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Inspection on 03/06/08 for Southbank Nursing Home

Also see our care home review for Southbank Nursing Home for more information

This inspection was carried out on 3rd June 2008.

CSCI found this care home to be providing an Good 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The manager and staff encourage prospective people to look around and ask questions to make sure they are making the right choice of care home before agreeing to secure a place at the home. People living at the home and their relatives knew how to make a complaint and who to speak to if they are not happy. The survey from people living at the home of relatives showed that generally the staff acted and listened to what they said. The procedures and management of medication were satisfactory at the time of this visit. There was some evidence to show the plans of care had been drawn up and reviewed with the involvement of the person living at the home and or their representative.

What has improved since the last inspection?

The person centred care plans were now in place for all people living at Southbank and these were detailed to give the staff the information to deliver care and monitor it effectively. Improvements had been made to the documentation in relation to wound care, food and fluid monitoring, daily pressure sore prevention and the management and recording of care delivered. Since the last inspection staff have undertaken training in a number of areas including infection control, fire safety, first aid, manual handling violence and aggression, dementia care and adult protection. There have been changes in the staff structure and unit managers have been appointed which staff were pleased with. Of seven requirements that were made at the last inspection, all these were met and improvements were seen.

CARE HOMES FOR OLDER PEOPLE Southbank Nursing Home 1-2 Cavendish Road Bowdon Altrincham Cheshire WA14 2NJ Lead Inspector Elizabeth Holt Unannounced Inspection 3rd and 4th June 2008 09:30 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 Southbank Nursing Home DS0000006722.V365256.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. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southbank Nursing Home Address 1-2 Cavendish Road Bowdon Altrincham Cheshire WA14 2NJ 0161 927 7200 0161 929 0042 Southbank@craegmoor.co.uk www.craegmoor. Co.uk Parkcare Homes Ltd 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) Ms Dawn Adey Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (48), Physical disability (10) of places Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. All service users require general nursing care. The overall number of service users for whom accommodation is provided at any one time shall not exceed 58 (a maximum of 48 older people and 10 younger adults with a physical disability). Service users requiring care by reason of old age shall be aged over 60 years. Service users requiring care by reason of physical disability shall be aged over 18 years and shall be accommodated on the first floor of the building Minimum staffing levels as specified in the Notice issued under Section 25(3) of the Registered Homes Act and dated 12 July 2000 shall be maintained. 7th June 2007 Date of last inspection Brief Description of the Service: Southbank Nursing Home provides 24 hour nursing care and accommodation for 48 older people and 10 young adults with a physical disability. The home consists of two large detached Victorian buildings where an indoor link corridor connects them. Southbank is the first building, which contains the Young Disabled Unit, and Delamere is the name of the second building. In the Southbank building there are 19 bedrooms (4 were not occupied due to difficult access). Five of these bedrooms were double rooms. Bedroom accommodation in Delamere consists of 16 bedrooms, 8 of which are double rooms and 8 single rooms over 3 floors. Passenger lifts were available in both buildings. The home is within easy reach of Altrincham town centre. The fees charged range from £498-£1,169 54 (Young physically disabled) with additional charges for hairdressing, personal toiletries, newspapers and magazines. Southbank Nursing Home DS0000006722.V365256.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 2 star. This means the people who use this service experience good quality outcomes. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social care Inspection in relation to this home prior to the site visit. Prior to the inspection the provider completed an Annual Quality Assurance Assessment (AQAA). This self-assessment and a dataset that is filled in once a year is one of the main ways that the CSCI obtains information from providers about how they are meeting outcomes for people using their service. The AQAA also provides the CSCI with statistical information about the individual service and trends and patterns in social care. Service user, staff and relatives surveys were provided for distribution before the inspection and 12 were returned from service users/relatives and 4 from members of the staff team. Comments from these surveys have been included in this report where possible. The visits were unannounced and took place over the course of 9.5 hours on Tuesday 3rd June and Wednesday 4th June 2008. During the course of the visit time was spent sitting and chatting with people who use the service, some of the staff including the registered manager and visitors to the home. Records were looked at in relation to the running of the home and health and safety and a partial tour of the premises was made. Since the last inspection there has currently one safeguarding allegation, which was investigated under Trafford Council’s adult safeguarding procedures. The outcome of this investigation was for the home to follow their internal disciplinary procedures, which they have told the Commission they have followed. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Pre admission assessments are completed before prospective people move into the home, however the information was not always detailed and used to develop the care plans. New pre-admission forms are to be introduced according to the manager. As noted at the last inspection if the full refurbishment programme goes ahead this would greatly improve the environment for the people living at the home. The manager stated that plans are being made for this work to start shortly. