Inspection on 23/01/06 for Southdowns Nursing Home

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Southdowns Nursing Home 06/07/07

Southdowns Nursing Home 24/04/06

Southdowns Nursing Home 09/06/05

Southdowns Nursing Home 01/02/05

Southdowns Nursing Home 02/07/04

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

CARE HOMES FOR OLDER PEOPLE Southdowns Nursing Home The Green St Leonards on Sea East Sussex TN38 0SY Lead Inspector Lindy Latreille Announced Inspection 23rd January 2006 09:15 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 Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 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. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Southdowns Nursing Home Address The Green St Leonards on Sea East Sussex TN38 0SY 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) 01424 439439 01424 439439 Paydens Limited Mr Dennis Charles Pay Barbara Ann Ford Care Home 48 Category(ies) of Dementia (48), Mental disorder, excluding registration, with number learning disability or dementia (48) of places Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is forty eight (48) That service users with a dementia type illness who require nursing care must be aged forty-five (45) years or over on admission That service users with mental disorders who require nursing care must be aged sixty-five (65) years or over on admission Date of last inspection 09/06/05 Brief Description of the Service: Southdowns Nursing Home is registered to provide care and accommodation to Forty-eight residents with dementia from the age of forty-five years and to residents with a mental health disorder from the age of sixty-five years. The service is located on The Green in St Leonards-on-Sea in a residential area. Shops and transport links are nearby. The home has two floors with forty-eight bedrooms, all of which have en suite facilities. There is a passenger lift, communal rooms and well maintained gardens all of which are fully accessible to the residents since the completion of the recent extension. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection with three Inspectors from 0915 to 1900. This report should be read in conjunction with the previous one from 09/06/05 during which twenty-five (25) standards were assessed and two were met. Six care plans were seen and the care of these residents was tracked through accidents, complaints, incidents, activities and daily routines. Residents, carers, activity co-ordinators, housekeeping and kitchen staff and nursing staff were spoken to throughout the day. Lunchtime was observed. A tour of the building took place. The Police, for their investigation into an Adult Protection case, have taken some records. These records were seen at the local police station. What the service does well: What has improved since the last inspection? There has been an increase in the size of the home to forty-eight beds. A new brochure of the service has been produced. All pre-admission assessments are now completed on appropriate forms and inform the care plans. Care plans are reviewed routinely. Residents call bells and drinks are with in reach. A second activity co-ordinator has been appointed. The duty roster shows the number of staff that worked the shift and those on training. Five staff commenced National Vocational Qualification training in September 2005, joining the six already following the training. A staff recruitment interview form has been put in place. Window restrictors have been fitted and necessary repairs to the original house maintained. Since the last inspection the Commission for Social Care Inspection has received one Regulation 26 monthly report, carried out in January 2006. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 6 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. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. A new brochure has been printed to describe the service, though a residents’ guide has yet to be developed. Pre-admission assessments were evidenced but some were not thoroughly completed. EVIDENCE: A new brochure has been printed but as yet has not been given to the relatives of current residents. The residents’ guide has yet to be developed and the Registered Manager is aware that it should meet the needs of the residents and that the information might be best explained through pictures or symbols. The Registered Manager, or her deputy carry out pre-admission assessments. Visits are made to the prospective resident, and in practise much of the information is gathered from relatives or care staff. Not all sections of the preadmission form were completed or signed by staff. At present any referrals who are not deemed appropriate are not kept, but this is a way that the service can show their selection of appropriate residents whose needs they cannot meet. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 7, 8, 9 and 10. The content and reviewing process of care plans lacks thoroughness and detail. Personal risk assessments were not in place in relation to reclining chairs. In consequence of poor recording it is not easy to track that all the residents’ needs have been identified and are met appropriately. No resident is selfmedicating and the home has actioned the advice from the Commission for Social Care Inspection’s Pharmacist. Staff do treat residents with respect but residents choices are not recorded in the care plan. EVIDENCE: Care plans sampled had some record sheets of another home, referred to the residents by the wrong gender or name, used correction fluid and failed to give clear instructions for staff to follow. Some did not have a photograph of the resident. One assessment detailing 2 litres in a twenty four hour period and another entry stating 1.5 litres, neither gave a clear reason or if this action was to be the upper or lower of fluid intake, actions to take in the event of the amount not being reached or a cross reference to the fluid balance chart. One resident had an indwelling catheter but no related care plan. Some areas of the care plans were left blank