Inspection on 18/03/08 for Southerndown Nursing Home

This inspection was carried out on 18th March 2008.

CSCI found this care home to be providing an Adequate service.

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

Southerndown Nursing Home 18/07/06

Southerndown Nursing Home 02/03/06

Southerndown Nursing Home 27/07/05

Southerndown Nursing Home 03/01/05

Southerndown Nursing Home 22/07/04

Southerndown Nursing Home 02/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Southerndown Nursing Home Worcester Road Chipping Norton Oxfordshire OX7 5YF Lead Inspector Marie Carvell Unannounced Inspection 10:50 18 & 19th March 2008 th 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 Southerndown Nursing Home DS0000027169.V359452.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. Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southerndown Nursing Home Address Worcester Road Chipping Norton Oxfordshire OX7 5YF 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) 01608 644129 01608 641737 southerndown@barchester.com www.barchester.com Barchester Healthcare Plc Mrs Shirley Ann Archer Care Home 87 Category(ies) of Dementia - over 65 years of age (42), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (42), Old age, not falling within any other category (45), Physical disability (3) Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. On admission persons should be aged 60 years and over. Admittance of two named residents under the age of 60 in the PD category 18th July 2006. Date of last inspection Brief Description of the Service: Southerndown Nursing Home consists of two units providing a total of 87 beds for residents aged 60 and over. There are 45 beds in the original house for people who are physically frail. An extension (Memory Lane) was completed in 2002 to provide a further 42 beds for residents with mental health needs, generally dementia. The two units are linked by a covered walkway. Registered nurses are on duty 24 hours a day and are assisted by a team of carers and ancillary staff. Spacious lounges and dining rooms are provided on both units and there are extensive grounds surrounding the home. There is a secure area of garden at the back of the main house with fencing and a locked gate, and a secure courtyard garden on Memory Lane. The main house has a mix of single and double rooms, with Memory Lane having only single bedrooms. En-suite facilities are provided in some bedrooms in the main house and in all bedrooms on Memory Lane. Recreational activities are provided on both units and the home has transport that can be used for outings. The fees for this service range from £845 to £1071 per week. There are additional charges for hairdressing, chiropody (none diabetic service users), newspapers, toiletries and some outings. Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service 1 star. This means the people who use this service experience adequate quality outcomes. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’ carried out over two days. The inspector arrived at the service at 10.50 and was in the service until 17.00 on the first day and from 10.45 until 17.30 on the second day. It was a thorough look at how well the service is doing. It took into account detailed information provided by the registered manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection or who responded to surveys that the Commission had sent out. Eleven relatives, four healthcare professionals and three service users responded to surveys sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standards of the service. The inspector toured the building, examined records and met with service users individually and as a group. The inspector also spent time with the manager, deputy manager, nursing, care and ancillary staff. In addition the inspector spent time observing how care was being delivered to service users and joined service users for lunch on both days of the inspection. At the (main) inspection carried out in July 2006, six good practice recommendations were made; these are referred to in the body of the report. An additional unannounced, focussed inspection was carried in March 2007, following concerns expressed by the family of a service user about the conduct of a staff member employed at the home. No requirements or good practice recommendations were made at this inspection. Feedback was given to the manager and deputy manager, who were present throughout the two days. What the service does well: Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 6 All prospective service users and their representatives are provided with a copy of the home’s Service User Guide, Statement of Purpose and the home’s brochure. All service users receive a copy of the home’s terms and conditions, which details fees payable and additional costs. The manager or deputy manager then undertakes a pre- admission assessment to ensure that the home is able to meet the needs of the service user. Prospective service users and/or their representatives are encouraged to visit the allocated unit, before making a decision to move into the home. The medical needs of service users are met by local GP practices, who visit the home twice per week and as necessary. A range of healthcare professionals visit the home on a regular basis. From evidence seen and from discussion with service users and nursing staff, the health and medical needs of service users are well met. Staff were observed to interact with service users in a respectful and appropriate manner. Staff were observed addressing service users by their preferred term of address and in discussion with staff, were clear about the need to respect service users privacy and dignity. Two enthusiastic, full time activity organisers