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 7 The manager should monitor the staffing levels and the deployment of staff in order to make sure that the people are supported appropriately at meal times and to make sure there is sufficient staff to spend time with people who spend the day in their bedrooms. 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. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people admitted to the home and their representatives can be confident they will have their needs assessed as part of the admissions procedure. EVIDENCE: Pre admission assessments were looked at for three residents who had recently been admitted to the home. Two of these contained a personal assessment checklist and were reasonably well detailed, however the forms were not particularly “user friendly” and one was not fully completed for a person recently admitted. Staff spoken to said they felt the forms did not give them much chance to write any detail and the manager confirmed that new pre admission assessment forms were to be introduced. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 10 Following a recommendation made at the last inspection that assessments of prospective people moving into the home are completed by people qualified to carry out this role. The sample looked at showed a senior staff member carried out these assessments and the manager said she oversaw these. Staff members spoken to could describe the admission process and talked of how they had recently assisted a person to settle into life at Southbank. The pre admission process involved the prospective person visiting the home and his/her representative and staying for a meal if they chose to. All twelvesurvey responses showed residents and or their representatives received enough information about the home before they moved in so they could decide if it was the right place for them or their relative. One of the surveys recently filled in by a person’s relative who has recently moved into Southbank said, “The home itself was warm and inviting and the staff so courteous and kind.” Copies of care management assessments carried out by a referring agency were available and this information was used to start the care planning process. Southbank does not offer an intermediate care service. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments in place are detailed to provide staff with the information they need to meet the health, personal and social care needs of the people living at the home. The procedures for dealing with medication protected the people living at the home. EVIDENCE: Since the last inspection the person centred care planning system was now in use across the home and staff spoken to were confident in using this. A sample of care plans were looked at as part of this inspection which showed that the information gathered at the assessment stage was used to identify the individual needs of the people living at Southbank. Improvements were seen in the system in place for the recording of pressure relief charts and fluid charts and staff were aware of the importance of keeping accurate records. Care plans were regularly reviewed and updated so that the Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 12 staff involved in providing support was aware of each person’s current needs and how they should be met. For one person there was the potential for their needs to not be met in full. A care plan was in place to show the person had a problem in relation to pain but a discussion with the nurse in charge highlighted the need to use a recognised tool and record the outcomes in order to monitor the individual’s pain level. The information was confusing as the person had an appointment with a pain specialist but was not in pain any more according to the nurse in charge and the medication administration record showed that the strong medication was regularly being written as “not needed.” There was some evidence to show the plans of care had been drawn up and reviewed with the involvement of the person living at the home and or their representative. For a person who had recently moved into Southbank, the person centred care plan included examples of things that are important to the person in their daily life. Following some concerns raised by the Tissue Viability Nurse since the last inspection there were improvements seen to the monitoring and recording of wound care and the monitoring of the pressure relieving mattress systems in place. From observations made during the visits and from discussions with people living at the home, visitors and staff it was evident that the nurses, care and support staff treated the people with respect and dignity. Four residents/relatives replies to the surveys stated that their relative “Always” received the care and support needed. Five residents/relatives responses to the surveys stated that they “usually” received the care and support they needed and a further respondent added, “At times there are problems with the stand up hoist, it sometimes takes a long time before it is located and brought to the toilet. If a patient is having a shower it can be quite a wait”. A relative wrote in the survey, “The care home always rings if my father is not well or if he has seen the optician or dentist. But I am not sure they have told home they would help him to make a phone call or send a letter and he is too proud to ask for help”. Eight people who responded felt they were kept up to date with important issues affecting their friend/relative whilst another relative felt communication with the family was not always good and the staff were not always accessible to discuss any issues. All respondents felt the staff did listen and acted on what they said. People living at the home were registered with local General Practitioners and there were recordings in the care plans of visiting healthcare professionals to the home. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 13 The systems in place for the recording, administration and recording of medication were satisfactory. A sample of medication administration records (MARS) was looked at and these were appropriately recorded with the use of codes as necessary if drugs were not administered. