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Inspection on 07/06/07 for Southbank Nursing Home

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

This inspection was carried out on 7th June 2007.

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

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

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. One relative said, "the staff were very helpful in showing me round all areas of the home and they also provided me with a comprehensive booklet to take home." The people living at the home feel that the staff will generally listen to them if they have any worries and that the manager will make attempts to sort these out. One person living at the home said, "The staff are lovely and kind and all my needs are met here." 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 in relation to the administrations and recording of medication were satisfactory at the time of this visit.

What has improved since the last inspection?

Since the last inspection, changes have been made to update the information provided to people looking for a care home. A new pre-admission form has been created, however these must be fully completed. The registered nurses and the care staff have received training in person centred care planning and some improvements were seen in the recording of the risk assessments and care plans. The matters raised from the last fire safety officer`s inspection had been addressed to ensure the people are living in a safe environment. Some improvements were seen in the care plans showing the recreational needs of the people living at the home and one of the people accommodated said, "They do their best to keep me interested in things going on. I am quite happy with what is offered here". Improvements have been made to a number of bedrooms in the home where redecoration has occurred and new light fittings have been put in, this is helping to make the environment more pleasant for the people living in the home. The manager had commenced some training and a system for carrying out the formal supervision for some staff. This programme needs to continue to make sure the staff are appropriately supported. Since the last inspection the manager had reviewed the staffing levels and had increased the amount of supervision of care staff by the Registered nurses and increased the attention to detail of the care provided. This is soon to be backed up by plans to change the policy for the monitoring, supervision and recording of care delivered. All staff had received training in the Protection of Vulnerable Adults and had made improvements to the recording of any accidents/incidents.

What the care home could do better:

Some shortfalls in the recording of pre-admission information in the care plans may put people at risk of not having their needs fully met. The information gathered at the admission assessment phase should be used to ensure the people`s health, personal and social care needs are fully met. Shortfalls in the length of time taken to act on information and treatment from other professionals may lead to the health care needs of people not being met in full.There is a need to ensure that once staff have undergone specific training they must be monitored to ensure they put into practice what they have learnt, particularly in relation to moving and handling and adult protection. Staff must complete the food and positional change charts for people they are caring for to show that people`s needs have been met. The registered person for the home has failed to inform the CSCI of all significant events that have occurred at the home since the last inspection. If the full refurbishment programme goes ahead this would greatly improve the environment for the people living at the home.

