Inspection on 07/12/05 for South Wold Nursing Home

This inspection was carried out on 7th December 2005.

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 05/04/06

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 Unannounced Inspection 7th December 2005 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.V268551.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 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) 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.V268551.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of Service Users in the home with Nursing needs must not exceed 13. 23rd May 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. South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in December 2005, with two inspectors. A tour of the building took place and records relating to the running of the home were looked at. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 6 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.V268551.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 The home conducts a pre-admission assessment, which identifies need, however they need to assure prospective residents that they can meet those needs. EVIDENCE: Pre-admission assessments were available on individual files. The assessments include areas of need such as the reason for admission, communication, personal hygiene, behaviour and voting arrangements. Not all sections of the assessment are fully completed. There is also an additional information format that is signed and completed by the service user or their representative, which details personal history, leisure preferences and general likes and dislikes. There is no evidence of formal confirmation to service users to say that the home can meet their needs. Staff could not clearly identify which residents were admitted for nursing or personal care needs only. A recommendation made at the last inspection regarding terms and conditions, which remains at this inspection. South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 8 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 Most residents benefit from having a care plan, however some may be placed at risk due to shortfalls in the care planning and risk assessment processes. Some residents may also be placed at risk due to shortfalls in the arrangements for storage and administration of medications. EVIDENCE: Four residents files were looked at on the day of the inspection. All but one file contained a care plan. Those care plans that were seen related to needs such as falls/mobility, personal care and asthma. There is a wound management formulary in place and clear instructions on how to meet tissue viability needs. Care plans do not demonstrate that end of life arrangements have been made or agreed with the resident and/or their representatives. May of the files did not contain a photograph of the person. There are dates for monthly reviews recorded on each care plan but there are no details as to whether the plan remains the same or alterations have been required. General risk assessments are available in each file but there were none for specific issues such as smoking. One resident was having a cigarette in the lounge with the patio doors open, which had impact on the other residents in South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 9 regard to the room temperature. There were also no risk assessments for the use of bed rails, nor was there evidence of consent to use bedrails. Storage of medication was generally satisfactory however one resident has control of inhalers but has no lockable storage in his room. There was also no protocol for the ‘where necessary’ (prn) use of medication, and the administration records were not clear as to the doses given. South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 10 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 Resident’s social and leisure needs and preferences are not adequately being met, and there is little demonstration of choice, but residents were happy with the diet offered. EVIDENCE: There was no record of social activities provided by the home. Staff were not able to describe how residents with dementia were socially stimulated. One resident said ‘there are no activities provided, not that I am aware of anyway’ and another said that ‘it would be nice for some organised activities to be sorted out’. Once a month a vicar visits to give communion but individual religious needs are not recorded. One resident felt that he would like some measure of independence within his local community. This was discussed with the deputy manager in regard to risk assessing the situation. There was some uncertainty from staff as to the purpose of a regular visitor to the home who does not have a relative at the home anymore. The issue of having a clear policy regarding visitors was discussed with the deputy manager. Likes and dislikes for food and drink were recorded in individual files, and nutritional assessments were available. There is a set menu but when asked, residents did not know what was for lunch. There is also no evidence of choices offered. One resident said that ‘meals are quite good’, another said that ‘I South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 11 enjoy meals, the meat is tough sometimes’. The cook is currently off sick and a member of staff with basic food hygiene training is currently filling this role. South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 12 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 at risk due to shortfalls in staff training and knowledge. Having guidance that is out of date may also increase risks. EVIDENCE: There have been no complaints since the last inspection. The homes’ policy on safeguarding adults does not link with or reflect the current local authority guidance. The home has a version of the local authority guidance however this is not an up to date version. Some staff were able to say what they would do in a situation relating to the protection of vulnerable adults but some were not. To date there was no evidence that staff have received training in safeguarding adults however, there was evidence that training has been booked for January 2006. South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 13 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): 19,22,23,24,25,26 Resident’s benefit from a good standard of hygiene. The home does not fully meet resident’s safety needs in regard to unguarded radiators and access to call bells. EVIDENCE: The general environment was clean and tidy and a cleaner was present in the home on the day of the inspection (see Standard 38). The Environmental Health Officer had visited the week prior to this inspection and had made