are in post. A weekly activities programme is displayed in the entrance hall as well in each of the units. In addition there is a monthly list showing events to be held in the home and a range of outings. Each service user has a social activities log, which details activities undertaken each day. These are well maintained. The home has its own vehicles for service user outings. The home records all complaints whether received verbally or in writing. Complaints were seen to be appropriately recorded with action taken and outcomes recorded. All areas of the home was seen to be clean, were carpets are in place these were seen to be clean and stain free. It is evident that the housekeeping team work hard to keep such a large home clean. From a sample of staff files examined, it was evident that the home has robust recruitment procedures in place. Quality Assurances systems are in place and the manager carries out monthly audits. Evidence was available to demonstrate how the views of service users are obtained to measure the home’s success in meeting the aims, objectives and statement of purpose of the home. In discussion with staff most felt that the home was well managed and run in the best interests of the service users. Service users and staff spoken to were positive about the manager and her management of the home. Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Southerndown Nursing Home DS0000027169.V359452.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 Southerndown Nursing Home DS0000027169.V359452.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): Standards 1,2 and 3. Standard 6 is not applicable, as the home does not provide intermediate care. Quality in this outcome area is good. Service users and their relatives are provided with sufficient information about the home prior to admission to be able to make an informed choice as to whether the home can meet their needs. Service users are assessed before admission to ensure that their needs can be effectively met by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All prospective service users and their representatives are provided with a copy of the home’s Service User Guide, Statement of Purpose and the home’s brochure. All service users receive a copy of the home’s terms and conditions, which details fees payable and additional costs. Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 10 The manager or deputy manager then undertakes a pre- admission assessment to ensure that the home is able to meet the needs of the service user. Prospective service users and/or their representatives are encouraged to visit the allocated unit, before making a decision to move into the home. From examination of a sample of service user records it was evidenced that health and social care professionals are involved as appropriate, in the admission process and supporting documentation was seen. All service users are admitted for a trial period of four to six weeks, followed by a review, before a decision is made to make the placement permanent. Comments recorded on surveys completed by relatives included ‘ the original selection of the home was through our own research without any assistance’, ‘my X was made to feel welcome and encouraged to make this his/her new home and has settled into the home’s routine very well and has made the transition easier on the family’. Southerndown Nursing Home DS0000027169.V359452.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): Standards 7,8,9,10 and 11. Standard 7 was subject to a good practice recommendation at the inspection in July 2006. Quality in this outcome area is adequate. Care plans need to contain sufficient information to demonstrate that the needs of the service users are being met. Medication administration records demonstrated gaps in recording. Service users feel that they are treated with dignity and respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From examination of a sample of service user files, it was not evident that the service user/representative is involved in the care planning process. Not all care plans were signed and dated. Care plans seen were not in sufficient detail regarding lifestyle choices or the preferences of the service user with regard to when care is to be provided and how. Care plans made no reference to cross Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 12 gender care preferences, psychological health or end of life care. Entries made in daily contact sheets did not consistently validate information recorded in care plans. The manager and deputy manager accepted that there is a need to develop more person centred care plans and to develop life histories for all service users. Further care planning and record keeping training is to be provided to all nursing and care staff. Following the inspection the Commission received a written action plan detailing action being taken to develop care planning documentation and the care planning process. Surveys completed by service users stated that two service users felt that they receive the care and support they needed ‘usually’ and one service user stated ‘always’. It was observed that all service users were appropriately dressed and well groomed. Comments made on surveys completed by relatives included ‘ I have seen an improvement in how they treat people’s personal dignity’, ‘ there are some very experienced and skilled staff. If the staff had the time to get to know individuals better then I think misunderstandings would be broken down. This would give the staff the opportunity to see the person as someone special rather than just a ‘resident’, to have staff who can speak and understand English well’, ‘they provide constant care and watch very closely for any changes in my