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social, cultural religious and recreational activities generally meet the expectations of people living at the home. EVIDENCE: At the time of the visit the home did not employ an activities organiser but we were told this position was being advertised for. A range of activities were provided which included singing, listening to music, bingo, birthday parties and arts and crafts. A hairdresser visited the home on a regular basis and one of the people living at Southbank said, “I always feel better when my hair is nice”. The home has an open visiting policy and resident’s visitors and friends were present during the site visit and they said they were made to feel welcome. A discussion was held with the manager in relation to communication following the concerns raised by one of the people living there. A person who had recently moved into the home said, “I don’t think that the staff understand old people sometimes, well some of them. Generally they are very kind and nice but sometimes they carry out a task and do not speak to me.” The manager Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 15 has responded since the visit saying that they will continue to improve on communication and are providing English lessons for any overseas staff that require this. There was evidence of family involvement and encouragement of families to enjoy meals with their relative where possible. One person was having lunch with her mother during the visit and said she enjoyed this time they spent together. Another person sat with her father who was bright in mood and said he was happy at the home. During the visit some music was playing, and some people spoken to said they enjoyed this whilst staff encouraged some of the people to join in. People living at the home were seen having their nails cleaned and trimmed by the staff during the course of the visit. A number of people living at the home stayed in bed for the day due to their dependency needs and other people spent the day in their bedroom, these people did not appear to receive much mental stimulation. One of the people said, “it was so nice to have a chat with you, I do get lonely some of the time.” There was no chair at the side of this person’s bed to show that the staff may sit with them for any period of time. One relative was distressed that her relatives bedroom door was closed, “all she can see is the door why is this?” A discussion with the manager highlighted that due to the lift being repaired at the time of this visit more people than usual were not able to leave their bedrooms. The care plans did not show clearly how these people spent their day and how their social care needs were met. One of the people who had not been living at the home very long said, “They are marvellous people here, I have a nice view from my window and I am happy here. The food is good, if you turn your nose up at it you are given something else”. There was some evidence of the religious and cultural needs of the people living at the home being met. Some of the people living at the home said they received communion as they wished and visits were made from the local priest and vicar. The mealtime observed showed that people living at the home are generally given the support they need and are encouraged to eat a well balanced diet. One observation made was that whilst sitting with one of the people who needed support, the care worker got up to cut up another person’s meal and also left the room for a number of minutes whilst this person still needed support. In order to make sure that the people are supported appropriately and in a dignified manner, there is a need to make sure there is sufficient staff at mealtimes to make sure this is a pleasant occasion. An observation made during the visit was that all the people were seated at small individual tables for their breakfast in the large lounge. Two people said they thought they Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 16 would like the chance to sit with other people and a discussion with the manager highlighted that some people may like the chance to have their meal at a dining table to make it a more sociable and enjoyable occasion. The menus showed a range of meals and a discussion with the chef highlighted these were under review. He said that he is flexible in changing the menu to meet the needs of individual residents if they do not want what is on the menu and it was clear he knew the likes and dislikes of the people living at the home. One person commented that the lunch was “very nice, it is chicken and it is very tasty”. The menu was on display on the Young Physically Disabled Unit however this is placed near the notice board. Consideration should be given to this being available in alternative formats, i.e. use of photographs to enable the people to be able to choose their choice of food. One person commented that the lunch was “very nice, it is chicken and it is very tasty”. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has systems and procedures in place that protect people from abuse and allow people to express their complaints and concerns, knowing that they will be listened to. EVIDENCE: The home had a complaints procedure and all twelve people living at the home and /or their representatives who responded to the service user survey, said they knew how to make a complaint. The atmosphere in the home was friendly on the days of the visits. Since the last inspection one complaint/concern had been sent directly to the home and a copy forwarded to the CSCI. This was in relation to poor personal care practices of a person living at the home and poor communication with some staff members. There was evidence of communication to say the concerns were addressed by the home. The home had policies and procedures in place to inform the staff about the Protection of Vulnerable Adults. Staff spoken to were aware of the steps to take in the event of an allegation of abuse and the staff confirmed they had been trained in the protection of vulnerable adults. A policy was available on Whistle Blowing and staff said they felt safe to Whistle Blow if the need arose. Since the last inspection one serious Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 18 concern/allegation was looked at under Trafford Council’s Adult Safeguarding procedure. The home followed their own policies and procedures as requested and action was taken by the home. A number of cards and letters were seen from relatives and family members thanking the staff for the kindness, support and care they had provided. People living at the home and some survey responses were positive about the kind and caring staff members in the home. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises were generally were clean and comfortable for the people living at the home. EVIDENCE: The company has made a proposal for refurbishment of the home both internally and externally which would be fully supported to modernise and upgrade the facilities available. Since the last inspection these proposals have been accepted and plans are now being made for the work to commence. During the visit there was some odour noted in the corridor between the reception area and the lounge, since the inspection the manager has introduced new cleaning materials and is monitoring this as a measure before the refurbishment. People who live at Southbank have bedrooms that are clean and tidy and have Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 20 been personalised with their own belongings. There was no evidence that orientation aids were in use throughout the home even though there are a number of people with a dementia type illness. Procedures are in place for infection control practices and staff were aware of good hand washing practice. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 21 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for employing and training staff were sufficient to ensure that the needs of the people living at the home are met. EVIDENCE: At the time of this site visit the home provided care and accommodation for a total of forty people. The staffing levels appeared sufficient to meet the care needs of the people living at the home however from observations made during the visit there was little evidence of staff visiting people who were spending the whole day in their bedroom to have the time to sit and chat with them. A housekeeper and cleaning staff, administrators, a cook and laundress support the care team. One relative wrote in the survey that, “The home normally works with a minimum of staff and if any are off ill the others have to cover for them, which means that instead of getting a look in every two hours it becomes every three hours. We make up for the staff shortage by visiting in the afternoon every day and split the time between two of us from 2pm until 6pm. This makes sure that at least during this time somebody is usually available.” As raised at previous inspections the numbers and deployment of staff require reviewing to ensure the staffing levels meet the needs of the people living there. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 22 A review of the duty rotas showed the staff team was stable and there was no use of agency staff. On the days of these visits observations of moving and handling were satisfactory. Staff said they had received updated training in moving and handling. The manager showed a commitment to the training and development needs of the staff in post and a system was in place for the manager to identify the training and development needs of the staff. All the staff had received the mandatory training, which included basic food hygiene, equal opportunities, fire safety, health and safety first aid and moving and handling. Staff spoken to were enthusiastic about the courses and study days they had completed. The training matrix showed that all staff had also received training in dementia care, violence and aggression and infection control. The manager reported that 5 staff had successfully completed National Vocational Qualification 2 and 3, and fourteen staff were currently working towards these qualifications. The staff files for three staff members were looked at and were all found to contain information in line with the Care Homes Regulations 2001. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 23 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards and practices in the home promote and safeguard the health, safety and welfare of the people living there. EVIDENCE: Since the last inspection a new manager has been appointed, who has a number of years experience in nursing and care home management. The manager has begun the process to register with the CSCI and has been in post since March 2008. Comments from the staff surveys showed that some of the staff were struggling with changes in management however comments made during the two visits were generally positive and staff felt the manager was supportive and that she spent time out and about in the home observing and monitoring the care practices. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 24 One person living at the home wrote in the survey that, “Judging by her first few days she has a good sense of humour and mixes and talks to the people in the lounge. She talked about changes at an introductory meeting.” A change to the staffing structure has been introduced with the appointment of unit managers for each unit within the home, staff spoken to were pleased with this increase in responsibilities. Staff were responsible for providing a daily nursing report to the manager to make sure she is aware of the health status of the people living at Southbank. There is an internal quality assurance system in place to obtain the views of people living at the home, relatives and visiting professionals. This survey has not been sent out in the last six months although the manager was keen this will be carried out within twelve months. Fire records were looked and were satisfactory. Advice from the last fire safety officer was acted upon. The most recent fire drill was carried out in January 08 and showed a record of an out of hour’s fire drill. Water safety and maintenance checks were available. Procedures for the management of people’s money were satisfactory. The Commission were notified under regulation 37 of the Care Homes Regulations 2001 of any notifiable incidents that had taken place since the last inspection. Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 25 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 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 3 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 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP27 Good Practice Recommendations It is recommended the numbers and deployment of staff require reviewing to ensure the staffing levels meet the needs of the people living there. It is strongly recommended the programme of redecoration /refurbishment continues to ensure the home is homely for the people living there. 2 OP19 Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Southbank Nursing Home DS0000006722.V365256.R01.S.doc Version 5.2 Page 28 - 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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