CARE HOMES FOR OLDER PEOPLE Southbank Nursing Home 1-2 Cavendish Road Bowdon Altrincham Cheshire WA14 2NJ Lead Inspector Elizabeth Holt Unannounced Inspection 7th June 2007 10:00 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 Southbank Nursing Home DS0000006722.V337789.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.V337789.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 Limited 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.V337789.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 16th November 2006 3. 4. 5. 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 consisted of 16 bedrooms, 7 of which are double. One is currently used as a single room. Passenger lifts were available in both buildings. The home is within easy reach of Altrincham town centre. The fees charged range from £477.60-£1,105 (Young physically disabled) with additional charges for hairdressing, personal toiletries, newspapers and magazines. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was unannounced and took place on Thursday 7th June 2007 from 11.00 until 16.45 hours. A further visit to continue the inspection process was made on Friday 8th June 2007 with a total of 10 hours spent at the home. During these site visits time was spent talking to some of the people who were living at the home, visitors/relatives, some of the staff, the manager about day-to-day life in the home and to establish what the home was like for people living there. A partial tour of the premises was undertaken and examination of documents and care files. Information was gathered as part of the inspection process, which included a Self Assessment Quality Assurance questionnaire. This was well completed by the registered manager. Five resident/relatives survey forms were completed and returned to the Commission. Since the last inspection the Commission has received no complaints/concerns. Two complaints had been made directly to the home, one in relation to personal care and the environment and the other regarding the management of a person living at the home. These were not upheld by the home; however there was evidence of communication to say the concerns had been addressed. What the service 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. One relative said, “the staff were very helpful in showing me round all areas of the home and they also provided me with a comprehensive booklet to take home.” The people living at the home feel that the staff will generally listen to them if they have any worries and that the manager will make attempts to sort these out. One person living at the home said, “The staff are lovely and kind and all my needs are met here.” 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 in relation to the administrations and recording of medication were satisfactory at the time of this visit. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Some shortfalls in the recording of pre-admission information in the care plans may put people at risk of not having their needs fully met. The information gathered at the admission assessment phase should be used to ensure the people’s health, personal and social care needs are fully met. Shortfalls in the length of time taken to act on information and treatment from other professionals may lead to the health care needs of people not being met in full. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 7 There is a need to ensure that once staff have undergone specific training they must be monitored to ensure they put into practice what they have learnt, particularly in relation to moving and handling and adult protection. Staff must complete the food and positional change charts for people they are caring for to show that people’s needs have been met. The registered person for the home has failed to inform the CSCI of all significant events that have occurred at the home since the last inspection. If the full refurbishment programme goes ahead this would greatly improve the environment for the people living at the home. 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.V337789.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.V337789.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): 1, 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 and their representatives admitted to the home can be confident they will have their needs properly assessed as part of the admissions procedure. EVIDENCE: Since the last inspection the manager had updated the Statement of Purpose to accurately show the changes in the senior management of the home. The manager had introduced a new form for the pre-admission assessments for people admitted to the home. Three pre admission assessments were looked at. 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. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 10 A senior staff member carried out the assessments. An adaptation student had carried out two of these and there was no countersignature from the registered nurse. This should be countersigned to ensure the person is moving into a home that can meet their needs fully. 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 any relevant professionals. One person’s relative wrote;”she was very frightened and apprehensive when she first arrived but soon settled in due to the wonderful care she received from each and every one of you”. One of the surveys recently filled in by a person’s daughter who now lives at the home said, “The staff were very helpful in showing me round all areas of the home and they also provided me with a comprehensive booklet to take home.” A person who was admitted to the home recently, said, “everyone is lovely. I have been really well cared for since I came in. I am really well looked after.” For people who were referred through Care Management arrangements the home had a copy of the Care Management assessment prior to admission. The home did not provide intermediate care. Southbank Nursing Home DS0000006722.V337789.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 adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in meeting in full the health care needs of some of the people living at the home may put people at risk. The systems and procedures for dealing with medication protected the people living at the home. EVIDENCE: A requirement made at the last inspection showed the need for care plans to contain sufficient and accurate information to provide staff of the actions to be taken to meet in full the residents’ health and welfare needs. Since the last inspection the manager has introduced a new system, person centred care planning. The system is not yet fully in practice, however the staff had been trained in the new care planning process and could discuss this new system with some confidence. One staff member said he found this a better way to record the necessary information and on the younger person’s unit they had started to transfer the information into a person centred careplanning format. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 12 During this visit serious concerns were identified in the care plans: a) A person living at the home had been seen by the Tissue Viability Nurse and a request for a change to the air mattress was made. However, there was a time delay for this change in mattress to be made, which could have led to deterioration in the well being of the person. b) A person living at the home had removed an indwelling catheter. Problems with accessing the new prescription for this individual led to a delay of seven days before a replacement was available. This delay potentially put a frail person at risk of deterioration in their health care needs being fully met. Although 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. For some people the position changes had not been recorded or the drinks given were not written on the charts. Staff must complete these or review the necessity to have them in place in line with the risk assessments. During the visit one person was noted to have acquired a sore heel. Once this was recognised appropriate treatment was carried out, however this could possibly have been prevented with more attention to appropriate pressure care management. Some improvements were seen in the care plans and risk assessments and the daily statements showed the nursing care that had been provided. There was an increase in the information recorded by the night staff and the care plans were generally reviewed and updated. There was some evidence to show the plan of care had been drawn up and reviewed with the involvement of the person living at the home and or their representative. 