X condition’, ‘in general I feel all the staff do a very good jobeveryone is always helpful and welcoming when the family visit. Also the menu looks excellent and my X seems a lot better physically since X has been at Southerndown’, ‘staff take time to help with feeding and drinking’, ‘staff are always around the clients and not working in the offices, they keep visible by form filling in the communal areas’, ‘all dietary, medical and nursing requirements are met in full’, ‘a approachable, caring and friendly staff’, ‘this care home is by far the best that I have witnessed. People are treated as individuals and a lot of time is spent by staff taking a personal interest in each client’. At the last inspection a good practice recommendation was made that a falls risk assessment should be completed on service users soon after admission and kept under review. This has been addressed. The medical needs of service users are met by local GP practices, who visit the home twice per week and as necessary. A range of healthcare professionals visit the home on a regular basis. From evidence seen and from discussion with service users and nursing staff, the health and medical needs of service users are well met. Surveys completed by three service users stated that they felt that they ’usually’ received the medical support they needed. Comments made by surveys completed by healthcare professionals included ‘we are fortunate to have such a facility as the utilisation of our community hospital is no longer a dynamic force in the town’, ‘as much as we try and forewarn the home that the Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 13 optician is visiting by arranging appointment, the home is never prepared or ready for us, which means that sometimes we are not always able to see all patients due to lack of time’. Medication administration records in Southerndown unit evidenced that there were gaps in recordings of medication administration. There were some inconsistencies in the way nursing staff use the code letters on the MAR sheet to show the reason for a service user not receiving a prescribed medication. Staff should always use the agreed code letters so that the doctor is aware of any specific problem for the service user that results in them not taking their prescribed medication. Medication storage and records relating to controlled drugs were well maintained. None of the current service users administer their own medication. Risk assessments would be undertaken for any service user wishing to take responsibility for their own medication. The manager undertakes monthly medication audits in the home. Staff were observed to interact with service users in a respectful and appropriate manner. Staff were observed addressing service users by their preferred term of address and in discussion with staff, were clear about the need to respect service users privacy and dignity. None of the service user files examined during the inspection contained information regarding the service user’s wishes regarding the arrangements to be made at the time of their death. This was discussed with the manager and deputy manager, who are developing an end of life care plan for each service user involving the service user, if appropriate, relatives/representatives and medical staff. As in many other care homes, there is a wide range of racial, ethnic and faith backgrounds represented within the staff group compared with the current service users. From discussion with the manager, the inspector considers that the home is able to provide a service to meet the needs of individual service users of various religious, racial or cultural needs. However, there are indications that service users sometimes find that some staff cannot communicate satisfactorily because English is not their first language. Southerndown Nursing Home DS0000027169.V359452.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): Standards 12,13,14 and 15. Quality in this outcome area is good. Service users are encouraged to make choices and to remain independent for as long as possible. There is a wide range of activities in place to meet the social needs of service users. Service users are provided with a varied, nutritious and wholesome diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two enthusiastic, full time activity organisers are in post. A weekly activities programme is displayed in the entrance hall as well in each of the units. In addition there is a monthly list showing events to be held in the home and a range of outings. Each service user has a social activities log, which details activities undertaken each day. These are well maintained. The home has its own vehicles for service user outings. On the second day of the inspection a group of service users went to a local brewery for a gentleman only outing. Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 15 Surveys completed by two service users stated that ‘usually’ there were activities arranged by the home that they could take part in and one service user stated that there was ’always’ activities arranged by the home that they could take part in. Comments made on surveys completed by relatives included ‘when staffing levels were higher the home used to send a carer or two to represent the home at funerals of the residents. This no longer happens on a regular basis. I think it is a pity as it is a need f the relatives’, ‘ I feel that there are residents who are isolated by their location in the building. I would like to see staff have the time during their busy days to spend with individuals, talking, reading or just offering a friendly face to listen to them’, ‘ since Barchester is a large group, an arrangement for a clothes supplier to visit the home with stock