Inspection on 05/04/06 for South Wold Nursing Home

This inspection was carried out on 5th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

South Wold Nursing Home 08/04/08

South Wold Nursing Home 03/04/07

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 Wendy Taylor Key Unannounced Inspection 5th April 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 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.V286636.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of Service Users in the home with Nursing needs must not exceed 13. 7th December 2005 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 £380.00 - £470.00 South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was carried out over 6½ hours at the home. Information already held by the Commission for Social Care Inspection (CSCI) has been taken into account when compiling the report. The site visit consisted of following the care experiences of a sample of residents by speaking with them and looking at their records and those of their key workers. The inspector spoke with 5 residents, the manager, three members of staff and a relative. A tour of the building took place, and a range of general records was looked at. What the service does well: What has improved since the last inspection? What they could do better: Although residents are given information prior to admission, they would benefit from having terms and conditions and contracts, and written confirmation that the placement can meet their needs. The home also needs to demonstrate that they consult with residents regarding their care planning and it needs to record the content of care plan reviews. Improvements are needed regarding risk assessment completion, with specific regard to fire safety, bed rails and radiators. Improvements are also required and/or recommended for the recruitment process, staff supervision processes, repairs to a patio door leading to the garden from a resident’s bedroom, leisure and social programmes, notifying resident’s accidents to CSCI, hot water temperature monitoring and recording end of life arrangements. South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 6 Recommendations have been made for the provision of an alternative privacy lock for one resident, further work on the vulnerable adults procedure and recording. 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 Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6 The home provides prospective residents with enough information to make an informed choice about living at the home, but they would benefit from having a contract and written confirmation that the placement can meet their needs. EVIDENCE: The home does not provide intermediate care. During a tour of the home service user guides were seen in several resident’s bedrooms. One resident said that she had received enough information before moving into the home and that the manager had undertaken an assessment of her needs before admission. Another resident said that he had been to look around the home before moving in. A recommendation was made at the previous visit for the home to provide terms and condition/contract and written confirmation that the home can meet the person’s needs. This recommendation remains in this report. South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 The home provides care plans based on assessed needs but the resident’s would benefit from consultation and involvement in their development. There are some shortfalls in the care plan review processes and risk assessments that may place residents at risk. EVIDENCE: Three service user files were looked at and all contained individual care plans. They also contained risk assessments for areas such as continence, falls and moving and handling. There was no evidence of consultation or involvement in their development and service users said that they have not seen their care plan. There are no smokers currently residing in the home but there is an outstanding requirement in respect of the use of bed rails. Photographs were available on all files. Residents said that staff meet all of their needs in a polite and respectful manner, and they see their GP and/or District Nurses whenever they need to. A relative also said that that staff treat people with respect. One service user said that he would like a new lock on his door so that he could keep other residents from entering but wanted staff to be able to have access in an South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 10 emergency. The manager said that he would look into the options for him. Professional visit records show evidence of this. There was specialist equipment in bedrooms as per care plans such as hoists and pressure care mattresses. There was no evidence of a review process for care plans on two of the three files and there is and outstanding recommendation for the home to gather information on end of life arrangements. There is a medicines policy in place, which refers to self-administration and the manager said that a lockable facility is available for the one resident who does self-administer medication. This was not checked on this occasion. Arrangements for administration, record keeping and storage were satisfactory but a recommendation was made to obtain a copy of the Royal Pharmaceutical Society guidance on medicines in care homes. South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Although there have been some improvements in the provision of activities, resident’s needs are still not fully met. Residents now benefit from choice and consultation regarding menus. EVIDENCE: All residents spoken to said that they have visitors any time they like and a relative said that the staff make them feel welcome and treat everyone with respect. Activities were also discussed with residents, relatives and the manager during the