Inspection on 06/07/07 for Southdowns Nursing Home

This inspection was carried out on 6th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Southdowns Nursing Home 24/04/06

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 Caroline Johnson Key Unannounced Inspection 08:50a 06th July 2007 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.V345924.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 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 718806 adminr@southdownsnursinghome.co.uk Paydens Limited Mr Dennis Charles Pay vacant post 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.V345924.R01.S.doc Version 5.2 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 15th January 2007 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 £516-£738 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.V345924.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection process two site visits were carried out. The first was on 6 July 2007 from 08:50am until 16:30pm and the second on 9 July 2007 from 09:30am until 13:00pm. During the inspection there was an opportunity to meet with the manager, deputy manager, head of housekeeping, chef and with two care staff. In addition time was spent observing lunch, part of an activity and in speaking with some of the residents. A wide range of documentation was examined including, pre admission assessments for two recently admitted residents and four care plans. Records held in relation to quality assurance, staff recruitment, rotas and training, accidents, menus, fire records and health and safety were all examined. Whilst not all bedrooms were seen, a tour of the building was carried out and this included a number of bedrooms, all communal areas, bathrooms, and kitchen and laundry areas. In advance of the inspection the manager completed an AQAA (annual quality assurance assessment) and information from that document has also been included in this report. Prior to the inspection a range of surveys were sent to the home for distribution to the residents and to their relatives/representatives. Ten of the residents completed the surveys with support from staff. Eight responses were received from relatives. Following the inspection three relatives were contacted by telephone to seek their views of the quality of the care provided in the home. Comments from relatives included: - ‘I’m very happy, couldn’t wish for better care’, ‘the home do their utmost to involve my relative in activities’, ‘the home is beautifully clean’ and the ‘staff are always friendly and if worried you can talk to them at any time’. ‘The staff are kind and work really hard, everything is always clean and tidy, they really can do with an extra person on each floor to help’. I feel relaxed and confident that mum’s needs are met and that she is treated with respect and dignity’. ‘Always a pleasant greeting when we arrive plus an offer of tea and biscuits’. In relation to the residents’ surveys, overall the response was positive. However, in relation to a question asking if they had received enough information in advance of moving in, six said they did not and in relation to knowing how to complain, seven said they wouldn’t know how to complain. Other comments made included ‘I am quite happy here’ and ‘very good’ in response to cleanliness in the home. Since the last inspection the registered manager has resigned from her position as manager. A new manager has been appointed and he will shortly Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 6 be submitting his application for registration. The manager is a qualified nurse and is currently studying for the RMA (Registered Managers Award). Since the last Key inspection a random inspection was carried out in January 2007. At that time good progress had been made in addressing the requirements of the key inspection but there were still some requirements outstanding and a few additional requirements were made. What the service does well: What has improved since the last inspection? What they could do better: Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 7 As a result of this inspection four requirements and three good practice recommendations were made. Most refer to building upon and improving upon quality rather than the need to introduce systems. Whilst the range of activities is wide, participation in activities is often low. This in part is due to the complex needs of the residents accommodated and the home now needs to explore additional ways of meeting residents’ recreational needs. The policies in place on both restraint and on adult protection need to be amended to provide clearer advice for staff. The home carries out periodic environmental assessments and following this, agreement is reached about the areas that require redecoration or work undertaken. This needs to be formalised so that a record is kept of all action plans and proposed timescales. In order to improve the quality assurance system even further the registered person should draw up an annual development plan. 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. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information provided to prospective residents is detailed and the plans to enhance this even further will be of benefit to future residents. The improvements made to the pre-admission assessments particularly in relation to meeting residents’ emotional needs will assist in helping residents as they move into the home. EVIDENCE: The statement of purpose was not seen on this occasion. However the service user guide was seen and it had last been updated in September 2006. The document contained detailed advice about the home and the facilities available. Six out of ten of the residents that completed a survey in advance Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 10 of the inspection stated that they did not receive enough information about the home before they moved in. Within the AQAA (annual quality assurance assessment) completed by the home in advance of the inspection there was reference to