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Inspection on 02/03/06 for Southerndown Nursing Home

Also see our care home review for Southerndown Nursing Home for more information

This inspection was carried out on 2nd March 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is comfortable and there is a relaxed atmosphere. Residents looked well cared for and made comments such as: "Feel safe"; "Staff are caring". The manager provides good leadership and is supported well by her senior staff. She started in the home in June 2005 and has developed a good rapport with her staff, and is well liked by residents. The company provides good training opportunities for all grades of staff.

What has improved since the last inspection?

Some rooms have been redecorated and new bedroom carpets fitted. Two new weighing hoists have been provided. The home`s policy and procedure regarding the management of an allegation of abuse has been improved. One room has been redesigned to be a `quiet room` for relatives or staff. Drinks are now regularly taken to residents on Memory Lane, as many of the residents on this unit need encouragement to drink and also need to have their fluid intake carefully monitored.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Southerndown Nursing Home Worcester Road Chipping Norton Oxfordshire OX7 5YF Lead Inspector Annette Miller Unannounced Inspection 12:30 2 March 2006 nd 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.V282450.R02.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 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 Barchester Healthcare Plc 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.V282450.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. On admission persons should be aged 60 years and over. The total number of persons that may be accommodated at any one time must not exceed 87 of which 42 may be in either the DE(E) or MD(E) category. Admittance of two named residents under the age of 60 in the PD category 27th July 2005 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’s own transport is available for outings. Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by two inspectors from 12.30pm to 430 pm. A tour of the building took place and documents were examined. A conversation was held with a number of residents and staff to obtain their opinions of the home. The manager was on duty and was present throughout the inspection. She is in the process of registering with CSCI as the home’s registered manager. The inspectors were made to feel welcome by all staff and appreciated their co-operation. In order to gain an overview of the standards inspected during 2005/06 it is recommended that the previous report dated 27th July 2005 is read in conjunction with this report. What the service does well: What has improved since the last inspection? Some rooms have been redecorated and new bedroom carpets fitted. Two new weighing hoists have been provided. The home’s policy and procedure regarding the management of an allegation of abuse has been improved. One room has been redesigned to be a ‘quiet room’ for relatives or staff. Drinks are now regularly taken to residents on Memory Lane, as many of the residents on this unit need encouragement to drink and also need to have their fluid intake carefully monitored. Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected at this inspection. EVIDENCE: Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected at this inspection. EVIDENCE: Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 Residents can keep contact with friends and relatives as they wish. EVIDENCE: The inspector spoke to visitors during the inspection, who said they could visit their relatives at any reasonable time. The home’s policy is to welcome visitors, and visitors can join their relatives at mealtimes if they wish. Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home works to protect residents from abuse. EVIDENCE: The home’s policy on managing allegations of abuse has recently been strengthened, and now files containing the company policy, a copy of ‘No Secrets’ and the local guidance are easily available at several locations for staff. An inspector discussed the care of one resident with the nurse in charge and also saw the resident, who raised some issues. The inspector followed up two concerns and found them to be unsubstantiated. The third concern was that staff twist her arm when lifting her. The inspector asked the manager to follow this complaint up, and to talk to the resident about the issue. Training on the protection of vulnerable adults features as mandatory training within the home’s training programme. Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The home is well maintained and safe. EVIDENCE: The home is well located near to Chipping Norton, and Memory Lane provides a safe environment for individuals with dementia. The inspector saw most areas of the home including private rooms, and spoke to the manager about the coming plans to improve the home. Rooms are redecorated and carpets are replaced on an ongoing basis, and safety measures such as restricted windows are in place to protect residents. Fire exits were free from obstruction. Standard 26 was not fully assessed, but during the inspection an inspector was aware of an unpleasant smell in two areas on Memory Lane and discussed this with the manager. She was already aware of this issue, and although she had tried to address the problem, the smell was still there at certain times of the day and action to rectify this continues. Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 30 The number of carers with a National Vocational Qualification in Care has not yet reached the required ratio of 50 , but good progress is being made towards achieving this ratio. All grades of staff attend training to ensure that they are qualified and competent to undertake their work. EVIDENCE: Forty-six carers are employed and 21 have an NVQ in Care (or equivalent qualification). Ten carers are also on this training. This situation reflects well, not only on the staff undertaking this training, but also on the commitment and enthusiasm shown by senior staff in providing encouragement and support to staff throughout their training. There is a thorough and comprehensive induction programme that is based on the nationally approved Skills for Care induction course. Workbooks are issued to new workers to complete when each element of learning has been completed, which is then countersigned by a trainer when the level of competency required has been reached. The company provides a good level of training to all grades of staff and training records showed staff attendance was good. Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The manager is well supported by senior staff in providing clear leadership throughout the home, with all staff demonstrating an awareness of their roles and responsibilities. The safety of residents was put at risk in one area of the home because the temperature of hot water to a shower in the main house was above the recommended level. EVIDENCE: The manager is in the process of registering with CSCI as the home’s registered manager. She is a registered nurse and has a Higher National Diploma in Business Management. It was clear that she had a good rapport with staff, and they spoke favourably of her management style, saying they felt able to approach her about any matter they wished to discuss. Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 15 The manager obtains informal feedback from residents and people visiting the home during day-to-day conversations, as well as formal feedback from questionnaires completed by residents and other key people. There are regular residents’ meetings chaired by a representative of Age Concern that provide further opportunities for residents and relatives to express their views. Minutes are taken and displayed. The company has a policy to look after residents’ money for incidental expenses, such as hairdressing and chiropody. This money is paid into a pooled bank account from which the home pays for residents’ incidental expenses as they occur, with invoices sent out to residents monthly. The account is separate to the company’s assets. The inspector viewed the accounting procedures and was satisfied that everything was in order, except that the manager was the only signatory for the account. She explained that the person who was previously the second signatory had recently left the home and a new second signatory was being arranged. An inspector discussed health and safety issues with the home’s head of maintenance and found procedures to be generally good, with the required checks being carried out on a regular basis and recorded. The only exception to this was the temperature of hot water to a shower accessible to residents that recorded 53ºC, which is significantly above the safe temperature level of 41ºC, as recommended by the Health and Safety Executive. An immediate requirement was made to disable the shower until a thermostatic control valve was fitted. The inspector noted that the maintenance records showed the shower was last tested on 27 February 2006, when hot water recorded 53ºC. It was unclear why action was not taken at that time and this was brought to the attention of the manager during verbal feedback at the end of the inspection. Fire safety training records showed that staff had attended the required amount of training during the previous 12 months. There are eight trained fire marshals working within the home, which provides an excellent level of staff expertise to monitor fire safety procedures. Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 X 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score N/A X 3 X 3 X X 2 Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 17 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 OP38 Regulation 13(4) Requirement The manager must ensure that hot water to water outlets accessible to residents is controlled at a safe temperature. Timescale for action 02/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26 Good Practice Recommendations Further action is needed to identify the cause of the unpleasant smell in two areas on Memory Lane, and to implement procedures to eliminate the smell. Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Southerndown Nursing Home DS0000027169.V282450.R02.S.doc Version 5.1 Page 19 - 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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