which is washable, fashionable and in small sizes would be good. It is difficult to source these in the high street’. Many of the service users have friends and family who are able to visit on a regular basis. Service users are encouraged to maintain contact, as far as possible, with the local community. Relatives who completed surveys confirmed that they are always made welcome. Relative meetings are held every three months and the inspector was informed that these meetings were well attended. Religious ministers visit the home on a regular basis and arrangements could be made for service users to attend a local place of worship, if requested. Service users confirmed that routines in the home are flexible such as being able to choose how they spend their day, when to go to bed and when to get up in the morning. The inspector joined service users for the mid day meal on both days of the inspection. Tables were laid with napkins and condiments. The day’s menu was displayed. Service users are offered a choice of meals and this was recorded. Most service users said that the food was “very good”, “tasty” and “ always a choice”. Menus seen evidenced that service users are offered a varied, well balanced and nutritious diet. The meals served were hot, tasty and served attractively. Staff were observed to be assisting service users in an attentive, discreet and dignified manner. Each unit has a selection of snacks, which are offered to service users during the day. Protected mealtimes have been introduced in the home, which means that all nursing staff are available in the dining room to assist with feeding service users and monitoring food intake. Surveys completed by two service users stated that ‘usually’ liked the meals at the home and one service user stated that they ‘ sometimes’ liked the meals at the home. Southerndown Nursing Home DS0000027169.V359452.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): Standards 16 and 18. Quality in this outcome area is good. The home has a comprehensive complaints process in place. Policies and procedures are in place to protect service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a comprehensive complaints procedure in place. In the last twelve months the home has received thirty-one complaints, all complaints were upheld and all resolved within twenty-eight days. The home records all complaints whether received verbally or in writing. Complaints were seen to be appropriately recorded with action taken and outcomes recorded. Service users spoken to were aware of the complaints procedure and said that they felt that their concerns/complaints were listened to, taken seriously and addressed. All surveys completed by service users and relatives confirmed that they were aware of the home’s complaints procedure. Comments made on surveys completed by relatives included ‘ I have not yet had to raise any concerns about my X care’, ‘my X and I did submit a formal complaint last summer and were given a meeting with X’ (senior manager), ‘since the summer. I have had meetings with the head nurse keeping me informed on my X general health and giving me the opportunity to express any concerns that I may have’, ‘ encouraged to speak to staff and forms can be posted directly to site manager and are always available’. Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 17 Since the last full inspection in July 2006,the Commission has received information regarding two complaints about the service. The manager has addressed both complaints. The Commission followed up one complaint by undertaking an unannounced, focussed inspection in March 2007. No further action was required and no requirements of good practice recommendations were made. All staff receive training in the home’s policies and procedures for protecting service users from abuse and the home’s whistle blowing policy. Staff on duty confirmed this. Training is provided to staff during their induction and then updated on a regular basis. The home has a copy of the Oxfordshire Safeguarding Adults procedures. Five safeguarding adult referrals have been made in the last year and five safeguarding adults investigation has taken place. One referral has been made for inclusion on the POVA (Protection of Vulnerable Adults List) Southerndown Nursing Home DS0000027169.V359452.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): Standards 19,21,22,24,25 and 26.Standard 26 was subject to a good practice recommendation at the last inspection in July 2006. Quality in this outcome area is good. The home provides safe, well maintained and spacious accommodation for service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hot water outlets in bedrooms and bathrooms are maintained at the recommended temperatures. All windows are fitted with window restrictors and radiators are covered. A call alarm system is fitted in all bedrooms, bathrooms and communal areas of the home. Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 19 Bedrooms are comfortably furnished and service users are encouraged to personalise their bedrooms with items of furniture and personal possessions. Appropriate aids and adaptations are fitted in communal bathrooms and toilets. All areas of the home was seen to be clean, were carpets are in place these were seen to be clean and stain free. It is evident that the housekeeping team work hard to keep such a large home clean. At the last inspection a good practice recommendation was made for action to be taken to eliminate the smell of urine on Memory Lane unit, this has been addressed. The laundry is well equipped. All housekeeping and laundry staff have received training in COSHH, infection control and health and safety. Policies and procedures are in place. Staff are provided with protective clothing, such as disposable aprons and gloves for use when carrying out personal care to service users. Southerndown Nursing Home DS0000027169.V359452.