recommendations regarding the hygiene in the kitchen area and will be visiting again in one month’s time to check on improvements made. Radiators in hallways were protected by radiator covers, but other unprotected radiators were too hot to place a hand on. There is an outstanding requirement in regard to risk assessing radiators. The majority of call bells in residents’ bedrooms were not accessible as the beds were placed at the other end of the rooms. Wheelchairs were stored in the smaller lounge, which limited space and the ambience of the room. South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 14 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 Residents benefit from good relationships with the staff, but their safety is compromised by shortfalls in the home’s recruitment procedures. EVIDENCE: Four staff files were looked at during the visit. Files did not contain references, proof of identity, photographs or application forms. One file did not contain a Criminal Records Bureau (CRB) check and two files contained CRB’s that had been completed by previous employers. There was no evidence of Protection Of Vulnerable Adults checks or applications for new CRB checks by the home. There was evidence that two staff have undertaken NVQ Level 2 and one staff has commenced NVQ Level 3. There is also evidence of staff receiving training in fire safety, first aid, moving and handling, basic food hygiene and dementia awareness (see Standard 18 re: safeguarding adults training). South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 15 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): 32,34,35,36,37,38 The home is not fully meeting the resident’s health, safety and welfare needs with specific regard to fire safety and resident’s financial arrangements, and there is a continuing shortfall in staff supervision arrangements. EVIDENCE: One resident said ‘this is a grand place, the staff are good company and are cheerful and chatty’. Another resident said that ‘staff are pleasant’. Staff were seen to conduct themselves in a respectful and pleasant manner during the inspection. Policies and procedures including health and safety, dementia care, accidents/incidents, complaints, COSHH, medication, whistle blowing and confidentiality were available. There was no policy available for managing resident’s finances and a member of staff was not fully aware of the risks involved with shopping on behalf of residents. South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 16 There was no evidence of regular supervision sessions for staff, and they said that they had not received any since the last inspection. The home still continues to practice the wedging open of most doors throughout the home. There was no evidence of advice given by the local fire officer following a requirement at the last inspection. There were 2 unsecured oxygen cylinders stored in an unlocked cupboard with no signage to indicate their presence. Other health and safety issues were identified such as no evidence of hot water temperature testing, no evidence of training for staff in health and safety issues, limited COSHH data sheets and no reporting of an incident to CSCI relating to a resident wandering off from the home. South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 X 11 3 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 1 2 X X X X X 1 3 STAFFING Standard No Score 27 X 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 2 2 1 3 1 South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 15(1)(2) Requirement The registered person must prepare a written plan as to how individual needs are met, and make the plan available to the service user. The home must provide photographs of residents on their individual files. The registered person must ensure that risk assessments are in place for risks associated with smoking and the use of bed rails. The registered person shall make arrangements for the recording, handling, safekeeping and safe administration of medication within the home. The home must provide a programme of leisure and social activities based on the preferences of the residents The home’s vulnerable adult policy must link with and reflect current local authority and procedure. This requirement has been carried forward from 08.12.04 The responsible person must DS0000061987.V268551.R01.S.doc Timescale for action 08/12/05 2 3 OP7 OP8 17(1)(a), Schedule 3 13(4)(b) (c) 13(2) 31/01/06 31/01/06 4 OP9 31/01/06 5 OP12 16(m)(n) 31/01/06 6 OP18 12(1)(a) 31/01/06 7 OP25 23(2)(p) 31/01/06 Page 19 South Wold Nursing Home Version 5.0 8 OP29 19, Schedule 2 9 OP29 19, Schedule 2 18(1)(2) 10 OP36 11 OP38 23 12 OP38 13(4)(c) 13 14 OP38 OP38 23(2)(c) 13(4) 15 OP38 37 ensure that risk assessments are carried out for radiators. This requirement has been carried forward from 08.12.04 Evidence of POVA/CRB checks must be forwarded to CSCI within 72 hours along with evidence that the registered person has taken appropriate action to safeguard residents. The registered person must ensure that all information required under Schedule 2 is available in individual staff files at all times. All care staff must receive formal, documented supervision at least six times per year. This requirement has been carried forward from 08.12.04. The registered person must review and amend the fire risk assessment in accordance with advice obtained from the local fire authority. The registered person must ensure that signage is displayed on the door of a cupboard containing oxygen cylinders, and ensure that the door is kept locked. The vacuum cleaner must be repaired or replaced. The registered person must ensure that all risks to the health, welfare and safety of residents are identified and so far as possible eliminated. The registered person must inform the Commission of any event in the care home, which adversely affects the well-being, or safety of any resident. 12/12/05 31/01/06 31/01/06 16/12/05 08/12/05 08/12/05 31/01/06 31/01/06 South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 20 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 6 7 Refer to Standard OP2 OP3 OP7 OP11 OP13 OP14 OP24 Good Practice Recommendations 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 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 regarding visitors to the home, who have no connection to current residents. It is recommended that the home keep a record of the choices of food offered to residents. It is recommended that the home review the placement of call bells in resident’s bedrooms to ensure there is access to them. South Wold Nursing Home DS0000061987.V268551.R01.S.doc Version 5.0 Page 21 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. 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