Inspection on 08/04/08 for South Wold Nursing Home

This inspection was carried out on 8th April 2008.

CSCI found this care home to be providing an Adequate service.

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 03/04/07

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 Ken Hague Unannounced Inspection 8th April 2008 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.V361961.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.V361961.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 sov1971@aol.com shailenm7@aol.com Mr S Munnien Mrs Satiavanee Munnien Mr S Munnien Care Home 16 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) 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.V361961.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 April 2007 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. At the time of the inspection the home confirmed that the weekly fees ranged from £450 - £499 depending on the residents assessed needs. Additional charges are made for services such as chiropody, hairdressing and toiletries. Information about these costs as well as the day-to-day operation of the home, can be found in the home’s statement of purpose and service user guide. These documents are available in the reception area. An additional copy is kept in the home’s office. These documents are made available to all new potential residents. The care home does not offer a dedicated intermediate care service. South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection took place over 5 hours. The registered manager who is also the provider was given feedback at the end of the inspection. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them and the staff, and where more appropriate observation of interaction between staff and residents and related care practices. A sample of care records was inspected. Two members of staff were interviewed and the opinions of three residents were sought. An (AQAA) Annual quality assurance assessment was completed by the care home and sent to the Commission for Social Care Inspection prior to this report being completed. This is a self- assessment document completed by the providers of the care home. It sets out evidence from the provider to demonstrate that they are meeting the Care Home Regulations. It is normal procedure to obtain written feedback from residents prior to the site visit using a document called “have your say”. This was not possible on this occasion due to time constraints. However residents and relatives were spoken to during the site visit. Their opinions are reflected within the inspection report. What the service does well: There is a comfortable and homely atmosphere, in which residents are supported to maintain their privacy, dignity and independence. Residents said that they like living in the home, and that staff look after them very well. They have good access to local health services, and can see their GP’s or District Nurses at care home. The registered manager makes sure that there are enough staff on duty to be able to meet resident’s needs. South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. South Wold Nursing Home DS0000061987.V361961.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.V361961.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): Standards 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is enough information and support to help prospective residents make an informed choice of where to live. There are assessment processes in place, which ensure that individual needs can be met within the home. EVIDENCE: There is an up to date statement of purpose and service user guide in place, and both documents are available to residents. There are copies available for new residents and people considering a placement at the home The registered manager said that he make sure copies of both documents are given to new residents at the time of their assessments. The registered manager stated that he sees all new residents to make an assessment of their needs. Three residents files were looked at and each contained an assessment of needs, which include personal hygiene, advocacy, risk taking, social activity, religious and cultural needs and mental health needs. South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 9 A resident said that the manager had visited to discuss their individual needs before they were admitted to the home. Staff were helpful they said on the day they moved into the home. Signatures on the assessment documents indicate the involvement of the resident in the process. The home does not provide an intermediate care service. South Wold Nursing Home DS0000061987.V361961.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): Standards 7,8,9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual needs are reflected in clear, comprehensive and up to date care plans; and the privacy and dignity of residents is maintained. EVIDENCE: Care plans are in place and cross-reference with assessed needs. They set out the care required for needs such as mobility, relationships and personal hygiene. Records show that the plans are reviewed 2 monthly. Residents said that staff talk to them regularly about their care plans and they sign them. Care plans do refer to maintaining privacy and dignity for the residents. Residents said they have keys to their rooms for privacy, and staff talk to them with respect. Staff on duty were observed, for example, talking to residents in private about their needs, making sure they knocked on residents doors before entering, and using the resident’s preferred form of address. Risk assessments are in place for things such as the use of bed rails, selfmedication and trips and falls. When a risk is identified risk management South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 11 strategies are put in place and were found to be recorded on individual care plans. Residents said that staff know how to help them and will remind them when it is time for appointments such as chiropody, dentist or opticians. Staff help them to see their doctors, and the District Nurses visit them when they’re needed. Equipment is made available where required, such as specialist mattresses. The medication records for four residents were looked at and all were completed in full. Administration procedures were carried out satisfactorily. Records show that staff, who administer medication have undertaken training in relation the administration and storage of medication. All of the medication records, and care plans for the residents case tracked contained a photograph of the resident. A sample inspection was made of the controlled drugs register. Drugs were found to be stored correctly and records were accurate. South Wold Nursing Home DS0000061987.V361961.