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): Standards 27,28,29 and 30. Standards 27 and 29 were subject to a good practice recommendation at the last inspection. Quality in this outcome area is good. Staff recruitment procedures are robust and protect service users from harm. Staffing levels are adequate to meet the needs of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From discussion with the manager, deputy manager, staff on duty and examination of duty rosters, staffing levels appear to be adequate to meet the needs of the service users. At the last inspection a good practice recommendation was made that cover for staff absences should be provided. The manager confirmed that this has been addressed. The home currently has vacancies for four full time care assistants. In the last year thirty members of staff have resigned for a variety of reasons, mainly due to work permits expiring. Exit interviews are conducted, if possible. The inspector was advised that twenty-one care staff are qualified to NVQ level II or above and eight care staff are working towards NVQ level II. All staff completes a detailed induction programme that meets Skills for Care standards. Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 21 The home has a training and development programme in place. All staff are expected to complete mandatory training as well as specialist training. From a sample of staff files examined, it was evident that the home has robust recruitment procedures in place. At the last inspection a good practice recommendation was made that all staff should provide a recent photograph that is not a photocopy. This is currently being actioned. Two senior members of staff conduct all interviews and the recruitment process is well evidenced. Many of the staff on duty have worked in the home for many years. Staff spoken to said that they enjoyed working in the home and felt valued by the manager. Communication systems in the home appear to be well organised, with staff handovers taking place at the beginning of each shift. Staff meetings take place and staff feel that morale is good in the home. All grades of staff were observed to be professional in their approach to service users, throughout the two day inspection. Southerndown Nursing Home DS0000027169.V359452.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): Standards 31,33,35,36 and 38. Standards 33 and 36 were subject to good practice recommendations at the last inspection. Quality in this outcome area is good. Service users benefit from a well managed home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a well-qualified and experienced nurse and manager, having completed the Registered Managers Award. Both the manager and deputy manager are supernumery to the home’s staffing levels and are supported by two administrators. Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 23 At the last inspection a good practice recommendation was made that service users should be provided with an opportunity to give formal feedback, anonymously if they wish, on the care and services received. This is being addressed. Quality Assurances systems are in place and the manager carries out monthly audits. Evidence was available to demonstrate how the views of service users are obtained to measure the home’s success in meeting the aims, objectives and statement of purpose of the home. In discussion with staff most felt that the home was well managed and run in the best interests of the service users. Service users and staff spoken to were positive about the manager and her management of the home. Procedures are in place for dealing with service users monies, financial records are well maintained and receipts obtained for all expenditures made on behalf of service users. At the last inspection a good practice recommendation was made that formal supervision for staff comprising of one to one time with a senior member of staff should be implemented. Following the inspection the Commission received a written action plan detailing action being taken to develop formal staff supervision, which will take place once all staff with supervisory responsibility have received appropriate supervisory skills training. Communication systems in the home are well organised, with regular meetings held with nursing and care staff, catering, laundry and maintenance/health and safety staff. Meetings are well attended and are minuted. Policies and procedures are in place and are reviewed on a regular basis. Reports written by a provider representative, following a monthly unannounced visit to the home, were available for examination by the inspector. A sample of records relating to health, safety and welfare were examined and found to be up to date and well maintained. Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 X 3 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 X 3 X 3 2 X 3 Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 OP9 Regulation 13 Timescale for action All medication administered must 23/04/08 be recorded on the service user’s medication administration record. Staff must use the listed code letters consistently to indicate the reason for omitting a prescribed medication dose. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone 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. Extracts may not be used or reproduced without the express permission of CSCI Southerndown Nursing Home DS0000027169.V359452.R01.S.doc Version 5.2 Page 27 - 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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