Inspection on 24/04/06 for Southdowns Nursing Home

This inspection was carried out on 24th April 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 23/01/06

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 Jo Mohammed Unannounced Inspection 24th April 2006 9:15 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.V289870.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.V289870.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.V289870.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 23rd January 2006 Date of last inspection Brief Description of the Service: Southdowns nursing home is registered to accommodate forty-eight service users. The home is located in St Leonards-on-Sea in a residential area. Shops and transport links are nearby. There are two floors; forty-eight single bedrooms, all with en-suite facilities. There is a passenger lift, communal rooms, laundry and gardens all of which are accessible to service users. The current fee charges range from £550-£700 per week, with additional charges for hairdressing and Chiropody. It was reported a copy of the home’s brochure and service user guide is sent out to prospective service users and interested parties. The home also advised they plan to make changes to the service user guide by making it pictorial, and display it alongside inspection reports so that current, prospective service users and other interested parties have information about the home. Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place between 9.15am and 7.30pm, conducted by three Inspectors. All the key standards were inspected as well as some additional standards. This report should be read in conjunction with the last announced inspection report dated 23rd January 2006. On the day of the inspection there were thirty-nine service users. Several service users were observed and met during the course of the inspection as well as staff carrying out their duties. A partial tour of the premises took place. Some individual and joint discussions were had with the Manager, regional Manager, and a selection of staff. The home’s fire consultant/trainer was also present during the inspection and interviewed. Time was also spent examining records, taking a lunchtime meal and explaining the changes to the frequency of inspections and methodology. Pre-inspection information and service users surveys were given to the Manager on the day of the inspection to complete and return to the Commission by the end of the week, this information was subsequently received. In February 2006, after the last inspection, the Commission met with the provider, registered Manager and a senior Manager to discuss concerns, a serious concern letter was also sent. The outcome of this meeting was positive and led to assurances from the provider and senior Managers that attention would be given to action matters raised to address ongoing issues, including attending to past requirements and recommendations. The home was advised that an early unannounced key inspection would take place during the new financial year 2006-2007 to follow up on a range of serious issues discussed. What the service does well: Due to service users levels of dementia and mental health needs the care provided by staff was observed at varying times during the inspection. This showed staff undertook their duties with energy and commitment and good interactions were observed. The health needs of residents are satisfactorily met, with evidence of good links with other health professionals. Good procedures are in place for recording medication entering and leaving the home. Service users wishes in the event of illness/dying and information about different faiths are held in the home. The quality of meals served to service users is good. The activities co-ordinator tries to achieve as much as possible within allocated time, resources available and the number of service users residing in the home. The home presents as well maintained, it is clean, comfortable and free from odours. Completed service users surveys were returned to the Commission following the inspection. The Manager reported these were filled out by the activities co-ordinator with a selection of service users. The information in these indicated on the whole service users felt they received the care and support they needed, with activities arranged in which they could take part. Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 6 It was noted from these surveys that staff would usually/sometime listen and act on what they said, were usually/sometime available when needed and they always/usually liked the meals. Service users indicated they either knew or sometimes knew who to speak to if not happy. It was clear from all the surveys the home was clean and fresh. Some general comments made included; - ‘I like it here’. The information received about the home before moving in was ‘Very good’ and ‘pleased that everybody does their best’. What has improved since the last inspection? What they could do better: Ultimately, it is important the good progress and efforts put in by senior Managers and staff in the home since the last inspection must continue to ensure the home operates to an acceptable standard. The effective conduct and overall management of the home is vital to ensure the daily running and monitoring is smooth and sustained with clear roles and responsibilities in place and findings followed through in a pro-active and robust manner by the registered provider, Manager and senior Manager. There are still a high number of requirements and recommendations made as a result of this inspection, including some that remain outstanding. It is however anticipated these will be addressed within the timescales set and reduced in future by way of the home monitoring its own performance more actively through their quality assurance systems. The content of service users surveys returned to the Commission that will need following up were relayed to the Manager to do with some service users saying they did not have contracts or did not have enough information about the home prior to moving in, availability of staff, medical support/information and other general comments, one being ‘there is a need for more carers’. Please contact the provider for advice of actions taken in response to this Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 7 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.V289870.