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Inspection on 22/02/07 for Southcrest Nursing Home

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

This inspection was carried out on 22nd February 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 home continues to offer a high standard of care to elderly residents. The home has a committed staff group who understand the needs of the residents well; the home uses agency staff infrequently. The registered manager spends time with the residents and ensures staff are aware of the needs of residents through documentation such as risk assessments and care plans. The home is clean and odour free

What has improved since the last inspection?

All of the requirements made at the time of the last inspection have been met. Environmental improvements are ongoing, windows at the rear of the building have been replaced.

What the care home could do better:

The statement of Purpose needs to be updated to provide the detail required by the amendment Regulations 2006.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Southcrest Nursing Home 215 Mount Pleasant Southcrest Redditch Worcestershire B97 4JG Lead Inspector Lorraine Briggs / Pat Scott Unannounced Inspection 22nd February 2007 10:00 X10029.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 Southcrest Nursing Home DS0000004103.V326508.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 and Care Homes for Adults 18 – 65*. 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. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southcrest Nursing Home Address 215 Mount Pleasant Southcrest Redditch Worcestershire B97 4JG 01527 550720 01527 550738 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) Dr Sabarathnam Ananthram Mrs Kalpana Ananthram Gail Elizabeth Gilbert Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (3), Physical disability of places over 65 years of age (40) Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All persons admitted within category PD must be at least 55 years of age and on a named basis, with the prior agreement of the registration authority The Home to allow 1 named resident between the age of 61-65 years of age. Date of last inspection Brief Description of the Service: Southcrest Nursing home is a forty-bedded care home providing nursing care for people over the age of 65 years. Accommodation is provided on three levels/floors (in single or double occupancy bedrooms), and there is a passenger lift and two staircases to all levels. There is a variety of aids and adaptations around the building to allow people to move about more independently. There are communal toilets, bathrooms and lounges on each floor. The home is situated on the perimeter of central Redditch, and local services and resources can be easily and readily accessed. Fees range from £443 - £485 per week. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider, staff records kept in the home, medication records, discussion with people who use the service, discussions with the staff team, discussion with the manager, tour of the premises, previous inspection reports, quality assurance process, Fire Authority reports, Environmental Health Office reports, observation of care experienced by people using the service. What the service does well: The home continues to offer a high standard of care to elderly residents. The home has a committed staff group who understand the needs of the residents well; the home uses agency staff infrequently. The registered manager spends time with the residents and ensures staff are aware of the needs of residents through documentation such as risk assessments and care plans. The home is clean and odour free. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. Prospective service users and their representatives have most of the information required to choose a home which will meet their needs They have their needs assessed and a contract which informs them about the service they will receive. This judgement has been made using available evidence including a visit to this service. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 9 EVIDENCE: Prospective service users are given the opportunity to spend time in the home. From records seen admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective service user. The staff team are qualified and experienced to work with the needs of the service user. Documentation and training logs show that specialist areas of work have been explored and that staff have access to detailed guidance and training materials. The service helps prospective service users to understand the service by providing an information pack. The home provides a statement of purpose (SOP) that clearly sets out the objectives and philosophy of the service supported by a service user guide that summarises the SOP and provides good clear information about the home. The guide is precise in what the prospective service user can expect and gives a good detailed account of the quality of the accommodation, qualifications and experience of staff and how to make a complaint. Each service user is provided with a statement of terms and conditions prior to moving to the home. It does not comply with the changes in the Care Home Regulations as amended in September 2006. Terms and conditions are reviewed on a regular basis. Admissions are not made to the home until a full needs assessment has been undertaken. The service is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the statement of purpose. For people whom are self funding and without a care management assessment the assessment is always undertaken by a skilled and experienced member of staff. Evidence confirms that the assessment is conducted professionally and sensitively and has involved the family or representative of the service user. Where the assessment has been undertaken through care management arrangements the registered person has insisted on receiving a summary of the assessment and a copy of the plan. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. The health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 11 EVIDENCE: Each service user has a plan that has been agreed with them. This is written in plain language, is easy to understand and considers all areas of the individual’s life including health, personal and social care needs. The plan also includes a risk assessment element. Staff have skills and ability to support and encourage service users to be involved in the ongoing development of their plan and make the process interesting, and worthwhile using a variety of ways e.g. appointing key workers who build up special relationships with service users and work on a one to one basis. The home ensures that each service user’s plan is reviewed regularly and involves the service user and where agreed their family. The plan is updated and the necessary action taken to respond to any changes. All members of staff regard the plan as a working tool, they understand the plan and work to it. Service users receive clear feedback on all decisions and actions that affect the placement and their individual care. Service users have right of access to health and remedial services and the home’s policies, procedures and practice guidance support this. Staff work very hard to make sure that those service users who are fit and well enough, have regular appointments and visit local health care services, supported by family, care staff or volunteers. The health care needs of those service users too frail to leave the home are managed by visits from local health care services. Service users’ personal aids are well maintained and the home provides the necessary aids and equipment to support both staff and service users in daily living. Service users have individual health care plans that give a comprehensive overview of their general health and acts as an indicator to changing health needs. Service users have the choice to shower or bath when they wish, and are supported and facilitated to be independent in their personal hygiene. Care staff are trained and accredited to meet the health care needs of the service users and have access to training in health care matters. The home works to an efficient medication policy supported by procedures and practice guidance. Staff are aware of and understand the guidance, and quality assurance systems confirm that practice reflects policy. Service users who have the capacity are encouraged to keep and take their own medication. Thought has been given to providing safe facilities for keeping medication. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 12 The aims and objectives of the home reinforce the importance of treating service users with respect and dignity and these values are applicable to all aspects of their life and are fundamental to the philosophy of care. Particular attention is given to ensuring privacy and dignity when delivering personal care. Staff make every effort to enable service users to choose who delivers their care and respect their preferences. Service users sign for agreement their preference of staff when receiving personal care. Recruitment of staff takes into consideration the need to employ a varied and balanced staff group. Induction training covers privacy and dignity. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the 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. Service users are well supported by staff and relatives in continuing to live in a way that satisfies their interests and needs. This judgement has been made using available evidence including a visit to this service. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 14 EVIDENCE: The routines of the home are planned around the service users needs and wishes. Systems enable the service to be flexible and changed to meet individual wishes. The home encourages service users to take control of their life and be actively involved in the running of the home. Service users have the confidence to discuss what makes them happy and comment where improvements can be made. The home takes service users feedback seriously and makes changes where possible. Staff listen to service users and make considerable effort to provide a flexible service, which enables them to enjoy a better quality of life. The home has confidence in its quality assurance system to confirm that practice reflects the policies, procedures and guidance. Sufficient staff resources are provided to allow time for activities and stimulation. The home operates a key worker system, which enables closer service user staff relationships where likes, dislikes and needs are shared. Key workers use the information to plan activities which service users will enjoy. The home has developed a system for displaying information and bringing attention to community events and activities. When service users have particular interests every effort is made by staff to help the service user maintain their interest and keep up any community involvement. Family and friends feel welcome and know they can visit the home at any time. Staff always make time to talk to visitors and share information with the agreement of the service user. The design of the home provides seating areas within the communal areas of the home where service users can entertain their visitors, in addition to the privacy of their own room. It is clear that the home encourages individuals and groups from the community to visit the home. Service users are encouraged to take responsibility for their own financial affairs and to use their money as they wish. Staff will support those service users who need help in financial matters, they work to a clear robust policy that protects the service users from financial abuse and clearly directs staff in their practice. The home is able to offer service users information and telephone numbers for contacting independent people who will act as advocates on the service users’ behalf where the service user prefers the help of an independent person. Service users have the choice to bring a limited amount of small goods with them on admission to the home and are encouraged to keep personal items which are important to them in their own room. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 15 The home believes that service users should always be aware of any information held and written by the home, and have the right to read any documents they wish and staff promote this. An experienced cook is responsible for providing quality nutritional meals that meet the dietary needs of the service users. The cook meets regularly with service users, listens to their choices and suggestions for the menu, and encourages them to be adventurous and try new tastes as well as traditional foods. Tables are set attractively with the necessary cutlery and aids to help individuals during their meal. They are encouraged to serve themselves and help themselves to drinks. Birthdays and celebration are made special for individual service users. Service users enjoy the flexibility of meal arrangements and enjoyed being able to eat in their own room if they wished. Regular drinks are available and staff will always make a cup of tea at any time when asked. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is good. Service users have access to a robust, effective complaints procedure, are protected from abuse and have their legal rights protected. This judgement has been made using available evidence including a visit to this service. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 17 EVIDENCE: The service has a complaints procedure that generally meets the national minimum standards and regulations. The complaints procedure is available within the home. Service users and others associated with the provision understand how to make a complaint. Complaints are recorded in the manager’s diary and not in any form of specific log. The policies and procedures regarding protection of service users are satisfactory and are reviewed and updated in line with regulations and other external guidance. Within the policy it is clear when incidents need external input and who to refer the incident to. Links with external agencies are now satisfactory and include CSCI, police and adult protection teams. All relevant staff have received adult protection training and know what immediate action to take and when and who to refer any incident on to. Service users and others associated with the home state that they are satisfied with the service provision, and feel safe and supported. The homes aims and objectives include the rights of service users. Service users are supported to live as independently as possible, exercising their rights to make choices and decisions with assistance when needed. The home is aware of the need to facilitate advocacy services and makes efforts to access advocacy services on the service user’s behalf. The home facilitates the right for all service users to vote in elections when ever possible Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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. Service users have bedrooms that suit their needs and offer enough space for them to arrange them in a way that they prefer. This judgement has been made using available evidence including a visit to this service. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the service users. Where rooms are shared it is only by agreement, and screens are provided for privacy. Service users are always given the choice to move into a single room when one becomes vacant. They have the choice to bring small personal items of furniture into the home. All the homes fixtures and fittings meet the needs of the service users and can be changed if their needs change. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy or in their own rooms. There is a choice of bathing facilities, both assisted and unassisted, showers and baths and there are a number of toilets strategically placed around the home. The home is well lit, clean and tidy and smells fresh. The management has a good infection control policy. They seek advice from external specialists, e.g. infection control, and encourage their own staff to work to the homes’ policy to reduce the risk of infection. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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. Staff in the home are being trained and are in sufficient numbers to fill the aims of the home and meet the changing needs of residents. This judgement has been made using available evidence including a visit to this service. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 21 EVIDENCE: Service users have confidence in the staff that care for them. The manager ensures that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the service users. The service clearly defines the roles and responsibilities of staff through accurate job descriptions and specifications. Records show that staff working with service users are skilled in their role, and are consistently able to meet their needs. The service ensures that all staff within its organisation receive relevant training that is targeted and focussed on improving outcomes for service users. The service uses external providers to deliver this training if they have not got the appropriate skills within the organisation. This training can be small scale and individualised if necessary in order to promote the delivery of person centred services. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of service users. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The management and administration of the home is based on openness and respect and has effective quality assurance systems developed by the provider. This judgement has been made using available evidence including a visit to this service. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has the required qualification to meet he National Minimum Standards and is competent to run the home. She works to continuously improve services and provide an increased quality of life for service users. There is a strong ethos of being open and transparent in all areas of running of the home. The manager is service user focused and leads and supports a strong staff team who have been recruited and trained to a good standard. Staff are positive in their approach to translate policy into practice. Efficient systems are in place to monitor staff adherence to policies and procedures during their practice. Management processes ensure that they receive feedback on their work. The home works to a clear health and safety policy and regular random checks take place to ensure they are working to it. Records are of a good standard and are routinely completed. Where issues have been identified, for example, in care plans, these have been acted upon successfully to ensure service users care is not compromised. The service provides a quality assurance and monitoring processes. A survey for 2006 has been carried out with the results to be collated. The last survey for 2005 was displayed within the service user information folder and the home achieved 100 satisfied result in most areas. Comments included: “the girls are like angels”, “all the staff work very hard”. If they wish and are able to, service users are helped to take responsibility for managing their own money. They are provided with facilities to keep their valuables and money safe. Where the home is responsible for service user’s money it works to a very rigorous system, it maintains very clear records that are routinely kept up to date and can be used to track individual service users finances. The service understands the need to meet external requirements where it acts as agent or appointee for service users. Southcrest Nursing Home DS0000004103.V326508.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 2 2 3 3 4 X 5 X 6 X 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 3 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Southcrest Nursing Home DS0000004103.V326508.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 OP1 Regulation reg5A. Requirement Timescale for action 31/05/07 2 OP2 The registered person shall amend the SI No. 1493. The Care service user guide to provide the detail Standards Act 2000 (Establishments and required by the Agencies)(Miscellaneous amendment Amendments) Regulations 2006. Regulations 2006. Schedule 4 (8). The registered person shall maintain a record of the care home’s charges to service users, including any extra amounts payable for additional services not covered by those charges, and the amounts paid by or in respect of each service user. 31/05/07 Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 26 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 OP16 Good Practice Recommendations That a log of complaints is maintained. Southcrest Nursing Home DS0000004103.V326508.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. Southcrest Nursing Home DS0000004103.V326508.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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