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): Standards 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. There are not enough suitable activities provided for residents that are in accordance with their needs and wishes. A healthy and balanced diet is provided that is based on resident’s likes and dislikes. Residents are enabled by staff to retain control over their lives. EVIDENCE: An events file is kept at the home, which shows that activities are provided for residents. However there is no activity organizer in post and activities are not provided on a daily basis in a planned manner. The registered manager stated that a new co-ordinater is to start employment in May 2008. Not all residents were happy with the activities offered at the time of the site visit. Relatives were however happy with activities provided. Menus are available which offer choice and meet the needs of the individual residents. However the dinning room is not large enough to allow all residents to eat together. Staff stated many residents chose to eat in their own room. Residents said that the food is very good and they get lots of choice. South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 13 Residents said that they are able to make their own minds up about everything they do, and they are able to have their own furniture brought in to the home. South Wold Nursing Home DS0000061987.V361961.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from comprehensive complaints and adult protection procedures. Trained care staff ensure residents are protected from any possible abuse. EVIDENCE: The care home has a detailed, complaints procedure given to all residents, which is also displayed, in the care home reception area. Residents said that they do know how to make a complaint. One resident stated “we can approached the manager or any member of staff at any time if we are unhappy”. A second resident said “I can talk to any member of staff if I have any problems”. Staff confirmed that they were aware of the home’s whistle blowing policy, have had training and they would use it if they have any concerns about care practice. The registered manager stated that all staff had been trained in the prevention and recognition of abuse. South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean well maintained care home, which provides them with safe comfortable accommodation. The infection control policy is followed and a safe environment is maintained. EVIDENCE: The home is well maintained, and clean throughout. The registered manager stated in the AQAA that improvements have been made to the general appearance of the home. New furniture has been placed in social areas. Carpets have been replaced in all rooms. Repairs have been carried out to outside paved areas. Residents stated the home is very comfortable to live in. A resident said “my room is comfortable warm and clean. I am very happy with it”. A second resident said “I like the new furniture which has been bought for the home”. South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 16 The area outside the home is well maintained and safe. Residents are encouraged to bring possessions into their rooms and to make them homely. Each room is individually furnished, and residents stated that they were fully supported to use their rooms safely and in the way they wished. There are enough bathrooms and toilets to meet the needs of the residents and appropriately serviced equipment is in place to support resident’s physical needs as appropriate. South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 17 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): Standards 27.28.29 730 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by appropriately trained staff. The recruitment procedure of the home is not being followed which places residents at risk EVIDENCE: During the site visit a relaxed atmosphere was evident, call bells were answered promptly, and staff demonstrated efficient management of residents needs Staff said that there are enough people on duty to meet needs. They were working very hard for all of the time the Inspector was in the home. The manager and residents confirmed that they were happy with present staffing levels. Records show that staff have received training in areas such as moving and handling, fire safety, health and safety. There is also evidence that induction training is provided and training for a nationally recognised qualification is available. Staff confirmed this and said that access to training is very good and they received a good induction process. Residents they that they felt safe living in the care home and they felt there was always staff around to help them. A relative interviewed as part of the site South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 18 visit stated their satisfaction with the services provided by the home and the quality of care provided by staff. The manager could produce a training plan and the AQAA gives no details of NVQ training. The care home does not have a paid cleaner this means care staff are using care hours for cleaning despite the fact they are very busy providing everyday care for residents. The registered manager stated a cleaner had been recruited and is awaiting their CRB check, before commencing employment. The inspector did a spot check of the recruitment records for two new members of staff recruited since the last key inspection. Both members of staff had only one written reference on their file. South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 19 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): 31,33,34,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interests of the residents, and there are quality assurance systems enabling residents to contribute to the development of the service. Out of date policies put staff and residents at risk. EVIDENCE: The care home has an experienced registered manager. A resident stated “we have a good manager here, staff do their job well. The home is well run’. Staff said that the registered manager, is very supportive and will listen to what they have to say. Staff confirmed that they had received supervision regularly and that they find it useful in terms of communication, and discussing training needs. Records provided additional evidence that supervision does takes place and that there are regular staff meetings. There are financial South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 20 procedures in place to ensure that resident’s financial interests are safeguarded and protected. The AQAA document states that a number of important procedures and policies have not been reviewed since 2004. Residents and relatives have happy with the care being provided by the care home. South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x 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 X X X x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 3 3 3 2 2 South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 22 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 2 Standard OP12 OP29 Regulation 16 19-1 Requirement Daily activities must be provided to ensure that residents heeds are met. New staff must provide two satisfactory written references before commencing employment, to ensure staff are appropriate to work with vulnerable people. All policies and procedures must be reviewed yearly. This is to ensure they continue to meet National Standards. Timescale for action 30/05/08 14/05/08 3 OP36 24 30/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 23 South Wold Nursing Home DS0000061987.V361961.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V361961.R01.S.doc Version 5.2 Page 25 - 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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