the home re-writing their brochure and that they had plans to edit the service user guide. They are also looking at having the document produced in different languages. Pre admission documentation was seen in relation to two residents recently admitted to the home. Record keeping was very detailed however, in one case it was noted that the assessment was not dated or signed. A care plan to cater for emotional needs on moving into the home has been introduced and this included detailed advice for staff to follow. In relation to one resident there was specific information about the resident’s condition and about the need to give extra time for them to mobilise safely. In relation to the second resident there was clear advice for staff about the need to repeatedly explain whom they are and what they are going to do for the resident. There was also advice about encouraging walks and showing the resident a photo album as a way to helping them to settle in. The home does not cater for intermediate care. A resident who had recently moved into the home advised that staff had been very helpful. The room they were in had been personalised and they enjoyed telling a story that related to one of the photos on display. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home made significant progress in ensuring that care plans are more holistic so as to ensure that all staff have an even greater understanding of the needs of the residents and how they are to be met. EVIDENCE: The manager advised that they are in the process of introducing a new way of care planning. In the past the system was heavily focussed on meeting the physical needs of the residents and care staff had very little involvement in the plans other than to report to qualified staff what they observed and the nurses would then update the changes. As a way of encouraging all staff to be involved in care planning, global care plans are to be introduced in the next Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 12 three weeks. Care staff will receive basic information about the nursing needs of residents and will continue to report their observations to nurses. In addition they will receive very detailed information about the social and emotional needs of the residents and they will be responsible for recording how they are met. The intention is that everyone will be involved in the process. Since the last inspection the improvements made to the current system for care planning are significant. Four care plans were examined in detail and all assessments were up to date. Care plans were detailed and had been reviewed at regular intervals. Where cot sides are used then relatives are also asked to sign that they are in agreement. Advice is included on meeting the emotional needs of the residents. In some of the files seen choice sheets were included so that staff could seek the views of the residents in relation to what they wanted to wear, whether to have a bath/shower, what to eat, what time to get up/go to bed and whether to participate in activities. In relation to one resident where it was considered possible that there could be a sudden deterioration in their condition there was advice for all staff on possible signs to watch out for that could mean a deterioration was about to occur. In relation to another resident’s care plan there was very detailed information about their sight impairment and separately information about meal times but no information about any impact poor sight could have in relation to meal times. In another resident’s care plan it was evident that this resident had epilepsy. Whilst there was information about what to do should this resident experience a seizure there was no information about the type of seizures experienced by this person so that staff would be aware of what to watch out for. The arrangements in place for the storage and administration of medication were in order. It was reported that a double signature is maintained in the CD (controlled drug) register and that there is now a double signature in the MAR (medication administration record) chart. Four of the qualified staff have attended training in the past year in medication management and five have attended training on liquid medication management. Records are also kept of all other relevant courses attended including wound care, bowel management and anaphylactic shock training. Throughout the inspection staff were observed to treat residents with respect and dignity however there was one exception to this where a member of staff was overheard speaking to a resident in an inappropriate manner. This was reported to the manager who advised the action that would be taken to ensure that this did not occur again. Following the inspection the home was advised to report the matter to Social Services for possible investigation as an adult protection matter. Over the lunch period, and whilst observing one of the group activities a bit later, it was noted that one resident repeatedly told another resident to be quiet. This would have been difficult for staff to notice Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 13 as often the comments were said in a quiet voice but could nonetheless be detrimental for the resident concerned. This was reported to the manager who advised that they would monitor this more closely. The home is to be commended for the progress made in this area. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has worked hard to develop their activity programme and to ensure that everyone is offered regular opportunities to participate in interesting and stimulating activities. EVIDENCE: An activity programme is organised four weeks in advance. The home aims to have an outing and an external entertainer in the home on a monthly basis. One of the most recent trips was to the Sealife centre. Activities are held each day. The home has just recruited a second activity organiser so it was reported that the range of activities would increase and develop even further. Mornings are generally a time for the organisers to work on a one-to one basis with residents and in the afternoons group activities are organised. On the day of inspection there was a bingo session and board games were played. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 15 Approximately seven residents participated in the bingo and in addition to the activity organiser a carer also supported residents to participate in the activity. The residents appeared to enjoy the activity. A religious service is held on a weekly basis and twice a month there is Holy Communion. The range of activities available includes art, bingo, gardening, seasonal craft, musical bingo, knitting, physical motivation, bowles, baking, board games and pat dog. There is also a hairdresser in the home on a weekly basis. It was reported that the activity co-ordinators would be attending a course in September on organising group activities for older people. Record showed that for group activities the numbers of participants varied from three to fifteen. Some residents attend activities regularly and others need encouragement. Between the two days of inspection the home had a very successful garden party. The turnout for the party was very good and the home was fortunate with the weather so a large number of the residents were able to spend time in the garden. Money raised from the event will be used to enhance the activities available and to fund further outings. The co-ordinator advised that the next big event would be the Summer Fayre. The manager advised that they have organised a relatives meeting to be held in August. This is the first of what is hoped will become an annual event. There was an opportunity to observe the lunchtime meal served on the ground floor on the first day of inspection. Approximately seven residents ate at the dining tables and a further nine residents ate in the lounge area either using a lap table or being fed in the recliner chairs. It was noted that one resident had chosen to have an alternative to the main meal and that one resident chose to have a glass of Guinness with her meal. There are two choices of main meal and a vegetarian option every day. In the evening there is a hot meal and a selection of sandwiches. At 3pm each day a menu sheet is distributed to each resident and those that require support are assisted to make choices for their meals the following day. The chef has a list of each resident’s likes and dislikes and how they should have their food, for example, if it needs to be pureed. Any changes to the way food is to be presented must be agreed by a qualified member of staff. The four-week menu provided looked varied and well balanced. Five of the qualified staff attended nutrition training earlier this year. Following the last inspection the home put together eating and drinking guidelines to assist staff in supporting residents with this task. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst the home has ensured through staff training that all staff are aware of the correct procedure to be followed if they witness or suspect abuse, the home’s policy on the subject remains out of date and this could potentially cause confusion. The home needs to remind residents and relatives how they can make a complaint if they should so desire. EVIDENCE: There was only one complaint in the complaint folder and it was reported that this was the only complaint made since the last inspection. A detailed investigation had been carried out and the matter was resolved satisfactorily. It was reported that communication with relatives has improved in recent months and that relatives now approach staff more readily if they have a concern so that it may be dealt with swiftly without the need for a formal complaint process. The importance of keeping a chronological list of all complaints made to the home was stressed. Four of the ten residents that completed a survey in advance of the inspection said that they would not know who to speak to if they were unhappy and Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 17 seven of the ten said that they didn’t know how to make a complaint. Of the eight relatives surveys received, five stated that they would know how to make a complaint about the care provided; one stated that they couldn’t remember, and two stated that they didn’t know. However, all stated that if they have ever raised any issues with the home, the home has responded appropriately. The home’s complaint procedure is on display in the reception area and it is also included in the service user guide. The home’s policy on restraint has been amended since the last inspection but further amendments are required to ensure that the advice provided is clear. There is a detailed policy and procedure in place on the protection of vulnerable adults. However, the policy needs to be amended to show that Social Services are the lead agency on adult protection. Separately the home has a flowchart in place detailing the correct procedure. Six of the nine qualified staff, 24 of the 35 care staff and 5 of the 8 house keeping staff have completed training on the protection of vulnerable adults. Two adult protection alerts have been made to Social Services since the last key inspection. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from living in a home which is well decorated and the periodic environmental checks ensure that the standards of décor are maintained and the building is kept comfortable, clean and homely. This could be enhanced further by finding a way of monitoring that all work identified through the environmental checks is attended to. EVIDENCE: A tour of the building was carried out including all communal areas, the kitchen, laundry and several bedrooms. All bedrooms seen were decorated well and had been personalised with ornaments and photos. The main lounge areas were also decorated well and some of the work carried out as part of the Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 19 activity sessions, were also displayed in these areas. Two of the lounges areas are used only for religious services, for meetings with relatives or for staff training purposes. These areas whilst decorated well are less inviting (layout of chairs) and generally not used much by residents. It was noted that a detailed audit of the environment had been carried out the week prior to the inspection. As part of this audit all areas in need of redecoration were highlighted. It was reported that following this audit the housekeeper would meet with the maintenance person and agree which areas were a priority. The maintenance person then keeps a record of all work carried out. Currently there is no record of these meetings or of the action plan agreed. At the time of inspection work was underway to paint the corridor areas in one part of the building. In relation to fire safety, a fire risk assessment was carried out in October 2006. Records show that all recommendations made as a result of this assessment have been completed. The majority of the staff team attended fire safety training in April 2007. Records showed that the weekly tests of the fire alarms and monthly tests of emergency lights were last tested in April 2007. Training on infection control was provided to staff on the first day of inspection. Two sessions were held, one in the morning and one in the afternoon. The manager advised that all staff were expected to attend the course. Staff are employed to carry out laundry duties and there is sufficient equipment in this area for this purpose. All relatives spoken with and a high percentage of the residents and relatives’ surveys make reference to the high standards of cleanliness in the home. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The training opportunities available to staff equip them to meet the varied and complex needs of the residents accommodated. EVIDENCE: Staff spoken with stated that within recent weeks staffing levels have improved and there have been fewer agency staff. Generally there are two nurses and eight care staff plus the manager and head of care on duty Monday to Friday. In addition there are catering, laundry and domestic staff on duty. At night there are two nurses and two care staff on duty. In respect of staff recruitment, three staff files were examined in detail. In each case there was an application form and two references although it was noted that the character reference in one file could have been from a relative. There was confirmation of identification and a photo in only one of the files seen. It was reported that CRB (Criminal Records Bureau) checks have been carried out on all staff and are stored elsewhere. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 21 All staff receive a thorough induction to the home. Staff advised that they shadowed a more experienced member of staff for three shifts before working on their own. Three induction folders were examined and this demonstrated that the induction is comprehensive covering a wide range of topics. Two of the files were fully completed and the third was at least half completed. However, this staff member confirmed that she had completed her induction. The manager advised that she would be completing a course that would enable her to train staff in manual handling. In addition another member of staff has completed an advanced health and safety course, which means that she will now be able to train on this subject and she is hoping to also complete a similar course on food hygiene. There are a wide range of training opportunities available to staff which conclude fire safety, infection control, food hygiene, concepts of mental illness, dementia, pova and health and safety. Nursing staff also have access to a wide range of training to enable them to keep their knowledge and skills up to date. At the time of the last inspection the housekeeper advised that she would like to introduce an induction package for auxiliary staff. This has since been introduced. All new auxiliary staff also shadow more experienced staff until they are confident and competent to work on their own. They too must complete mandatory training, receive a job description and are supervised at regular intervals. Records show that six care staff have completed NVQ level 2 or above and that nine staff are currently working towards achieving this qualification. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed for the benefit of all residents. The audits carried out in relation to accidents indicate that the home is clearly trying to identify why accidents occur and take measures to prevent similar occurrences. EVIDENCE: Since the last key inspection of the home the registered manager has resigned from her post. A new manager has been appointed and he advised that he Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 23 would shortly be submitting his application for registration. He holds an RMN qualification and is a little more that half way through the RMA (Registered Managers Award). He has previously been registered as manager of the home. All staff spoken with stated that they found the new manager to be very approachable. Quality assurance is carried out in a number of ways. The home has recently distributed satisfaction questionnaires to the relatives of the residents. At the time of inspection nine had been returned. The manager advised that once all responses have been received they would collate all the information and write to the relatives advising them of any taken as a result. He also advised that the outcome would be published in the service user guide. Of the nine responses received feedback was generally very positive. Some of the relatives provided constructive criticism and these had already been collated and a member of staff had been allocated to address each area. One area was already addressed and this was in relation to the appointing of a second activity co-ordinator. Weekly and monthly audits are carried out in the home. These audits cover a variety of areas including, care plans, medication, pressure sores, accidents, environment, kitchen, housekeepers