visit. Some residents said that they would like to get out of the house more and a relative said that there could be more activity/stimulation; he also said that he was aware that the manager is currently trying to sort this out. Some residents said that they prefer not to join in activities and prefer to stay in their room. A new activity record was seen which included activity such as hand and foot care and games. Staff said that there is also access to the mobile library. The manager said that he is about to employ a new activity co-ordinator for when the present one leaves, with increased hours. The manager also said that a visitor mentioned in the previous report now recieves social day care support and has lunch at the home. A recommendation has been made to ensure that care plans and risk assessments are in place. South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 12 Menus were seen in resident’s rooms. They said that the food is of a good quality, is served nicely and they are always asked what they want. They said that they can take meals where they wish and this was observed during the visit. Fresh fruit and drinks were available in resident’s rooms. There was evidence in records that the cook is to undertake an intermediate food hygiene course in May 2006, and other staff have undertaken basic food hygiene training. There was a good range of quality foods in the kitchen and a range of fresh vegetables. Two residents said that they had not voted in the last elections but would have liked to do so. The manager said that voting opportunities were offered at the time but declined although there is no evidence to confirm this. A recommendation was made in regard to this. South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 13 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 Residents are safeguarded by policies and procedures, and by trained and knowledgeable staff. EVIDENCE: There have been no complaints recorded since the last inspection. There is currently one safeguarding adults issue that is being investigated. There is a complaints policy available but some updating is required. There is also a vulnerable adults procedure and a copy of the Local Authority safeguarding adults’ procedures. The in-house policy has been updated but needs further work to clarify that the no investigation should be carried out prior to social service involvement. There is evidence in records that adult protection training has taken place for staff and further training is planned for July 2006. Staff demonstrated that they knew what to do if they suspected or witnessed any form of abuse. There is evidence of residents meetings being held every three months at which they can share their views, and relatives said that they would feel confident talking to the manager if there was a problem. South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 14 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): 19,22,23,24,26 Resident’s benefit from a good standard of hygiene and a programme of redecoration. The home does not fully meet resident’s safety needs in regard to central heating radiators. EVIDENCE: Radiators in communal areas are now covered but there is still an outstanding requirement to carry out risk assessments for those in resident’s bedrooms. The home was clean and tidy in all areas and the hallway was being redecorated. The manager said that individual bedrooms are to be decorated next in consultation with residents. Door guards are now in place where fire doors are kept open. Call bells were accessible in all bedrooms and the rooms were personalised with furniture, photographs and ornaments. There were hoists, walking frames and specialist mattresses available in the rooms. One bedroom has a patio door to the garden, which would not open smoothly. This was reported to the manager who said that he would ensure that it was fixed. South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 15 An Environmental Health Officer report for March 2006 was seen. All actions required have been carried out by the home with the exception of the siting of a shelf. The manager said that this would be done at the end of this week. South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29,30 Increased access to training for staff enables residents needs to be better met. There are still shortfalls in the home’s recruitment procedure that impact on the safety needs of residents but improvements have been made. EVIDENCE: Three staff files were looked at during the visit. One out of the three files did not contain a Criminal Records Bureau check, identification or a photograph. The manager agreed to take appropriate action to safeguard residents, and provided evidence within 24 hours of the visit that a Criminal Records Bureau check had been applied for. There was evidence of staff training in areas such as adult protection, fire safety, tissue viability, moving and handling, basic food and bowel management. The manager said that he has applied for a further six places on NVQ Level 2 courses, and a new induction pack has recently been introduced. Staff said that the manager provides good support and is making positive improvements to the home. They said that access to training has improved over the last year. During interviews they were able to identify health and safety issues and actions to take to correct any problems. They said that there is good team morale and the manager is approachable. They demonstrated a good awareness of residents needs. South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,36,38 Although some improvements have been made, there are continuing shortfalls in meeting the health, safety and welfare needs of residents with specific regard to staff supervision, fire safety arrangements, residents personal money and accident notifications. EVIDENCE: The manager is a registered nurse who has experience in caring for older people with dementia needs. Residents said that the manager ‘makes me feel better’ and ‘will go out of the way to help me’. They said that staff are very nice and the care is good. The manager said that they do not manage or keep any money on behalf of residents, however if a resident requests that staff buy them something from the shops, receipts are kept and given to the resident on return. One resident had receipts available in her purse. The manager said that he would adopt a South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 18 more appropriate means of safeguarding resident’s personal money when this occurs. Supervision has not yet commenced formally, but the manager said that the first sessions would all be completed by the end of April 2006. He agreed to inform CSCI when individual sessions when this has occurred. The manager also said that he is currently updating all policies and procedures, including Control of Substances Hazardous to Health (COSHH), Health and Safety and Whistleblowing. Servicing certificates were seen for hoists, electrical installation, fire alarms and emergency lighting. Oxygen cylinders were stored appropriately and signage was in place. COSHH materials were stored appropriately and a new register and risk assessments are in place but need to be fully completed. There is an outstanding requirement for the completion of fire risk assessments. The manager agreed to liaise with the fire authority regarding this and regarding the key operated front door. He agreed to inform CSCI of the outcome of the liaison. CSCI had not been notified of some accidents involving residents. The manger said that staff test the temperature of bath water before residents get in but they do not record this or routinely test the temperature of hot taps in residents bedrooms. South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 3 2 X 3 STAFFING Standard No Score 27 X 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 2 X 1 X 1 South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES 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 OP8 Regulation Requirement Timescale for action 31/05/06 2. OP12 3. OP24 4. OP25 13(4)(b)(c The registered person must ) ensure that risk assessments are in place for risks associated with the use of bed rails. This requirement has been carried forward from 07/12/05. 16(m)(n) The home must provide a programme of leisure and social activities based on the preferences of the residents. This requirement has been carried forward from 07/12/05. 23(2) The home must ensure that a patio door to the garden used by a resident is in sound working order. 23(2)(p) The responsible person must ensure that risk assessments are carried out for radiators. This requirement has been carried forward from 08/12/04 19, Schedule 2 The registered person must provide written evidence that a CRB/POVA check has been applied for within 24 hours, and DS0000061987.V286636.R01.S.doc 31/05/06 31/05/06 31/05/06 5. OP29 06/04/06 South Wold Nursing Home Version 5.1 Page 21 they must take appropriate action to safeguard residents. 6. OP29 19, Schedule 2 The registered person must ensure that all information required under Schedule 2 is available in individual staff files at all times. This requirement has been carried forward from 07/12/05. All care staff must receive formal, documented supervision at least six times per year. This requirement has been carried forward from 08/12/04. 30/04/06 7. OP36 18(1)(2) 31/05/06 8. OP38 23 9. OP38 23 10. OP38 37 The registered person must 30/04/06 review and amend the fire risk assessment in accordance with advice obtained from the local fire authority. This requirement has been carried forward from 07/12/05. The registered person must liaise 30/04/06 with the local fire authority regarding the key operated front door. The registered person must 30/04/06 inform the Commission of any event in the care home, which adversely affects the well being, or safety of any resident. This requirement has been carried forward 07/12/06. 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 Good Practice Recommendations DS0000061987.V286636.R01.S.doc Version 5.1 Page 22 South Wold Nursing Home 1. Standard OP2 It is recommended that the home provides individual terms and conditions, a copy of which should be kept on file. It is recommended that the home provide written confirmation prior to admission to say that they can meet the service users’ needs. It is recommended that the home demonstrate the content of care plan reviews, and records where changes have been made to the plan. It is recommended that the home provide an alternate privacy lock requested by one resident for their bedroom. It is recommended that the home record end of life arrangements, after consultation with the service user and/or their representatives. It is recommended that the home have a clear policy and risk assessment regarding people receiving day care in the home. It is recommended that the home record when voting opportunities are offered and whether they are taken up or declined. It is recommended that the home’s policy for vulnerable adults clearly identified that no investigation is made prior to social services involvement. It is recommended that written records be kept for when a staff member buys items for residents. It is recommended that the home samples hot water temperatures within resident’s rooms on a regular basis, and that they record hot water temperatures in bathrooms. 2. OP3 3. OP7 3. 4. OP10 OP11 5. OP13 6. 7. 8. 9. OP14 OP18 OP34 OP38 South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI South Wold Nursing Home DS0000061987.V286636.R01.S.doc Version 5.1 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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