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 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 the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home has a good process for assessing new service users. EVIDENCE: Pre- admission assessments are carried out by the Registered Manager. Records inspected showed pre-admission assessments are carried out on all new and potential service users. The pre-admission assessment form details all aspects of service users needs and provides a good overview of potential new service users capabilities, needs and preferences. The home also obtains a copy of a care management assessment from a placing authority where this exists. Therefore the previous inspection requirement that pre-admission assessments must be fully completed, signed and dated is met. Senior staff advised that following service users stay in hospital they were involved in undertaking a further assessment of service users needs prior to them being discharged from hospital and returning to the home. Intermediate care is not offered by this service. Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10 &11 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Although clear improvements have been made in care planning, further work and developments are needed to ensure all the care needs of service users are identified and met. All care staff must be fully aware of the content of care plans so that service users health and personal care needs are fully met and used by staff to guide and assist them in the delivery of care. EVIDENCE: Care plans were sampled at the inspection. It was evidenced the home has made improvements in the manner in which these records are maintained and reported revamping paperwork. The use of correction fluid has ceased and there was evidence of care plans being reviewed on a monthly basis, with some service users and/or their representative’s involvement, where this is possible. Suitable risk assessments were in place for the use of bed rails, complications associated with reduced mobility, trip/falls hazards and associated risks and whether service users have the capability to use a bedroom key and/or the nurse call bell. Therefore the previous inspection requirements; that correction Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 11 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 service user, care plans must also be shared with residents and relatives, that care plans must be regularly reviewed to ensure they accurately reflect the current situation and that bed rails must be risk assessed prior to use have now been met. It was noted that progress has been made in the manner in which fluid balance charts and position change charts are now maintained. Records viewed confirmed these two recordings tools are now utilised in the appropriate manner. There is though, a need for the home to ensure that care plans detail service users holistic health needs and current capabilities, in order that they can be monitored and actively promoted. Therefore the previous inspection requirement relating to this still requires attention. Daily care records are also in need of some improvement, as some, but not all, entries were noted to be written in the form of free text, as opposed to being care plan specific as detailed in the homes Care Planning policy. It was reported qualified staff complete and evaluate service users care plans and care staff do not write in service users notes, but provide feedback to qualified staff as well as completing a daily care audit form. It was also said care staff did not really look at care plans unless they were doing a National Vocational Qualification [NVQ] and did not always attend handovers. It was said only qualified staff had done ‘on the job training’ in care planning. There has been no external training sought in care planning. This will be recommended as it links to a recommendation made at previous inspections about care staffs knowledge and involvement in care plans which although it was said the appointment of a new care Manager would do, this is a matter that should be addressed sooner and on-going basis. From the records sampled it was evidenced the health needs of service users are met with good multi disciplinary working taking place, on an as required basis. The home has good procedures in place for the monitoring and recording of all drugs entering and leaving the home. The medication records were viewed and it was evidenced some improvements are required by the home, to address the manner in which staff record medications either administered or nonadministered. From the medication records viewed it was seen where medication had been omitted, recording the reason for omissions was not clearly recorded. It was noted on some, but not all; medication records the omission code ‘O’ had been entered onto the record but no explanation given for the medication not being administered. There were also some missed entries noted, an Inspector discussed the medication audit with the Registered Manager and the retrospective signing of medication administered, where missed entries had been highlighted by the audit. There is a need for the home Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 12 to revise this. It was also noted that some entries had been signed as given to the service user and had then been overwritten with an omission code, in particular ‘S’ (which signifies asleep) or ‘R’ (which signifies refused). The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. However daily monitoring of fridge temperatures was not consistent, with a high number of blank spaces noted where temperatures should have been detailed. Immediate requirements have been made as a result of these findings and the implications of these shortfalls and requirements were discussed with the Manager at the inspection. Overall, staff were observed providing support to service users in such a way that