Inspection on 09/06/05 for Southdowns Nursing Home

This inspection was carried out on 9th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Southdowns Nursing Home 06/07/07

Southdowns Nursing Home 24/04/06

Southdowns Nursing Home 23/01/06

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 09 June 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Southdowns Nursing Home Address The Green St Leonards On Sea East Sussex TN38 0SY 01424 439439 01424 439439 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Paydens Limited Barbara Ann Ford Care Home 39 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD) of places Dementia (DE) 39 Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is thirty-nine (39). 2. That service users with a dementia type illness who require nursing care must be aged forty-five (45) years or over on admission. 3. That the homes category of registration is a care home providing nursing care. 4. That service users with mental disorders who require nursing care must be aged sixty-five (65) years or over on admission. Date of last inspection 01 February 2005 Brief Description of the Service: Southdowns Nursing Home is registered to provide care and accomodation to 39 service users with dementia from the age of 45 years and service users with mental disorders from the age of 65 years.It is located on The Green in St Leonards-on-Sea in a residential area. Shops and transport links are close by.There are two floors, thirty-nine single bedrooms all with en-suite facilities, a passenger lift, communal rooms and gardens which are not yet fully accessible to service users. Since the last inspection the home has increased its registration from 30 to 39. Major building works are continuing as the home is proposing to increase its registration again from 39 to 48 by the end of July 2005. On the day of the inspection there were 33 service users residing in the home. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place between 9.30am and 5.15pm and was carried out by two inspectors. A total of 25 standards including 18 out of the 20 key standards were inspected. Several service users were met and spoken to during the course of the inspection as well as a relative who was visiting the home. A tour of the premises took place. Individual discussions were had with the Manager, deputy Manager and staff members. Time was also spent examining records and a lunchtime meal was taken. This report is published in the absence of a response or action plan being received from the home within the set timescale relating to the draft inspection report. What the service does well: What has improved since the last inspection? The home has completed the main part of their extension and increased their registration from 30 to 39. The staff team have remained motivated during the course of time the home has undergone extensive refurbishment. The new build that has been completed so far is well presented. More staff are either working towards a qualification in care or will be shortly. The home has made progress since the last inspection in organising training for staff and begun to arrange for staff to receive formal supervision sessions. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 6 Now that the home has a registered Manager it is anticipated areas that require attention will be addressed. Fire matters identified at the last inspection have received attention. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 The home’s statement of purpose and service user guide requires updating so that new and existing service users are fully informed about the details of the services the home provides to enable an informed decision to be made about admission and stay in the home. The pre-admission assessment documentation was not always fully completed and care plans lacked holistic details, therefore the full care needs of service users are not known in order to guide staff in meeting service users needs. EVIDENCE: Since the last inspection there has been some attempt to up date the home’s statement of purpose and service user guide, however the information contained in these documents is still incomplete. The requirement remains unmet and will be carried forward. Many pre- admission assessments were filed and incomplete, undated or signed, so it was not possible to evidence that the content was gained before admission. Some significant details were omitted ie MRSA. The care plans lacked detail in providing guidance to staff as to how care was to be managed. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Care plans lack actions to bring about identified outcomes. There was no evidence in the care plans of choices made by service users with regard to their care in the home. More information should be recorded so as to provide staff with the information they need to meet service users needs. EVIDENCE: Some service users admitted after 19th May 2005 did not have a care plan. Assessed needs were clear but some plans lacked detail ie “reasonable diet and fluids taken” related to a service user on fortified drinks and assessed by nutritional risk assessment to be underweight. There was no supporting information in the care plan to establish diet taken or fluids consumed over time for evaluation basis. There was no evidence that service users or significant others were involved in care planning or reviews. Oral care was not detailed in the care plan even for a service user with an identified dental problem awaiting an urgent appointment. Nor did her appearance support good oral hygiene that should have been provided that morning. Care plans were updated monthly. Waterlow assessments were reviewed frequently but there was not evidence to guide staff with clear action, new targets or goals. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 10 Wound dressings were clearly assessed and dressing identified but did not detail the frequency of the procedure. Staff used equipment available to promote tissue viability and had followed comprehensive continence training. Risk assessments for falls were in place. A new generic risk assessment for service users is also to be introduced. Identified at the last inspection was the need to increase care staffs knowledge and involvement in service users care plans. It was not evident from speaking to a staff member this had been achieved and the Manager confirmed this had not be done. The recommendation remains unmet and will be carried forward. A programme of activities is provided; daily records do not reflect service users involvement in activities. A new clinical room stores all medication and dressings on the first floor. A monitored dosage system is not yet in place. A Pharmacist from the Commission for Social Care inspection is to visit the home to advise on medication practices and systems. On the day of the inspection staff demonstrated a caring and respectful approach to service users, however some staff were heard to use verbal endearments that were unprofessional and this was shared with the Manager. Not all service users had their alarm call bells or drinks within reach in rooms and this must be attended too. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 There was no evidence of choice detailed in the care plans. Religious observance was mostly not recorded. There is not enough evidence to clearly show how service users recreational and social interests are met or evaluated so as to enrich service users lifestyles. Advocates can mediate for service users. Meals are mostly homemade, balanced and varied. Special diets are accommodated. EVIDENCE: There is currently one activities co-ordinator and another person is shortly to be appointed. The activities co-ordinator was not on duty on the day of the inspection. It was said by the Manager that when two co-ordinators are employed, activities for service users should improve by introducing flexible activities at weekends. At the current time the poor recording of activities does not enable staff to evaluate the benefit of activities for service users. It was seen during the course of the inspection that craft work had been undertaken by the activities co-ordinator and this was displayed in the lounges. It was reported that families tend to visit at weekends and every six weeks the home organises a fete. Whilst observing care staff there was minimal evidence to demonstrate how they engaged with service users to promote interests and recreational activities. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 12 Some service users expressed the view that they could not go out in the garden as much as before since the building works started. Some service users rise very early and their choices are not recorded in the care plans, nor is it possible to evidence evaluation. A visitor spoken to at the inspection praised the staff as well as the care and attention given to their relative who had recently been admitted. Visiting times are open and flexible. The home will facilitate service users to have contact with advocates to support their affairs. Service users are encouraged to bring small items of furniture or furnishings. The home has two experienced chefs and a kitchen assistant. The kitchen is new and purpose built. Meals are freshly prepared. Both inspectors consumed a lunchtime meal, one sat with service users at lunch. The meal was hot and tasty. Snacks are offered throughout the day. Service users commented on the good quality of the food. Menus are reviewed periodically. Staff were willing to assist, but it was observed they did not sit with the service user to do this. All catering staff have received training in food hygiene. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Although the home has adult protection policies and procedures in place it is difficult to judge staffs’ knowledge and understanding as they have not had training in protecting service users from abuse. There is a need for the home to keep a record of any complaints referred to them or ones they receive. It is important that interested parties and service users are aware they can refer a complaint to the Commission For Social Care Inspection in order that they are fully informed about the different ways of raising concerns should the need arise. EVIDENCE: Since the last inspection a current complaint sent directly to the CSCI has been referred back to the provider to investigate and report the outcome of the home’s investigation directly to the complainant. Following examination of the home’s complaint policy and procedure it was not apparent where the name, address and telephone number of the Commission For Social Care inspection was should the need arise to refer a complaint back to the CSCI. The complaints log examined was found to be empty. There is a need to keep a record of all complaints referred or received by the home in this log. An adult protection and whistle-blowing policy and procedure was available. Since the last inspection there has been one adult protection investigation that has been concluded. A copy of the Protection of vulnerable adults guidelines [POVA] was not found and steps must be taken to obtain a copy. It was reported that staff had not received training in adult abuse, however training sessions were planned to take place the week following the inspection. This standard will be examined again at future inspections to ensure all staff have received this training. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,24,26 There has been considerable noise and disruption to service users and staff over several months whilst extensive building works have taken place. When these works are finally completed it is anticipated that full attention will be given to ensure the home is safe, well maintained and fully accessible so as to provide service users with a comfortable home. In the interim matters identified that require attention must be addressed to ensure the safety and comfort of service users with particular attention given to maintaining service users’ privacy and dignity. EVIDENCE: Since the last inspection the home has increased its registration from thirty to thirty-nine. Ongoing building works continue as the home is proposing a further increase in numbers to forty-eight by the end of July 2005. It was originally anticipated these works would be completed by February 2005. A second variation application has been submitted to the Commission For Social Care inspection for this final increase and the home is aware they must contact the CSCI when these works are complete so that a site visit can be arranged to approve the use of additional rooms and communal space. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 15 Identified at previous inspections has been the need to produce a planned programme of routine maintenance, renewal of the fabric and decoration of the premises. This remains unmet and the recommendation will be carried forward. Although building works are reaching their final stages, it was seen that some working practices must be reassessed by the Manager on a daily basis as part of the home’s health and safety plan to ensure service users are not at risk of harm or injury in terms of wandering into areas where these works are taking place. The inner courtyard remains unusable to service users at the present time as well as most areas of the garden. Not all the communal areas are available to service users at the present time whilst building works continue, some of these rooms are storing aids and adaptations. All exit doors are alarmed. Wide window openings were found in the activities room and a first floor assisted bathroom. The door opening mechanism in a first floor lounge requires repair as this was found to be broken and propped open with a heater. There was a hole in a first floor bathroom ceiling. Several service users bedrooms were seen. On the whole these were found to be furnished and decorated to a standard that met service users needs. One service user’s bedroom did not have a chest of drawers or wardrobe, bed rails were in place as well as two arm chairs that were propped up against the bed. The alarm call lead was not nearby. The appearance of this room was stark and the manner in which this person was seen to be confined in their bed was undignified. A requirement has been identified about this person’s privacy, dignity, means of restraint and that any future practices must be agreed and approved as part of a multi disciplinary approach. A service user’s bedroom door on the first floor was sticking leading to difficulties in opening. The en-suite in the same room was untidy and contained a full bag of clinical waste, there was also a cracked wall socket. A jug of drink and glass in the same room was empty. It was reported that risk assessments had been compiled for all service users requiring bed rails and that new bed rails for service users had been ordered. Identified at the last inspection was the need to have an assessment of the premises and facilities carried out by suitably qualified persons. This remains unmet and will be carried forward. Since the last inspection a new laundry room has become operational and all laundry is now washed on site. This room was suitably equipped and separate hand washing facilities were available. Apart from a service user’s en-suite already mentioned and a bedroom that had some odours, the home was found to be clean. Other specific health and safety matters have been identified under standard 38. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Staff morale in the home is good and staff seen during the course of the inspection worked with enthusiasm. Close monitoring of staffing levels should be maintained according to service users changing needs so that where necessary one to one time is available to service users especially those who spend the majority of their time in bedrooms. The home has made progress in their staff training and development programme. It would benefit the home to have to have a dedicated training officer especially as the home is expanding in numbers in respect of service users and staff so that a clear and focused approach can be fully achieved in order to benefit the outcomes to service users. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 17 EVIDENCE: It was reported that sufficient staffing levels are in place to meet service users current needs. There are two registered nurses on duty throughout the day and eight care staff. At night there is currently one registered nurse and four care staff on duty. It was said that there is to be an increase in qualified staff by one at night. There are currently two staff off sick and it was reported that the same agency staff would be employed to cover this deficit. The Manager is in addition to these staffing levels working 9-5pm during the week. Staffing levels should be kept under regular review and increased as necessary according to service users changing needs. The deputy undertakes a dual role of being on duty as well as organising and delivering training to staff. Following examination of the rota there is a need to ensure that when staff are not undertaking care duties and are attending or organising training a clear record of this should be recorded on the duty rota. There must be sufficient staffing levels maintained at these times to look after service users. There are adequate numbers of separate ancillary, catering and administrative staff. Infrequent staff meetings take place and it is recommended that more regular meetings occur. When service users are in the lounge a member of staff remains in these rooms so that service users are not left alone. This practice was seen to happen during the inspection. Recruitment practices address Criminal Record Bureau checks and obtaining references, however there is no record kept of prospective staffs interviews, so it was not possible to evidence questions asked or if any gaps