Inspection on 25/05/05 for Southborough Nursing Home

This inspection was carried out on 25th May 2005.

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.

Other inspections for this house

Southborough Nursing Home 27/09/06

Southborough Nursing Home 07/02/06

Southborough Nursing Home 22/11/04

Southborough Nursing Home 28/06/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Southborough Nursing Home 12-14 Langley Avenue Surbiton Surrey KT6 6QL Lead Inspector Diane Thackrah Unannounced 25th May 2005 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 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. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Southborough Nursing Home Address 12-14 Langley Avenue, Surbiton, Surrey, KT6 6QL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 390 3366 0208 390 9394 jag@lrh-homes.com London Residential Healthcare Limited Katherine Mary Lister Care Home 56 Category(ies) of Old Age, not falling within any other category registration, with number (56), Physical disability over 65 years of age of places (56) Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Southborough Nursing Home is a registered care home with nursing for up to fifty-six service users over the age of sixty-five who require general nursing care and who may have a physical disability. The home is situated in a residential area of Surbiton, close to public transport, local shopping and leisure facilities. The home is owned and managed by London Residential Healthcare Limited (LRH). Bedrooms are situated on the ground and first floors of the home. Passenger lifts provide access to the first floor of the home. The main communal areas of the home are situated in the ground floor and consist of two large lounges, one small sitting room, a dining room and a large conservatory. A small sitting room is available on the first floor. To the rear of the property there is a large garden. Ample parking is available to the front of the property. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place between 09.30 – 13.00. A partial tour of the premises took place and care records were examined. The Registered Manager, care and nursing staff and service users were available for discussion. All service users spoken with during the inspection expressed their satisfaction with the service. What the service does well: The home was able to demonstrate that the care needs of service users are appropriately assessed and met. Care plans set out well the individual needs of the service user and how staff members should meet these needs. Care plans are drawn up, and reviewed regularly with the full involvement of the service user, and their relatives were appropriate. Service users’ health needs are well monitored and addressed. The home liaises with a range of health care professionals in meeting service user’s health needs. Service users are provided with a varied range of social and recreational activities and are fully involved in selecting these activities. Family members are actively encouraged to maintain contact with service users. The home has an accessible complaints procedure and no complaints have been made recently. The home is safe and comfortable and all areas are clean, homely and well decorated and maintained. There are good systems in place for ensuring that the quality of the service is monitored and that service users are involved in this process. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: There was one item of medication that had been prescribed to a service user, but was not available. Also, one service user was using medication that was not labelled. There must be systems in place for ensuring that issues such as these do not occur as they place a potential risk to health and safety of service users. In general, hygiene standards in the home are good. However, some items of food were stored in unsealed packets, leaving food open to the risk of contamination. This is particularly an area of concern as this issue was identified at a previous inspection of the home. All staff members who work with food in the home must be made aware of the need to keep all food items covered. Some staff members who work in the home have not been checked on the Criminal Records Bureau and Protection of Vulnerable Adults lists. This practice leaves service users at risk. Some staff members have not received formal supervision on a regular basis. A system must be implemented were by all staff members receive regular Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 7 formal supervision to ensure that they receive the support and guidance necessary for doing their jobs. 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. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The arrangements for planning care are good, ensuring that the health, personal and social care needs of people living in the home are fully met. EVIDENCE: There is a thorough admissions process that ensures that the needs of each service user are fully assessed prior to them moving into the home. This process involves discussions with the service user and their relatives in the service users own home, or in a hospital setting. All elements of the service users’ needs are assessed and documented. Records examined detailed that a representative from the home had obtained information about service users needs from the Care Manager involved in the service user’s care prior to them moving into the home. Information about needs had also been obtained from health care professionals. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. In general, the home continues to provide care that ensures that the needs of service user are well meet. There are however, some shortfalls in the way that medication is handled which has the potential for placing some service users at risk. EVIDENCE: Each service user has a plan of care that is drawn up following the assessment. Care plans were examined for the three newest admissions. These set out in detail how staff should deliver care. There were records detailing that care plans are reviewed regularly and updated to reflect changing needs. Records also detailed that service users and their relatives had been given opportunities for being involved in planning for their care. It was evident, from discussion with staff that care is delivered in accordance with care plans. There was documentation detailing that staff members receive ongoing training in the use of care plans. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 11 Risk assessments were evidenced on files. These included areas of risk such as manual handling. There were records detailing that service users had access to health care professionals, including GP’s. Written records of nutritional screening for service users are maintained. These include nutritional assessments and plans and monthly weight charts. Opportunities for exercise are included in the home’s activities programme. There are policies and procedures in places for ensuring that medication is handled safely. There were records detailing the medication prescribed to service users on admission to the home. One senior nurse described good practice for ensuring that service users receive medication that is prescribed to them, however, medication prescribed to one service user was not available in the home. Another service user had been prescribed medication that had not been labelled. Medication Administration Records were found to be in good order and medication was stored securely. All those who administer medication have a registered nursing qualification, and have received training in the safe handling of medication within the home. Staff training records examined detailed that staff members had received training in ‘dignity and respect’ as part of the induction training programme. Records also detailed that ongoing training occurs in respect of the needs of older people. Staff members were observed to engage in respectful relationships with service users and those spoken with indicated that they were aware of service user’s rights about being consulted about their opinions. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15. There are varied activities and wholesome and enjoyable meals provided. Service users are consulted about meals and activities and therefore differing expectations and lifestyles are well catered for. The failure to fully meet good hygiene standards has a potential risk to service users. EVIDENCE: An activities programme was available which detailed that a wide range of activities is available in the home. Activities include sing-alongs, quizzes, music, art and crafts and gentle exercise. A minibus is available each weekend for outings, with recent trips being made to local parks, pubs, shopping centres and a vineyard. There is a dedicated activities coordinator available who provides group work and one to one sessions. Some service users said that they enjoyed the activities provided. One service user said that visiting entertainers in the home were usually very good. The home has an open door policy. Service users are encouraged to have visitors and arrangements are made for those service users who wish to maintain links with local places of worship. There are a number of comfortable communal areas in the home were service users are able to socialize or choose to spent time away from were organised Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 13 activities are taking place. A number of service users were observed to spend time in their bedrooms listening to the radio or watching television. There is a hairdressing room in the home and a hairdresser visits weekly. There is a pleasant communal dining area, and meals can be taken in bedrooms if this is requested. Records indicate that service users are consulted about meals and that an alternatives meal is always available. The meal served on the day of this inspection was home cooked, appeared wholesome and appealing and was well presented. Service users spoken with said that meals served in the home were of good quality. Cultural and specialist diets can be catered for. In general the kitchen was noted to be clean and well organised. There were records detailing that hygiene standards are monitored. However, a number of dried food items were stored in a cupboard in unsealed containers. This practice does not ensure the health and safety of service users. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 There is a system in place for the effective handling of complaints and service user and their relatives are encouraged to raise any concerns they have. Service users therefore know that their concerns will be acted upon. EVIDENCE: There are policies and procedures in place for dealing with complaints. The system for dealing with complaints has been reviewed in line with a Requirement made at the last inspection of the home. Information is made available in the Service User Guide about how a compliant, concern or suggestion should be made, and how this will be handled. This information also includes details about how a complaint may be made to the Commission for Social Care Inspection. The Registered Manager said that service users and their relatives are encouraged to raise any concerns with staff member before they become problematic. No complaints have been made about the home since the last inspection. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 24 and 26. The home is decorated and furnished to a high standard and facilities are clean and safe. This ensures that service users live in a pleasant, homely and comfortable environment. EVIDENCE: The home is decorated and maintained to a high standard. Communal areas and bedrooms are homely and comfortable. There is a large well maintained garden to the rear of the building. This has been made accessible to wheelchair users. There is a routine renewal programme and a dedicated worker is employed to ensure that the home remains well maintained. There were records detailing that the home complies with the Requirements of the local fire service and environmental health department. Fire fighting equipment is available throughout the home. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 16 There are toilet and bathing facilities on each floor on the home. These were noted to be clean and accessible. Specialist baths are available. Bedrooms viewed were well decorated, safe and appeared comfortable. Service users spoken with said that they were happy with their bedrooms. Bedrooms contained all furniture and fittings in line with National Minimum Standards. Service users are able to bring items of their own furniture and other personal possessions in order to individualise their rooms. Keys are provided for bedrooms, as is a lockable storage space. The home was found to be clean and free from offensive odours. The laundry is sited well away from the kitchen. There is a contract for the collection of clinical waste and the washing machine has a sluice facility. Policies and procedures are in place to deal with the safe handling of clinical waste. Staff at the home receive in house infection control training. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30. The procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to people living in the home. Staff members are employed in sufficient numbers and there is a staff training and development programme that provides staff members with the skills necessary for meeting the needs of service users. EVIDENCE: Staffing levels, evidenced in staff rotas, and in numbers on shift at the time of this inspection were found to be appropriate and safe, in accordance with the care and social needs of the service users. There is a skills mix of staff including care and nursing staff, cleaners, a cook, administration workers, a activities coordinator and a maintenance worker. The home also employs up to six nurses from overseas on ‘supervised placements’ These workers carry out care tasks, whilst receiving supervision from the Matron to convert their overseas nursing qualification into one that is recognised in the UK. Staff recruitment files were examined for all nurses carrying out supervised placements. Each file contained identification documentation, an up to date photograph, two written references, visa information, a statement of terms and conditions and completed application form. Two files also contained police clearance documentation from the nurse’s country of origin. There was no documentation detailing that satisfactory Criminal Records Bureau or Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 18 Protection of Vulnerable Adults list checks had been carried out. In order to fully protect service users, no staff member should work in the home until they have been checked against these lists. A sample of staff training profiles was examined. These detailed that there has been ongoing staff training. Training is provided both in-house by the Training and Development Manager and Matron, and through courses obtained in the community and from the local council. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 36. A good quality assurance system is in place. Therefore, practice in general is in the best interests of service users. In general staff members are well supervised, however, some are not. There is potential for service users not having their needs fully met were staff members do not receive proper guidance. EVIDENCE: An annual development plan was available detailing arrangements for making improvements to the service. Service users, visitors and visiting professionals are asked to contribute their views about the home on a regular basis. This is done through surveys, formal meetings, discussions at reviews, and informal discussions. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 20 There are regular visits to the home by the Registered Person for the purpose of monitoring the quality of the service. Written reports of this monitoring are made available to the Commission for Social Care Inspection. All policies and procedures have recently been reviewed. Accounts and details of financial procedures were available for inspection and there was insurance cover. Staff members spoken with reported that they received formal supervision. All grades of staff receive supervision and records of supervision sessions were available. These detailed that supervision is used to review the work of staff members and to plan for future training and development. However, in four files examined, records were not available detailing that supervision had been held on a regular basis. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 x 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 3 3 x 2 x x Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 22 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 9 Regulation 13 (2) Requirement Timescale for action 01.08.05 2. 15 12 (1)(a) 13(4)(c) 3. 29 19 (1) Schedule 2 4. 36 18 (2) The Registered Provider must ensure that: 1. Any medication prescribed to a service user by a GP is available in the home. 2. All medication prescribed to a service user is labelled appropriatley. The Registered Provider must 01.08.05 ensure that all opened dry food items are stored in sealed containers that will prevent contaimination. The Registered Provider must 01.08.05 ensure that a satisfactory Criminal Records Bureau, and Protection of Vulnerable Adults list check is obtained prior to any staff member commencing work in the home. The Registered Provider must 01.09.05 ensure that all care and nursing staff members receive formal supervision at least six times each year. Records of supervision sesssions must be maintained. Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 23 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 Good Practice Recommendations Southborough Nursing Home G53-G53 S26258 Southborough V216516 250505 Stage 0.doc Version 1.30 Page 24 Commission for Social Care Inspection CSCI 8th Floor Grosvenor House 125 High Street, Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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