promoted and protected service users privacy and dignity. It was however observed how one service user was lying on top of their bed for the majority of the inspection, it was reported their chair was not safe to sit in and this person had not been out of bed in the day. It was also said this person could be noisy when they did sit in a chair and staff overview was necessary. It was unclear as to how much time by staff had been spent with this person whilst in their bedroom. This information and circumstances must be acted upon as well as providing a suitable chair and closer liaison between staff as to the length of time they spend engaging with service users in bedrooms. It was noted on finishing the inspection the service user was no longer in their bedroom. It was also observed that the majority of service users sat with tables in front of them. A staff member explained a lot of service users could move these away if they were mobile and they were used because not all service users could sit at dining areas. This practice does need further attention as well as expanding upon the home’s restraint policy and procedure. From the care records viewed, it was evidenced service users critical illness/death and dying wishes had been recorded. It was also seen that where service users have a living will directive, this information is made available in their care plans. It was reported there were detailed policies and procedures in place regarding death and dying and death rite guidelines were available for different cultures/faiths. Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 13 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): 12,13,14,15 The quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Although there is a designated activities co-ordinator, there is a lack of activities at weekends when this person does not work and there is only one activities person at the present time. Improvements have been made to the range of choices service users are supported to make, although this needs to be expanded. The quality of food prepared is good; there is a varied menu and special diets catered for. EVIDENCE: At the previous inspection, there had been two activities co-ordinators. At this inspection one of these was covering administration and reception duties. This has obviously affected the quality and quantity of activities and social interaction with service users. The activities coordinator goes round and meets all service users each day that she works. Therefore each service user has a brief time with her. She will identify particular interests for each service user and where possible attempt to engage with them and meet these needs. For example, she reads to one service user each day. Although a range of activities and equipment are left out for care staff to use at weekends, it is uncertain whether any of this is used. The home has begun to document choices in service users care records through a choice sheet, although this still needs further development to cover wider ranges of choices and how decisions are made if and when service users Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 14 are unable to participate in this process. It was said regular meetings with families are possibly going to start. Both chefs were met on the day of the inspection. The kitchen is fairly new, purpose built and well equipped. All meals are freshly prepared by chefs and special themed events/parties and special diets catered for. An enjoyable and tasty lunchtime meal was taken. A white board in the kitchen identifies service users dietary needs including those requiring special diets such as those needing their food liquidised or pureed. If there are any changes to service users requirements this is verbally exchanged by senior care staff and changes made to the white board. There is currently no written documentation kept of this information or of formally involving the chefs in meeting new service users as part of the admission process or in formal, periodic reviews of service users nutritional needs. The head chef does though introduce themselves to new service users and receives a copy of the original assessment page to do with service users food preferences but this information is limited. There are occasions when agency chefs are used and it was said this might happen about six to seven times a year. No standardised written guidelines other than the information recorded on the white board is in place. This practice must be reviewed to guide these staff and others when they are working in the Kitchen. There is a four-week rolling varied menu in place compiled by the Chef from this home and another within the same company. There is currently no involvement by service users in this and it was not clear if service users had choice in where to eat their meals. There are two to three menu choices each day for the lunchtime meal and two choices for tea. The activities co-ordinator currently ascertains service users meal choices a day in advance by seeing each person daily, this record was incomplete as the part to record whether service users were served with their food choices had not been filled out. No record is currently kept as to the reasons why service users may not eat their meals and chefs find this out when trolleys are returned to the kitchen with meals. Because of service users varying degrees of dementia and mental health, the activities co-ordinator may choose the meal of the day on behalf of service users. Further ways to develop and enhance service users exercising choice in terms of food, menu planning and where to eat is considered important to follow through. Some service users take their meals in the dining room and others stay in their rooms, it was reported all service users apart from one have breakfast in their rooms. It was observed the dining area on the ground floor was not utilised by any service users on the day of the inspection. All residents in this lounge-dining Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 15 area sat in easy chairs and had lunch from a table put in front of them. This prevented service users from having a choice of where they ate their meal and from making this a sociable time for them. Staff assist a number of service users at meal times and guidelines where needed are included in care plans. Staff were observed assisting service users with their meals and were aware of which meal was for which service user, for example whether it was liquidised or pureed. Since the last inspection weekly quality assurance audits of the kitchen have been introduced. Some additions and amendments to this audit may have to be considered to ensure it covers all it needs too. Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Steps should be taken to ensure all staff receive training in the protection of vulnerable adults and understand the homes policies and procedures including the complaints process so that service users are protected from abuse. EVIDENCE: At the last inspection a requirement was made for the home to follow its own complaints procedure. Following examination of the complaints file it was seen a recent complaint had been recorded and appropriately managed in line with the home’s procedure. There was no evidence of a record kept of any other past complaints and these should be included. When speaking to some staff about how they receive and manage a complaint it was said they had briefly looked at the home’s complaints process but were not aware of documentation to complete. This needs to be addressed so that all staff are aware of the home’s complaints policies and procedures. Advocacy services are not currently used by any of the service users living in the home. Due to the degree of dementia and mental health needs it is considered important that steps be taken to facilitate accessing available advocacy services. An adult protection and whistle-blowing policy and procedure was available. There are currently two adult protection investigations being investigated, one of which is being led by the police. No records outlining past or present investigations are kept by the home. A staff member spoken too said they had not read the adult protection policies and procedures and had not received training in adult abuse. It was also reported this training had been done by some staff last year but none had taken place this year. This matter has been reported upon at previous inspections and must now be fully addressed. Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 17 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean and comfortable home. EVIDENCE: The home is accessible, comfortable and well maintained. The grounds are tidy and accessible to service users. It was found a carpet in the lift had become loose and presented an increased risk of trips and falls to both service users and staff. The Manager was informed of this and in turn conveyed this information to the maintenance person immediately. A planned programme of routine maintenance, renewal of the fabric and redecoration of the premises is not in place. This has been a recommendation at previous inspections and will be carried forward. The laundry room was suitably equipped and with organised routines in place. Areas of the home toured were found to be clean and free odours. Infection control policies and procedures are in place and staff working in this area gave a good description about the management of this. Quality audits relating to housekeeping have been introduced. Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 18 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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Due to the home’s category of registration and current skill mix of qualified staff there is a need for the home to ensure there are sufficient numbers of qualified staff on duty trained in mental health nursing. There continues to be gaps in staff recruitment practices and staff training/development in specific areas, which does need to be completed so that service users needs are met by a staff team with sufficient skills, training, knowledge and competency. EVIDENCE: Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 19 It was reported there are sufficient numbers of qualified and care staff on duty to meet service users current needs with two registered nurses on duty throughout the day and night, eight care staff on duty throughout the day and five care staff at night with one agency carer used daily to cover staffing deficits. The Manager is in addition to these staffing levels working 9-5pm during the week and some on-call duties. As reported upon at previous inspections, staffing levels should be kept under regular review and increased as necessary according to service users changing needs and at key times when more assistance may be needed. It was reported that for qualified staff, a new registered nurse holding a registered mental health qualification [RMN] worked nights and one more was due to start. There are currently no registered mental health nurses working day shifts although it was said a carer was waiting for his nursing number and once received he would be appointed to work days. Later on during the inspection it was said this carer had confirmed his nursing number. It was also said the home would be looking to appoint another registered mental health nurse on days to either the deputy or team leader position. A requirement that there must sufficient numbers of Registered mental health nurses on duty will be made. There are separate ancillary staff who undertake housekeeping and catering duties and from discussions these levels are sufficient. The administrators position is vacant, this duty is currently being undertaken by one of the activities co-ordinators whilst the recruitment process is completed for a person who is to be appointed pending satisfactory checks. There is therefore only one activities co-ordinator who primarily carries out activities with service users at the present time. A requirement made at the last inspection that assurance must be sought that agency staff are appropriately trained to carry out the work is now being met. The home has devised a checklist to ensure they confirm with the agency prior to employment that agency staff are appropriately trained. A number of staff recruitment files were