in employment had been had been explored. There are currently two staff trained at NVQ level 3 and one person trained at level 4 in management. It was said that three staff are currently working towards their NVQ level 2 and five staff are to do level three. Since the last inspection a staff training and development plan has begun to be devised and induction packs have so far been compiled for carers and ancillary staff. The deputy manager organises and oversees training, quality assurance and supervision of staff in the home. Further attention should be given to how this is working in terms of this person having a mixed role of trainer, deputy Manager and head of care. Individual staff training and development profiles are being introduced that are in their early stages of development currently containing core training details. These will need expanding upon and systems set up so that triggers for when Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 18 refreshers for core and statutory training is due is clearly recorded and actioned. The deputy Manager advised about a range of different training sessions that had taken place to date as well as future sessions planned. This standard will be examined again at future inspections. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34,36,38 Further attention should be given to the overall running of the home in respect of health and safety matters, regular supervision of staff and collating feedback from quality assurance audits so that the home can act upon any findings and review its performance. There is also a need for the home to be more robust in actively complying with requirements made at previous inspections as there are current difficulties in judging the effective management of the home and senior staffs roles and responsibilities. Clearer lines of accountability, roles and responsibilities do need to be established. EVIDENCE: Since April of this year the Manager who is a qualified nurse has become registered with the Commission For Social Care Inspection and is working towards the Registered Manager’s award. Identified at previous inspections was a requirement for the monthly conduct reports of the home under Regulation 26 to be sent to the CSCI. These have not been received and were unavailable to examine on the day of the inspection. This requirement will be carried forward. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 20 Since the last inspection it was said that quality assurance questionnaires had been given to some service users and sent out to relatives or next of kin and other interested parties within the last two months with responses awaited. It was said at this inspection and the last one that this questionnaire required modification and that no collation of findings from the previous years questionnaires had been achieved. A requirement made at the last inspection in respect of developing further the home’s quality assurance systems will be carried forward. Identified at previous inspections was a requirement for the home to make available for inspection a business and financial plan. On the day of the inspection this was unavailable and the requirement will be carried forward. Following discussions with senior staff it was said that supervision sessions for care staff had begun, although this was not recorded and staff had not received these sessions at least six times in a year. The Manager and deputy have not had supervision sessions. It is recommended that a plan for when supervision sessions take place is introduced and although there has been some progress in this area the requirement made at previous inspections will be carried forward. A range of policies and procedures were available and a sample of different health and safety records were examined such as a current gas safety inspection, fire equipment checks, lift inspection, alarm call systems, portable appliance checks, COSHH and water temperature checks. The accident record was examined. Frequent recording was made and this was up to date. It was discussed with the Manager that due to the number of incidents recorded in this book where service users had fallen, steps should be taken to update service users care plans and risk assessments following these accidents. It was said that there were no staff trained in First Aid who were on shift during the inspection. Steps must be taken to ensure a First Aider is on duty. In respect of moving/manual handling training it was reported all staff with the exception of two new staff and the Manager had received training and sessions to include these staff has been arranged to take place in July. Infection control training has not taken place so far and this must be arranged. From examination of records and speaking to staff it was confirmed that all staff have received training in fire safety. Fire risk assessments of the building were examined. There is a need to follow through matters that have been identified as requiring attention within this document and keep a record of action taken. There was evidence that two fire drills had taken place so far this year including a record of staff attendance. It was reported that all staff have now taken part in these drills. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 21 Identified at previous inspections was for the home to compile a generic risk assessment for the house. It was seen that a monthly checklist for rooms was in place however this is not in a risk assessment format. This requirement will be carried forward. Reference to the top floor where staff receive training should be included as this was found to be cluttered and could pose a risk to staffs health and safety. Other specific health and safety matters raised during the inspection was that supplementary heaters are in several service users bedroom, one of which had unsteady legs. Risk assessments for these apparatus were not in place. A service user was seen without footplates or safety straps in their wheelchair. The safety of service users who do not wear safety straps whilst in wheelchairs must be addressed. Both of the above matters were requirements identified at the last inspection and remain unmet. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 x x 2 x 1 x 2 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 Standard No 16 17 18 Score 2 x 2 2 x 2 2 x 2 x 2 Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 6 [a] Requirement The home’s statement of purpose and service user guide must be updated. Refer to Schedule 1 of the regulations and standard 1.2 [Previous timescale of 30th September 2004 not met] Pre-admission assessment documentation must be fully completed and detailed care plans drawn up. Comprehensive and detailed care plans must be in place for all service users including documenting service users choices. Where possible the content must be drawn up and agreed with the service user or a representative. That staff must maintain a service users oral hygiene and record assessed needs in a care plan. That service users must have a call bell and drinks within reach in their rooms. That a joint review of practices must be undertaken in respect of meeting service users social and recreational interests by care staff and the activities coTimescale for action 1st September 2005 2. 3 14 [1] & 15 [2] 15 [1] [2] Immediate 3. 7 Immediate 4. 8 12 [1] Immediate 5. 6. 10 12 12 [4] [a] 16 [m] [n] Immediate 31st July 2005 Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 24 7. 16 22 [7] [8] 8. 9. 18 19 & 24 19 13 [4] & 23 [2] [b] 10. 10 & 24 12 [4] 13 [1] 23 [2] [m] 11. 27 17 [2] ordinator.Records of activities provided to each service user including evaluation of these activities must be introduced. The name,address and telephone number of the Commission for Social Care inspection must be recorded in the homes complaint policy and procedure. A record of all complaints in the complaint log must be maintained. A copy of the Protection of vulnerable adults guidelines [POVA] must be obtained. The safety of service users from wide window openings must be addressed. The door opening mechanism in a first floor lounge must be repaired. A service user’s bedroom door on the first floor must be repaired. The ensuite in the same room must be tidied & a cracked wall socket repaired.The hole in a first floor bathroom ceiling must be repaired. Safe working practices must be assessed daily whilst building works continue to ensure service users are not at risk of harm or injury around these areas. A review of a service user’s bedroom accomodation and facilities must be carried out as well as the way in which the management of care is currently provided including the current means of restraint.Clearly agreed muti- disciplinary practices must be sought and recorded. A clear record on the duty rota must be kept when staff either attend or organise training sessions.Sufficient staffing levels to look after service users must be maintained at these times. Immediate Immediate Immediate Immediate Immediate Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 25 12. 28 18 [1] [a] 13. 14. 29 31 19 [1] [a] [c] 26 [5] [a] 15. 33 24 [1] [3] 16. 34 25 [1] [2] 17. 36 18 [2] 18. 19. 20. 21. 38 38 38 38 13 [4] & 15 [2] 13 [4] 13 [3] 23 [4] 22. 38 13 [4] The home must ensure a minimum ratio of 50 of care staff have achieved NVQ level 2 or equivalent. [Previous requirement carried forward] That gaps in employment must be explored at interview. The monthly conduct reports of the home must be sent to the CSCI.[Previous timescale of 1st February 2005 not met] Further development of the home’s quality assurance and monitoring systems must be undertaken in accordance with this standard. [Previous timescale of 31st March 2005 not met] A business and financial plan,open to inspection and reviewed annually must be available.[Previous timescale of 30th September 2004 not met] Care and senior staff must receive formal supervision sessions at least six times a year. Records must be kept and and an overall plan compiled as to when these take place. [Previous timescale of 30th September 2004 not met] Steps must be taken to update service users care plans and risk assessment following falls. That staff trained in First Aid must be on duty. That training for staff in infection control must be arranged. That a record must be kept to show how matters identified as requiring attention in the fire assessment have been addressed. Compile generic risk assessments for the home.[Previous timescale of 2nd July 2004 not met] By 2005 Immediate Immediate 31st August 2005 Immediate Immediate Immediate Immediate 31st August 2005 Immediate Immediate Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 26 23. 38 13 [4] Risk assessments for supplementary heaters must be compiled. The safety of service users who do not wear safety straps whilst in wheelchairs must be addressed.[Previous timescale of 1st February 2005 not met] Immediate 24. 25. 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. 4. 5. 6. Refer to Standard 7 19 22 24 27 30 Good Practice Recommendations Care staffs knowledge and involvement in service users care plans should be reviewed. [Previous timescale of 1st February 2005 not met] 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] The Manager should arrange to have an assessment of the premises and facilities undertaken by suitably qualified persons.[Previous timescale of 1st February 2005 not met] A closer overview relating to daily maintenance of the home and wheelchair checks should be introduced. Regular staff meetings should be introduced. Further attention should be given to streamlining the training and development role. Southdowns Nursing Home H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 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 H59-H10 S41644 Southdowns Nursing Home V223105 090605 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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