this in mind. He has also identified the need for some staff to have more training in how to write care plans, and provided evidence that courses have been booked. Residents and/or their representatives sign the care plans; and comments on survey forms from relatives indicate that they get plenty of opportunities to discuss their relatives’ care. Records are available for health care support such as GP visits, chiropody and dental appointments, and monthly monitoring of weight. Medication is stored and administered appropriately, and good infection control procedures are carried out during administration, such as hand washing. Medication records are completed satisfactorily. Risk assessments are in place where bed rails are used, and information about the safe use of bed rails is displayed in staff areas. A previous visit also showed that there are risk assessments in place for falls, nutrition, continence and moving and handling. Drinks were freely available to residents throughout the visit, and all residents looked well groomed and comfortable. Staff were observed to be friendly and polite to residents and they were making sure that personal care was provided in private. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to a range of activities within the home but they would benefit from opportunities to participate in activity within the local and wider community. EVIDENCE: An activity co-ordinator is employed at the home and is available on most weekdays between 9am and 3pm. Records show when activity is offered and whether or not the resident has participated. Activities such as communion, 1:1 chats or walks, aromatherapy, board games, exercises, crafts and reminiscence sessions are recorded and some residents were seen participating in card making and knitting during the visit. A suggestion from a recent survey regarding the use of a Pat-a-dog scheme has been addressed by the registered manager and regular visits are now booked. The surveys also showed that people thought the provision of activities rated as ‘average’, and more outings from the home were needed. There is currently little or no evidence that activities outside of the home are being offered. Residents said that they have South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 13 plenty to do in the home and they can have visitors whenever they want, but three people said that they would like to go out more. Care plans refer to choice and decision-making, and residents said that staff are ‘lovely’ and they help them to do whatever they want. Residents also said that they have ‘lovely food’ and they can choose something else if they don’t like what is on the menu. There was a relaxed atmosphere at lunchtime; meals were presented nicely and in ample portions, and individual support is available where needed. There is a good range of foods available in the home. Staff described how they are reviewing the menus by sitting with residents and discussing what they want to have on them. Staff were able to clearly describe how resident’s likes and dislikes are incorporated in to the menu planning. There was evidence that some staff have recently attended an exhibition about good nutrition for older people. Care plans and risk assessments are in place for nutritional needs, and there is evidence that they are reviewed regularly. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are kept safe by good policies, procedures and staff knowledge, however they could be better informed and reminded about the complaints procedure and advocacy services. EVIDENCE: During the visit residents said that they feel safe living at the home, and that the staff know how to look after them. They said that they could talk to the registered manager if they are not happy with anything and he will ‘sort it out’. Staff were able to describe what to do if a complaint is made or if a safeguarding adult issue arises. Records show that staff receive training in safeguarding adult procedures. Records show that no complaints have been made since the last visit. The complaints procedure is available in the service user guide, however a recommendation has been made that the procedure is displayed clearly in the home. There has been one safeguarding adults issue reported, and records show that the situation was managed in accordance with policies and procedures. Risk assessments are available for needs such as pressure area care, mobility/falls and unprotected radiators; and there is evidence in records that South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 15 they are reviewed regularly. There is no information about advocacy services available in the home and a recommendation is made in regard to this. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 16 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, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are satisfactory standards of décor and general maintenance within the home, and there are good standards of hygiene and cleanliness. EVIDENCE: On the day of the visit the home was generally very clean and tidy, although during the early part of the morning there was an odour present in one area. A thorough cleaning process quickly eradicated this, and the registered manager said that he would continue to monitor this issue. The registered manager and staff described comprehensive cleaning processes such as weekly carpet shampooing, and there is now an air freshening system in place as discussed at the last visit. A new cleaning and monitoring system is also in place, which includes weekly checklists for cleaning tasks in each room in the building, South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 17 general maintenance checks such as ensuring there are no trailing wires, and checking that call bells are working. Relative’s surveys indicated that they are ‘very pleased’ with the cleanliness of the home, and residents said that they were comfortable in the home and they like their bedrooms. One resident said that they have everything they need at the home. Since the last visit communal areas of the home have been decorated and new carpets have been laid. New pictures and ornaments around the house also help towards a homely and comfortable atmosphere. The registered manager described plans for developing the outside space to be more accessible for residents, and there was evidence of material samples and quotations. He said that this was in response to suggestions made in surveys completed by relatives. Since the last inspection repairs have been made to patio doors in the lounge and a residents bedroom, and to the concrete base of the patio area. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 18 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, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by well-trained staff, who are recruited safely. EVIDENCE: Recruitment files contained applications forms, interview records, criminal records bureau checks, references and terms and condition. The registered manager has introduced a new recruitment checklist to ensure that processes are consistently followed. There is a comprehensive induction programme available for new staff and completed records were seen. Records show that staff have undertaken training in subjects such as safeguarding adults, pressure area care, fire safety, dementia awareness, first aid, care planning, supervision and palliative care. There is also evidence that staff are either undertaking or have completed nationally recognised qualifications at various levels. Training plans include courses for intermediate food hygiene, Mental Capacity Act awareness, Parkinson’s Disease, infection control, pain control and assessing care practice. The information contained in training files was difficult to track and a recommendation has been made in regard to this. During discussions staff said that they have good access to training that relates to the needs of residents, and they said that the registered manager supports them with training. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 19 Staff demonstrated through observation and discussion that they have a clear and detailed knowledge of resident’s needs, and their likes and dislikes. Residents said staff are ‘lovely’, ‘they are very helpful’ and ‘they are nice and polite’. Surveys completed by relatives indicate that they think staff are very responsive and friendly. Rotas show that there are enough staff to currently meet the needs of residents and staff said that there are enough staff to meet needs. Residents said that there are always enough staff around to help them. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 20 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, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management approaches and arrangements are now in place to ensure that the health, safety and welfare needs of residents are met. EVIDENCE: Quality assurance surveys are now being sent out, and there is evidence that the registered manager is taking action in response to suggestions made in the surveys (see Standards 12-15 and 19-26). Since the last visit a new health and safety audit has been introduced and it is completed every six months. A hazard identification list is developed from the audit, which records actions that have been taken to address risks. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 21 Information about substances that are hazardous to health is available, and water temperatures for baths and in resident’s rooms are now being recorded regularly as recommended at the last visit. There is evidence in records that fire safety checks, including evacuation drills, are carried out regularly; and the key lock on the front door has been changed to a key pad as advised by the local fire officer. Although the fire evacuation procedure is displayed in the staff area, it has been recommended that it is also displayed prominently for the benefit of residents and visitors. Infection control advice is displayed for visitors, and staff have access to gloves, aprons and paper towels, which they we seen to use appropriately. Resident’s or their representatives manage their own finances, but there is evidence that staff record when they have bought anything that a resident requests them to. Notifications made to the commission are in line with events at the home; and daily notes are detailed and refer to care plans. Pre inspection information shows that there are policies and procedures in place to cover issues such as safeguarding adults, quality assurance, administration of medicines, equal opportunities, fire safety, emergencies and crises, moving and handling, health and safety, record keeping, whistle blowing and staff supervision. Staff supervision records are available, and staff said that they have supervision at least every three months. A recommendation is made to record that sessions have taken place on a separate format so that the personal records of the sessions are kept private. Staff said that the registered manager gives them very good support and makes sure that they have the resources to do their jobs well. Surveys completed by relatives indicate that they are very satisfied with the care and support within the home; and they feel that their opinions are listened to and they feel involved in the home. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 22 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 2 3 3 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 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 Requirement All residents must have care plans, which document all of their needs and state clearly how those needs are to be met. Timescale for action 05/06/07 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. 3. 4. 5. Refer to Standard OP1 OP2 OP12, OP13 OP16 OP16 Good Practice Recommendations It is recommended that a record be kept of when the service user guide is given to prospective residents and/or their representatives. It is recommended that the home provide individual terms and conditions/contracts to all residents; a copy of which should be kept on their file. It is recommended that activity programmes include more activities that make use of the local and wider community. It is recommended that the complaints procedure be displayed in the home for the benefit of residents and visitors. It is recommended that information about advocacy services is made available within the home. DS0000061987.V333769.R01.S.doc Version 5.2 Page 24 South Wold Nursing Home 6. 7. OP30 OP38 It is recommended that the system for recording individual staff training clearly records all training completed so that any gaps can be identified. It is recommended that the fire evacuation procedure be displayed in the home for the benefit of residents and visitors. South Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Wold Nursing Home DS0000061987.V333769.R01.S.doc Version 5.2 Page 26 - 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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