and it was unconfirmed whether such practice was to indicate “not applicable” or just an incomplete care plan. The residents’ Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 10 choices were not detailed and this is very relevant at present as a current complaint is in progress about the time that residents are woken and prepared for the day. Of the files sampled there was no indication of the actions or wishes of the resident or their relatives in time of death. There was evidence of reviews, but there was some irregularity noticed and an identified plan of care with regard to the resident’s sleeping arrangements had not been amended in the light of change, as normal sleeping arrangements had resumed. There was no evidence to show that the care plan reviews were done to include the relatives or significant others. Many entries were unsigned. There were no risk assessments in place to address the management of reclining chairs and the daily mobility of a resident so restrained. A consequence of the poor recording was that it was not easy to observe if the needs of the residents were being fully met. The staff confirmed the care plan delivered to the residents, but as the number of plan. This relied on the care plan to be fully detailed to show that assessed needs were met. Staff did not always record the time that care was given, which is essential for evaluation. The inclusion of advice from external professionals, such as the Tissue Viability Nurse, was evident. Daily records were not holistic in manner and generally addressed the tasks done, not the psychological well being of the resident or appropriate interventions to reduce the risk of falls. Guidelines by National Institute for Clinical Excellence (NICE) in relation to falls were not known to the Registered Manager. Nutritional screening is undertaken but not all residents had their weight assessed or amendments made to care plans to identify actions needed. The Commission for Social Care Inspection’s Pharmacist has visited the home and made requirements that the home has actioned. None of the residents are self-medicating. Staff observed working with the residents were caring to them in attitude and manner. There were no actions recorded to take in time of death in some of the care plans sampled. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 12 and 14. There are now two activity co-ordinators in post and they deliver a varied programme of activities and some tactile care. Staff found occasions when they could ask for a residents’ choice and were caring and gentle in their work. EVIDENCE: There are now two activity co-ordinators in post who between them organise a range of activities appropriate to the needs of the residents based on the known history. Notes are kept of the activities for each resident on a fortnightly or monthly basis. A list of activities was advertised on the notice boards throughout the home. Residents are able to choose if they wish to attend. Some of these are group craft activities, as was taking place during the inspection in preparation for Burn’s night later in the week. On some days one of the co-ordinators carries out the hairdressing and both of them offer manicures and hand massage to all the residents. There is a weekly church service that residents are invited to attend. Staff were observed to offer residents choices during the days routine. What was less clear was the level of choice that residents made about getting up, breakfasting, mobility and retiring. As such choices are not recorded in the care plan it is not possible to see how the residents wishes were being Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 12 respected. As the level of dementia is very profound in many of the residents staff should make sure that their recording includes events, choices made and the overall psychological state of each resident to evidence the care given to meet the assessed needs. The chef on the day of the inspection explained the process of getting the food from the kitchen to each resident. A white board in the kitchen identifies which residents require special diets or have other special dietary needs, such as those needing the food liquidised or pureed. Kitchen staff then ‘plate up’ each resident’s food and cover with a lid with each resident’s room number in order to ensure that residents receive the right food, according to what is recorded on the white board. Kitchen staff become aware of any changes to dietary needs through senior care staff. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 16. The complaints policy and procedure is in place but the home is not fully following its own procedure. No assessment was made of standard 18, as there is an Adult Protection investigation being carried out currently, with the Police as the lead. EVIDENCE: The complaints file was seen during the inspection. One complaint had been received and appropriately managed, although the organisation’s own recording system had not been completed. The home has received a current complaint that was not in the file and there was no evidence of correspondence. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 19,22,24 and 26. The environment has been made safe through appropriate maintenance and completion of the building works. Not all residents had a risk assessment for bed rails, that are in place, relating to the usage. Residents’ rooms were in good order and appropriately furnished and there was no odour. EVIDENCE: Now that the building work has been completed the home is now a safe and clean environment. The Regulation 26 visit by the regional manager identified some re-decoration needed in the kitchen. Externally there is new fencing and security gate in place and rubbish and clinical waste are appropriately managed. A planned programme of routine maintenance, renewal of the fabric and redecoration was not seen at the inspection, which was a requirement of the last two inspections. Many of the residents need the protection of bed rails, no risk assessments were contained in the care plans. It was therefore not possible to evidence that there are monthly reviews that inform care in relation to the restraint of bed rails or linkage to accidents. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 15 The residents’ rooms were seen in good order clean and tidy and without odour. Residents are encouraged to bring some items from their homes as this enables reminiscence. Risk assessment relating to the call bells and door keys, outstanding from the last inspection, are in place for each room dated 18th and 19th January 2006. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Carers carried out their duties in an enthusiastic and relaxed manner. Agency staff are not checked to see that they fulfil the training and recruitment requirements. Six staff have achieved National Vocational Qualification level 2 or 3 in Care and nine are training for either level 2 or 3 National Vocational Qualification in Care. There is a satisfactory staff compliment though there are some peak times that need more. Staff training takes place weekly but no training in dementia care has been delivered through the whole of last year and there are insufficient qualified staff in mental health. A member of staff whose qualification had lapsed delivered some First Aid training. There are still gaps in the recruitment process and staff have been employed on poor references and other shortfalls. EVIDENCE: The service has identifying that there are peak times in the daily routine when more staff are needed; such as meal times. The Registered Manager is going to discuss ways to manage or recruit to meet this need. No carers, housekeeping or kitchen staff identified that their workload was too big. When agency staff are employed the Registered Manager does not ask for confirmation that they have received the appropriate training or recruitment checks to work in the service. Staff training takes place weekly and all staff work a long day so that there is sufficient cover to meet the residents’ needs without compromise. Some First Aid training delivered by the Head of Care cannot be recognised, as his Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 17 qualification is out of date. No training in dementia care has taken place during the past thirteen months and this is a key area that staff need to be updated in to meet the residents’ needs. There is also uncertainty around the number of qualified staff who have had specialist training in mental health, ie are Registered Mental Nurses (RMN). Of the personnel files sampled application forms were present, some had a CV but not all gave dates as years and months and as there was no question asked at interview about gaps in employment it was not possible to see that an informed judgement was made. No CV had been provided for one member of staff and so previous employers had not been checked and references only taken up from his last employer. Overseas staff had no reference from an employer from their home country in the files sampled. References received were from a person without a care background and who had made a positive comment as to the applicants’ ability to work with residents with dementia. There was no evidence that original qualifications were seen and then copied and endorsed on the back and signed. This is essential to determine the level of competence especially for a member of staff with training responsibilities. Some staff are still following National Vocational Qualification training at level 2 and 3. The staff compliment still does not reach the 50 requirement at present. Carers do follow induction training. The Head of Care’s induction was confirmed, by him, to be merely shadowing for two days during which time the policies and procedures were read. The Registered Manager rejected this as inaccurate as the induction was over a four-week duration; but did agree that the induction was poorly evidenced. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. The Registered Manager is following the Registered Managers Award and expects to complete by the July 2006. The lack of a quality assurance programme means that shortfalls in the service are not identified. The Regulation 26 monthly, visits required from June 2005, are only just in place. There has been some positive feedback from relatives but there is no advocacy offered to the residents at present. There is no staff supervision in place and this is carried over from the last two inspections. Aspects of health and safety are not being addressed and this has implications for risk assessments and reporting to RIDDOR. Significant events have not been reported to the Commission. A range of health and safety matters have been identified as shortfalls and needing actioning. Maintenance checks and contract servicing are being carried out. EVIDENCE: Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 19 The service must develop a quality assurance programme which will aid the running of the home by identifying the shortfalls on a regular, ie monthly basis. There are few systems in place for the trained staff to overview the continuing care and present a clear picture of all the care given. There are only infrequent staff meetings so exchange of information is ad hoc and unstructured. There was evidence of only one Regulation 26 monthly visit having been carried out since the last inspection, with this being in January 2006 just prior to this inspection. Once these visits, and reports, are carried out consistently, it will assist in an overview of the whole service, so that the Registered Manager can identify where support and changing strategies are needed. No residents’ monies are managed by the home. Some feedback has been achieved from relatives and this needs to be evaluated to contribute to the self-monitoring. As many of the residents are profoundly affected by their dementia communication can be difficult and at present there are no ways other than verbal to communicate to residents. The lack of staff supervision for carers is significant as without it the service has little informed knowledge. Similarly without staff meetings there