inspected. Although there had been much improvement since the last inspection, a few errors and omissions were identified. These included two staff where only one reference had been taken up and another two members of staff where there was no proof of qualifications, as outlined on their application form. Comments made by a member of staff confirmed they had completed document training, classification of mental illness and First Aid. However, the training sheet given to Inspectors was not up to date as there were gaps in the recordings. Some additional training for staff on dementia care and understanding core concepts of mental health, recommended at the Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 20 last inspection, had been planned for April 2006, but had been cancelled. Information recorded on the pre-inspection questionnaire showed there are currently five care staff with an National Vocational Qualification in care at level 2 or above out of a total of twenty-three care staff. Also recorded on this questionnaire was seven staff currently holding a First Aid certificate. It was difficult to locate evidence of induction for new staff, as the latter carry the documents with them. Of the one document seen, only day one of the induction process had been completed. Another person explained how they had transferred to day shifts in a senior position in the last two months but had not received a formal induction into this role. Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 21 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): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home has been a concern. Works to address past failings are now being worked towards. It is acknowledged a lot of hard work has been done since the last inspection and it is anticipated this will continue. The importance of the home acting, initiating and being pro-active in addressing matters cannot be emphasised enough in order that service users live in a home that is well run and managed. EVIDENCE: Following the last inspection of the home, the Commission and other interested parties met with the provider and senior Managers of the home to discuss and express concerns about a range of matters including the daily running, management, lack of quality assurance systems and outstanding requirements. This led to action points being made and agreement by the provider that where matters needed attention they would be attended too and addressed. Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 22 It is thus indicative in the summary of comments made by staff below how this has been taken on board with improved practices and systems being introduced. Comments received from staff about the management of the home did say that over the last couple of months operations had improved due to the efforts and work put in by all and that it was now the best its been for some time as long as this continued and things had taken a turn for the better. It was said by some that morale had been low but each department was now working well together with better communication channels, more openness and it was foreseen this stance would improve. They felt the atmosphere had improved since more permanent staff had been employed and felt more valued because of being involved in processes. There was follow up to actions, more feedback and regular meetings held. It was said there was more understanding about roles and responsibilities and the quality audits undertaken to date had achieved greater understanding in the running of the home. The Manager of the home acknowledged missing issues in the past and the importance of quality assurances systems but explained an awful lot of work had been achieved since February 2006 and in general good feedback was being conveyed from staff and a lot of support was being received from a senior regional Manager in the organisation to address past issues. From a senior Manager’s perspective the view held was that a back to basics approach had been taken by introducing better structures, following these through, there was a more focused management team and ownership of responsibilities, the Manager was working better as a result of this structure, re-induction and task orientated approach. It was said weekly reports and copies of regulation 26 reports about the conduct of the home were sent to the provider as well as meeting up about once a month, the intention was to formalise these meetings. This stance is supported. This senior Manager has also spent three days a week in the home since meeting with the Commission and said this would continue for the next six months. Another key point raised during the meeting with the provider and other senior Managers was about management support and structure within the home. At the inspection, it was reported the deputy position was vacant and in the interim a qualified nurse was currently acting deputy/team leader. There were plans to introduce a new tier of management namely a care Manager, team leader and possibly a training co-ordinator for the company. It will be necessary to keep the Commission informed about this structure and support as it takes shape. Monthly copies of Regulation 26 reports about the conduct of the home have since January 2006 been sent to the Commission. A requirement made at the last inspection for the Manager to complete the registered Manager’s award by the end of June 2006 is to be extended as the Manager reported they had stopped this training because of the issues in the home but intended to restart. The Manager advised attending recent training in Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 23 basic psychiatric illness, medication and was due to attend Dementia training next month. The Manager is currently being supported by a senior Manager in the daily running of the home. This is considered necessary to continue at least until the registered Manager’s award has been achieved. Only small amounts of service users pocket monies are managed by the home and from the information supplied these records appeared to be in order with policies and procedures in place. It is acknowledged, the home has made improvements to ensure