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 of the five people who responded to the service users survey said that the staff listened 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. Some times the information following these visits was not clearly recorded in the separate sheet provided and made up to date information difficult to find. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 13 Samples of medication administration records (MARS) were looked at and these were appropriately recorded with the use of codes as necessary if drugs were not administered. Southbank Nursing Home DS0000006722.V337789.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: The home has an open visiting policy and resident’s visitors and friends were present during the site visit. People living at the home said they were able to receive visitors during the day and visitors confirmed they were made to feel welcome. Following a recommendation made at the last inspection the staff have made attempts to look in more detail at the individual recreational needs of the people living at the home. Discussion with staff members and a review of the new person centred care plan will allow for a person’s social and recreational needs to be thought of more clearly. One person showed her excitement at the prospect of going on a short holiday accompanied by staff members and another person showed her artwork off that the staff had assisted and encouraged her with. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 15 The self-assessment survey showed that the manager had provided two larger tables in the lounge area for two people who wanted a larger space to put their belongings on and to make it their personal space. These two people have been pleased with this outcome. There was evidence of family involvement and encouragement of families to enjoy meals with their relative where possible. One person’s survey response said,” I have lunch with my Mum twice a week and I find them good.” A programme of activities was provided to show what is available in the home for the month ahead. This included visiting entertainers, bingo and in-house celebrations. There was very little seen during these two visits of activities provided and a discussion was held in relation to entertainment specific to old age and people with mental health needs. Staff spoken to did say it was frustrating at times as the people living in the home would not want to join in at times when they encouraged them to join in any activities. It is recommended staff receive training/input into what are appropriate activities for these people and how to engage them and provide these activities. Since the last inspection the manager had employed a person to some specific craft like activities with the people living at the home. Some of the people spoken to were aware of the summer show and had been involved in the preparations for this. Some people living at the home said they had a choice in where they spent the majority of their day and staff were willing to assist them back to their room if that was where they chose to spend their time. Different dining areas are available depending upon the part of the home the people are accommodated. The menus offered a variety of wholesome and nutritious meals. A discussion with the chef showed that he was aware of the dietary likes and dislikes of the people living at the home. One person eating in the dining room said, “ The food is lovely, the meat is very tender and I enjoy the meals provided.” Staff were seen to support people who required assistance with their meals in a discreet manner. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 16 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 had the systems and procedures in place that allowed people to express their complaints/concerns. People are likely to be protected from abuse as all staff had undertaken relevant training. EVIDENCE: The home had a complaints procedure and all five of people living at the home and /or their representatives who responded to the service user survey, said they knew how to make a complaint. Two complaints/concerns had been sent directly to the home. One in relation to personal care and the environment and the other regarding the management of a person living at the home. These were not upheld by the home, however there was evidence of communication to say the concerns were addressed. Following concerns raised in the past one person’s relative was having regular meetings with the manager to monitor the ongoing care of the person living at 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. Since the last inspection the manager had done some awareness training in adult protection. Staff spoken to were much more aware of the importance to record any bruising and to think about preventative measures. It was pleasing to see that following this Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 17 increased monitoring and awareness an extra bumper had been put in place for a person who received a bruise regularly in the same place following observation of their behaviour pattern. A policy was available on Whistle Blowing and staff said they felt safe to Whistle Blow if the need arose. A review of the training matrix showed all staff had received training in Adult Protection Awareness. 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. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 18 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: Since the last inspection improvements had been made in the lighting arrangements in the home for six bedrooms. Wallpaper was stripped off in places and there was written evidence of the priorities for redecoration. 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. Improvements had been made in the lighting arrangements in the home. 6 bedrooms had been improved. Following a brief tour of the premises it was noted that the radiator cover end had come off in one of bedrooms in Southbank. There was a hole in the bedroom wall where plaster had come Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 19 away and the headboard was not attached to the bed. The bedroom door to room 28 bedroom door sticking and would not close against its rebate. The small lift was noted to be unclean and required a thorough cleaning. Overall on the second day of the visit the home was cleaner and there was no unpleasant odour, which was noted on arrival on the first day of the visit. Four of the five people who completed the service user survey said the home was fresh and clean. One person wrote, “Very often the smell hits you when you enter the home. There would not appear to be any ventilation”. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. Arrangements for employing staff were robust, however shortfalls in the training of staff may lead to the needs of people living at the home not being met in full. EVIDENCE: At the time of this site visit the home provided care and accommodation for a total of forty three people. A discussion was held with the manager about the action that had been taken since the last requirement made about reviewing the staffing levels in the home. The manager said although they had not increased the staffing levels the Registered Nurses had done more supervision of care practice with the care workers and the staff had increased their levels of attention to basic care needs, for example, oral care and care of dentures and finger nails. From observations made there were some improvements in care practices. The home is staffed by a stable work force and they have a permanent night staff team. The turn over of staff has been minimal in the last twelve months. Two people who completed service user questionnaires stated that staff were always available when you need them and two people said staff were usually available. One person’s relative wrote, “very often there are no staff around Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 21 and it appears the home work with minimum staff.” During the visits to the home several people made positive comments about the staff, including “the staff are very kind and gentle”, “the staff are lovely and look after me well.” The manager has plans to introduce new charts to record the detail of the personal care carried out and for the staff to sign they have done this. New company policies are soon to be implemented regarding pressure care and care delivered to people accommodated at the home. These improvements would lead to accurate records being kept for the people who needed regular care and attention. Two staff members had completed the assessors training course in Moving and Handling. A discussion with one of these staff members highlighted she was due to attend for her refresher course. On the day of the visit observations of moving and handling were generally satisfactory, however the under arm draglift was used by two staff members to transfer a person from a chair to wheelchair. The communication with the person living in the home was not clear from the two staff carrying out the transfer. The staff did explain the person accommodated was a challenge to manage however this practice is not acceptable and the staff were going to re discuss the moving and handling risk assessment of this person with the nurse in charge. A discussion with the manager highlighted staff that have undertaken particular training courses must ensure they can share the knowledge and good practice gained to other staff at the home. Resident’s fingernails generally looked clean. The friends visiting one resident commented on how nicely polished her nails were, and she always used to look after them when she could herself. The home had a recruitment policy, however according to the quality assurance assessment completed by the manager this has not been reviewed since May 2004. It is recommended this is reviewed and updated to make sure it is in line with any new legislation. 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 required. Staff spoken to were enthusiastic about the courses and study days they had completed. Seven staff have achieved their NVQ level 2 qualifications out of the 18permanent or bank care staff employed at Southbank. The manager needs to encourage and support the staff to continue this training. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some shortfalls in the standards and practices in the home did not promote and safeguard the health, safety and welfare of the people living there. EVIDENCE: Although there are improvements in how the manager is dealing with her responsibilities, some observations made during these visits highlight some shortfalls in the management of the home. Although the manager has an open communication system there are some shortfalls in communication leading to the healthcare needs of the people living at the home not always being fully met. These shortfalls have the potential to lead to the health, safety and welfare needs of the people living in the home not being met in full. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 23 The manager discussed how she was developing the programme of staff supervision. Training had been carried out on what supervision was and the nurses had been asked to become supervisors. Care staff must receive formal supervision in line with the regulations. Staff at the home were recording accidents in an appropriate logbook. There was some evidence of these being reviewed by the manager, however it is of concern that in April 07 there were 21 records of entries for bruises, skin flaps and or redness. The monitoring chart showed a high number of falls for one person accommodated and a discussion highlighted the need to keep this in the persons care plan with the risk assessment. A number of falls and bruises were noted to be un witnessed. This could possible be due to lack of staffing or staff supervision. The manager must oversee that the care practices and the safety of the people in the home is promoted and protected. There is an internal quality assurance system in place to obtain the views of people living at the home, relatives and visiting professionals. Audits of medication care practices and finances were available including evidence of an action plan to review areas where shortfalls were identified. The manager and staff are holding regular meetings. Minutes are available of these. There was evidence of an increase in the manager’s confidence to share the homes achievements and plans for the future. Dawn was clearer about the residents needs and had become increasingly skilled at evidencing what she and the staff have achieved since the last inspection. 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 June 07 and showed a record of an out of hour’s fire drill. Gas safety and maintenance checks were available. The manager and senior staff of the home had failed to inform the Commission under regulation 37 of the Care Homes Regulations 2001 of some of the notifiable incidents that had taken place since the last inspection. This information should be provided without delay to the Commission. A policy and new procedure was in place for the management of people’s personal money. Computerised audited records were available to safeguard people’s money. Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 24 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 2 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 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 X 3 Southbank Nursing Home DS0000006722.V337789.R01.S.doc Version 5.2 Page 25 Yes 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. 1. Standard OP7 Regulation 12 Requirement 1.The residents care plans must contain sufficient and accurate information to show that proper provision is made to meet in full the residents’ health and welfare needs. This must include the assessed and changing needs of the people accommodated so the staff can act to meet those needs. (This remains outstanding from the 31/01/07). 2. OP8 15 Food and fluid records and 06/07/07 pressure relief charts must be clearly recorded to ensure people’s needs are met. In order that the identified 13/06/07 bedroom is safe and well maintained the following must be addressed: the radiator cover end must be replaced. Plaster must be replaced and the headboard attached to the bed. The small passenger lift used to 06/07/07 transport meals and residents must be thoroughly cleaned and maintained. DS0000006722.V337789.R01.S.doc Version 5.2 Page 26 Timescale for action 31/07/07 3. OP19 13(3) 4. OP26 23(d) Southbank Nursing Home 5. OP30 12 Staff in the home must be 31/07/07 appropriately monitored following training to make sure they meet in full the needs of the people accommodated. This results from an observation of poor moving and handling and in relation to the monitoring of falls and bruises. Staff working at the home must be appropriately supervised as part of the management process to ensure policies and procedures are put into practice. Notifications of death, illness or other events must be forwarded to the Commission to ensure the home is regulated for the protection of the people accommodated. 31/07/07 6. OP36 18 7. OP37 37 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations It is strongly recommended that assessments of people moving into the home are completed and fully assessed by people qualified to carry out this role. It is recommended that staff receive training specific to meeting the social needs of older people with a dementia type illness to assist in their communication and care of some of the people living at the home. It is strongly recommended the programme of redecoration /refurbishment continues to ensure the home is homely for the people living there. It is strongly recommended the odour reported is monitored and appropriately managed. 2. OP12 3. 4. OP19 OP26 Southbank Nursing Home DS0000006722.V337789.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.V337789.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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