audit. A detailed check is made of each area and if issues are highlighted then an action plan is put in place to address the issues or a record is made on the audit of the action taken. The deputy manager advised that since introducing the regular audits standards have improved greatly. The home is to be commended for the work achieved to date in relation to quality assurance. Currently there is no annual development plan in place. As part of the inspection process attempts were made to contact the relatives of four of the residents. Three relatives were spoken with. Everyone spoke very positively about the home with comments such as ‘I’m very happy, couldn’t wish for better care’, ‘the home do their utmost to involve my relative in activities’, ‘the home is beautifully clean’ and the ‘staff are always friendly and if worried you can talk to them at any time’. In advance of the inspection, survey cards were sent to the home for distribution to residents and their relatives. Ten of the residents received support to complete these forms. Eight relatives completed surveys. In relation to the residents’ surveys, overall the response was positive. However, in relation to a question asking if they had received enough information in advance of moving in, six said they did not and in relation to knowing how to complain, seven said they wouldn’t know how to complain. Comments made included ‘I am quite happy here’ and ‘very good’ in response to cleanliness in the home. ‘I don’t get tea in the morning (early)’ and in response to carers listening to what is said, the response was ‘usually’ with a comment ‘slack in the mornings’. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 24 In relation to the relatives’ survey forms, overall the response was also very positive. There were a number of comments made including ‘the staff are kind and work really hard, everything is always clean and tidy, they really can do with an extra person on each floor to help’. I feel relaxed and confident that mum’s needs are met and that she is treated with respect and dignity’. ‘Always a pleasant greeting when we arrive plus an offer of tea and biscuits’. ‘It provides a caring, professional environment for vulnerable people’. This person stated that they would like the home to ‘provide a brief annual report on the mental and physical health’ of their relative and information about ‘medication and its purpose’. Feedback was given to the deputy manager following the inspection on the result of the survey forms. Although some of the areas highlighted by residents could be a result of problems with memory loss they will endeavour to remind residents at regular intervals of the procedures in relation to the issues raised. When checking through staff files it was noted in one file that the staff member had received a supervision session in recent months but that there were no records for other staff. However, when speaking with four staff individually all stated that they received regular supervision. It was noted at the end of the inspection that a separate supervision file is kept for storing supervision records. This area will therefore need to be assessed at the next inspection of the home. Following the inspection the home sent information to the Commission showing the dates that all staff received supervision. Records provided showed that the majority of the staff team have had regular supervision. All of the nursing staff received supervision in March but three of these staff have not received supervision since. Records of accidents were seen. It was noted that the home now keeps a chronological list of all accidents that occur in the home on a monthly basis and that this has made it easier to identify if there are any patterns. As a result of this new procedure the home has updated risk assessments, arranged an eyesight test for one resident and ordered a new chair for another resident. There were a range of measures in place to ensure the health, safety and welfare of both residents and staff. Records showed that all equipment is serviced and tested regularly. Portable appliances have all been tested within the last year. In addition there is an emergency folder in place detailing who should be contacted in various situations. It was noted that the adult protection, ‘out of hours’, details could be added to this folder. The home has been tested for Legionella and this is due to be redone again in the near future. The housekeeper advised that she completed a Legionella awareness course in April 2006. Regular checks are also made by the home to monitor the water temperatures. Hot water temperatures tested at the time of inspection were within agreed safety limits. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 25 Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 X 3 Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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 Requirement Information on the types of seizures experienced by a resident must be included in their care plan. The registered person must ensure that work highlighted as a result of the environmental audits is carried out within an appropriate timescale. The acting manager must apply for registration. The registered person must ensure that there is an annual development plan for the home. Timescale for action 15/09/07 2. OP19 23(2b) 30/09/07 3. 3. OP31 OP33 9(1,2) 24(2b) 30/09/07 15/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP16 Good Practice Recommendations The home should continue to explore ways of encouraging residents to participate in interesting and stimulating activities. The home should clarify the complaints procedure with DS0000041644.V345924.R01.S.doc Version 5.2 Page 28 Southdowns Nursing Home 3. OP18 residents and their relatives/representatives. The policies on restraint and adult protection should be amended to provide clearer advice for staff. Southdowns Nursing Home DS0000041644.V345924.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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