is no vehicle to discuss, plan and create improvements to the service. Quality assurance underpins staff accountability and best practice. With regard to health and safety the Registered Manager needs to ensure that all trainers have current qualifications and are fit to train. A quality assurance programme would endorse that all health and safety management, risk assessments, checks and servicing are up to date and therefore legislation is being complied with. At present there is no audit of the accidents that occur each month or the enquiry as to whether there are themes and trends. All accidents are recorded; but accidents that lead to a resident being admitted to hospital with injuries, are not being audited or reported to RIDDOR. The current recording system does not state the outcome of the accident, such as having to go to hospital. One accident report sounded quite serious but there was no outcome recorded, in terms of what action the home took as a result of the fall. There is no system to record significant events that need reporting to Commission for Social Care Inspection. As a consequence matters that should have been reported have not been. One accident report had been completed but the incorrect name had been recorded. Another report had not been signed. Fire risk assessment of the building had been completed in October 2005 by an external expert and consultant. The report from this assessment was details and outlined a number of areas that required attention. The report stated that these issue are ones “which management will rectify as a matter of urgency”. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 20 Although the registered manager believed all these issues had been actioned and completed, Inspectors checked two matters, at random, and found neither had been completed. An ambulance crew recently were called to the home as an emergency, but had difficulty gaining access to the building and then difficulty in locating the room to assist a resident. A clear policy and procedure needs to be introduced and reinforced to all staff to prevent this from reoccurring. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 x 3 X X 2 X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 3 3 2 X 1 Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14(1)(a) Requirement That pre-admission assessments must be fully completed, signed and dated. This was a requirement at the last inspection with a timescale of immediate. That correction fluid must not be used in any record keeping. That care plans must be fully completed, related to each individual and effective to enable staff to meet all the care needs of each resident. Care plans must also be shared with residents and relatives when appropriate. This was a requirement at the last inspection with a timescale of immediate. That care plans must be regularly reviewed to ensure they accurately reflect the current situation. That restraint of residents must be risk assessed, recorded and monitored. That holistic health needs must be monitored and actively promoted. DS0000041644.V267236.R01.S.doc Timescale for action 28/02/06 2 3 OP7 OP7 17 15(2)(a)( b)(c)(d) 23/01/06 28/02/06 4 OP7 15(2)(b) 28/02/06 5 6 OP7 OP8 13(7) 13(1)(b) 28/02/06 28/02/06 Southdowns Nursing Home Version 5.1 Page 23 7 8 9 OP16 OP22 OP27 22(3) 13(4)(c) 18(1)(a) 10 11 OP28 OP29 18(1)(c)(i ) 19(1)(a)( b)(c) 12 OP30 13(4) 13 OP30 18(c)(i) 14 15 OP31 OP33 9(2)(b)(i) 24(1)(a&b 16 OP33 26 17 OP36 18(2) That the home must follow its own complaints procedure. That bed rails must be risk assessed prior to use. That assurance must be sought that agency staff are appropriately trained to carry out the work. That 50 of staff must be qualified at National Vocational Qualification level 2. That staff recruitment must fulfil all of Schedule 2. This was a requirement at the last inspection with a timescale of immediate. That a training programme in first aid must be set up and sent to CSCI by 17th February 2006 and training provided by 17th March 2006 for care staff. This was a requirement at the last inspection with a timescale of immediate. That a training programme in dementia care must be set up and sent to CSCI by 17th February 2006 and training provided for care staff by 17th May 2006. That the Registered Manager achieves Registered Managers Award. That a programme of quality assurance must be put in place. This was a requirement at the last inspection with a timescale of 31/08/05. That monthly visits must be completed and copies of these reports sent to CSCI. This was a requirement at the last inspection with a timescale of immediate. That all carers must be supervised at least six times a year. This was a requirement at the last inspection with a DS0000041644.V267236.R01.S.doc 28/02/06 28/02/06 28/02/06 31/03/06 28/02/06 17/03/06 17/05/06 30/06/06 30/06/06 28/02/06 30/06/06 Southdowns Nursing Home Version 5.1 Page 24 18 19 20 OP38 OP38 OP38 17(1)(a) 37 13(4)(c) 21 OP38 13(4)(c) 22 OP38 12(1)(a) timescale of immediate. That all accidents must be fully recorded, including outcome, and always signed. That all significant events must be reported to CSCI. That an action plan, with timescales, must be devised to rectify the matters identified in the fire risk assessment and that a copy of this action plan is sent to CSCI. This was a requirement at the last inspection with a timescale of immediate. That a policy and procedure must be devised on access to the building, particularly for emergency services, and that all staff are informed of this procedure. That health and safety must be audited through quality assurance and reports to RIDDOR as necessary. 23/01/06 23/01/06 28/02/06 17/02/06 28/02/06 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 OP7 Good Practice Recommendations That care staff’s knowledge and involvement in service users’ care plans should be reviewed. This was a requirement of the last inspection with a timescale 01/02/05. Southdowns Nursing Home DS0000041644.V267236.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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