the previous inspection requirement, about a programme of quality assurance must be put in place, is met by the target date of 30th June 2006. From discussions with the Manager and Regional Manager along with records viewed, it was evidenced that weekly audits had been introduced since April, completed by the Manager and head of departments with changes being made to these recording tools as the need is highlighted. There was no evidence of action plans in place to address matters from these audits, however it was said these were on the computer ready to use. Some areas such as staff recruitment, supervision, training, health and safety records and requirements from inspections, which are not currently audited, do need to be included. Quality assurance questionnaires were conducted in January 2006; a good response was noted from service users (who were able to reply) and from service users representatives. The data collected from these responses had yet to be collated, published and made available to all. The Manager said there are plans in place to conduct quality assurance questionnaires on a three monthly basis, however there has been no decision made yet as to how often the results will be made available to all. A requirement to forward a copy of a report showing the results/findings of service users views and interested parties will be made. Staff and heads of departments spoken with confirmed staff meetings and weekly head of department meetings had been introduced and minutes of such meetings were maintained. Some staff met confirmed recorded supervision sessions had begun to take place and if they were responsible for the supervision of other staff, training had been given by a senior Manager. It was said they had commenced supervising some staff with a supervision diary in place to plan for future dates. However, from staff files inspected, there was a lack of evidence of supervision for all staff having been implemented, particularly for relatively new staff. The home has a range of policies and procedures in place currently located in the main office. There are also some policies that belong to another home in the company that should be kept separately or removed as these were given to an Inspector to examine during the inspection. From speaking to staff it was explained that not all of the home’s policies and procedures would have been seen, read by existing staff including the recently compiled resuscitation policy, although this was included to do as part of any new staffs induction. It was Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 24 reported these policies and procedures were to be transferred into the two nursing offices. Following examination of the restraint policy this was found to be limited in content and does need expanding upon. The home’s maintenance files were viewed and it was evident that fire drills, fire alarm testing, emergency light testing and water checks are carried out on a weekly, monthly or annual basis. A fire training session for some staff on duty took place during the afternoon of the inspection. It was evidenced from other records viewed that portable appliance testing had been completed in January, February and March of this year and appropriate gas; electrical and insurance certificates were in place. Accidents and incidents that occur within the home are appropriately recorded therefore; the previous inspection requirement that all accidents must be fully recorded, including outcome, and always signed has been met. Identified at the last inspection was for an action plan, with timescales, to be devised to rectify the matters identified in the fire risk assessment and a copy sent to the Commission. This has not been received and on the day of the inspection this information was not found. This requirement will be carried forward. At the last inspection, requirements were made for all significant events to be reported to the Commission and health and safety audited through quality assurance as well as reports to RIDDOR as necessary. It was found that some progress in auditing health and safety matters had been achieved, however this will need to be expanded upon as part of the home’s quality assurance systems. The home’s action plan, following the last inspection indicates the Manager has familiarised herself with all events that require notification to the Commission and a new form for documenting this implemented. Having said this, the Commission has to date only received notifications relating to deaths and the outbreak of infections; this requirement will be carried forward. At the last inspection a requirement was made 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. In the home’s action plan following the last inspection they confirm this has been done and a copy of this was sent to the Commission. A member of staff confirmed they had seen and signed this as well saying all other staff had been given copies of the procedure. The safety of service users who are either permanently in wheelchairs or transported does need to be addressed. This was identified at previous inspections, as currently safety straps are not used. The home was advised to contact the Health and Safety Executive [HSE] for further advice, as they currently perceive safety straps as a means of restraint, however the balance between service users safety and rationale for using this equipment does need to be addressed. Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 2 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 2 2 2 Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 26 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 OP7 Regulation 15 [2] Requirement That care plans are further amended to fully detail the holistic needs of service users and include the current capabilities of service users’. That entries made in the daily care plan records are care plan specific. That further attention to all types of restraint must be recorded, rationalised and agreed via a multi disciplinary setting, risk assessed, closely monitored and regularly reviewed. That a suitable chair to meet the needs of a service user is obtained. That the use of medication omission codes are explained on the front of the medication administration record. That medications are signed for after they have been administered or nonadministered and retrospective signing of medications is ceased. That fridges utilised for the DS0000041644.V289870.R01.S.doc Timescale for action 31/05/06 2 OP7 13 [7][8] 31/05/06 3 4 OP8 OP9 12 [1] 13 [2] 31/05/06 24/04/06 5 OP9 13[2] 24/04/06 6 OP9 13[2] 24/04/06 Page 27 Southdowns Nursing Home Version 5.1 7 8 8 OP12 OP12 OP14 16[2][n] 12 [2][3] 16 [m] [n] 12 [2][3] 16 [m] [n] 9 OP15 12 [1] & 14 [2] 10 OP15 12 [1] 11 OP15 12 [1] 12 OP16 17[2] 13 OP17 12 [1] [a] storage of medication are temperature checked and the results recorded on a daily basis. That a full range of activities must be provided including weekends. That opportunities for service users to exercise more choice in the running of the home must be done and documented in more detail in areas such as menu planning, food choices, where to eat, activities and other areas that will need to be included following completion of the home’s quality assurance findings. That formal systems must be set up for chefs to be involved when new service users are admitted as well as on-going formal reviews to ascertain food preferences and nutritional needs. Improved methods of communicating between catering and senior care staff must be introduced and agreements recorded particularly around service users daily food requirements and nutritional needs. That written guidelines for agency chefs or other parties preparing service users meals must be drawn up outlining the routine of day, menu details, service users information and choices. That a record must be kept of all complaints received including those investigated by the home. [Previous timescale of 9th June 2005 not met.] That steps must be taken to facilitate access to advocacy services for service users where needed. DS0000041644.V289870.R01.S.doc 30/06/06 30/06/06 30/06/06 31/05/06 31/05/06 31/05/06 31/05/06 30/06/06 Southdowns Nursing Home Version 5.1 Page 28 14 OP18 13 [6] 15 OP27 18 [1] [a] & [3] That training for all staff in adult protection must be completed and on-going refresher training arranged. -There must be sufficient numbers of staff on duty with a registered mental health nurse qualification. -Staffing levels in the home must be kept under regular review and increased according to service users changing needs. -That details about qualified staff appointments and the new management structure when in place must be reported to the Commission. That 50 of care staff must be qualified at National Vocational Qualification level 2. [Previous timescale by the end of 2005 not met] That staff recruitment must fulfil all of Schedule 2. [Previous timescale of 9th June 2005 not fully met] That a training programme must be established, and completed, on key areas including first aid, dementia care and issues of general mental health and training records are kept up to date. [Previous timescale of 17/3/06 and 17/5/06 extended.] That induction and foundation training must meet National Training Organisation workforce training targets and clearer/ accessible records kept. That the Manager achieves the Registered Managers award. [Previous timescale of 30th June 2006 extended] That the registered Manager continues to receive on-going DS0000041644.V289870.R01.S.doc 30/06/06 30/06/06 16 OP28 18 [1] [a] 30/11/06 17 OP29 19 [1] 24/04/06 18 OP30 18 [1][c][i] 31/05/06 19 OP30 12[1] [a] [b] & 18 [1] [a] [c] 9 [2] [b] [i] 10 [1] & 12 [1]-[5] 30/06/06 20 OP31 31/12/06 21 OP32 24/04/06 Page 29 Southdowns Nursing Home Version 5.1 22 OP33 24 [1] [a][b] support and guidance in the daily running of the home from a senior Manager until the registered manager’s award is gained. A continuous review of practices must be established. 30/06/06 That a programme of quality assurance must be put in place. [Original timescale set was 31st March 2005, extended to 30th June 2006 at the last inspection] Quality assurance audits must be expanded upon where necessary according to different systems operating in the home and a record kept of action taken as a result of findings. The results/findings of service users views and interested parties must be acted upon, published and a copy of the report sent to the Commission. That all carers must be supervised at least six times a year. [Previous timescale of 30th September 2004 not fully met] That all significant events must be reported to Commission. [Previous timescale of 23rd January 2006 not fully met] That an action plan, with timescales, must be devised to rectify the matters identified in the fire risk assessment and a copy of this action plan sent to Commission. [Previous timescale of 9th June 2005 and 28th February 2006 not met] That the safety of service users in wheelchairs must be addressed. [Previous timescale of 1st February 2005 not met] DS0000041644.V289870.R01.S.doc 23 OP33 24 [2] 31/07/06 24 OP36 18 [2] 30/06/06 25 OP38 37 24/04/06 26 OP38 23 [4] [c] & 13 [4] [c] 24/04/06 27 OP38 13 [4] 24/04/06 Southdowns Nursing Home Version 5.1 Page 30 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 2 3 3 4 5 Refer to Standard OP7 OP7 OP7 OP37 OP19 OP37 Good Practice Recommendations That formal training in care planning should be arranged for all qualified and care staff. That care staff’s knowledge and involvement in service users’ care plans should be reviewed again. [Previous timescale of 1st February 2005 not met.] That the home’s restraint policy and procedure should be expanded upon. A planned programme of routine maintenance, renewal of the fabric and decoration of the premises should be drawn up. [Previous timescale of 2nd July 2004 not met] That attention should be given to ensure all staff sign, read and understand policies and procedures held in the home. Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 31 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. Extracts may not be used or reproduced without the express permission of CSCI Southdowns Nursing Home DS0000041644.V289870.R01.S.doc Version 5.1 Page 32 - 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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