Inspection on 17/01/07 for Southlands Nursing and Residential Home

This inspection was carried out on 17th January 2007.

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

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

Other inspections for this house

Southlands Nursing and... 16/01/08

Southlands Nursing and... 24/01/06

Southlands Nursing and... 28/06/05

Southlands Nursing and... 17/01/05

Southlands Nursing and... 20/05/04

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Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Southlands Nursing Home 9 Ripon Road Harrogate North Yorkshire HG1 2JA Lead Inspector Anne Prankitt Key Unannounced Inspection 18th and 25th January 2007 09:45 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 DS0000027979.V327376.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. DS0000027979.V327376.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlands Nursing Home Address 9 Ripon Road Harrogate North Yorkshire HG1 2JA 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) 01423 526203 01423 504015 www.bupa.co.uk BUPA Care Homes (GL) Ltd Mrs Susan Lesley Houghton Care Home 68 Category(ies) of Old age, not falling within any other category registration, with number (68) of places DS0000027979.V327376.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Aged 60 years upwards One identified service user currently resident within the home in the (PD) category may remain in the home until his needs cannot be met by the home or he reaches the category (OP). 24th January 2006 Date of last inspection Brief Description of the Service: Southlands Nursing Home provides physical nursing care for up to 68 service users. The home is close to Harrogate town centre. The service is provided on three floors and provides good quality accommodation. The occupancy has risen considerably since the last inspection, because a number of service users from another home owned by BUPA Care Homes have been transferred following assessment to Southlands. On 6 November 2006, information was given that the weekly fees range from £442 to £1000. Items not covered by the fee include hairdressing, chiropody, newspapers, taxis and escorts. The manager stated that before arriving at the home, prospective service users are given a sample copy of the menu and activities programme, along with the terms and conditions of the home, and service users’ guide, or ‘brochure’. DS0000027979.V327376.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the site visit, the management at the home sent a completed questionnaire to the Commission for Social Care Inspection. It provided information about the home, including who lives and works there. The inspector has also kept a record about what has been happening at the home since the last inspection. Surveys were sent out to some service users and also health professionals, so that their views about the home could be sought. Four hours of preparation took place before the unannounced site visit was undertaken. The site visit took approximately ten hours, and was conducted over one and a half days. Time was spent at the site visit talking to some service users, staff, and the managers of the home. Some records were also looked at, including some care plans, staff records and a sample of health and safety records. The managers were provided with feedback at the end of the site visit. What the service does well: The home is spotlessly clean and tidy, and a credit to the cleaning staff. It is kept well maintained. There are a variety of communal areas. This helps provide safe and pleasant surroundings for service users. The staff collect information about peoples’ needs before they are admitted, to make sure that they will be able to meet them. Staff seek guidance from professionals in the community where they need help about particular care needs. This helps to make sure that service users get the correct care. Staff understand the importance of passing on concerns, and of reporting matters, which affect the vulnerability of service users. This helps to keep service users safe. The company provides a range of training for staff. This helps to make sure that they know how to look after service users safely and with respect. The management at the home are well supported by the company. A representative visits the home regularly to check that the home is running smoothly. This helps to make sure that standards at the home do not fall. DS0000027979.V327376.R01.S.doc Version 5.2 Page 6 The home will look after service users’ personal allowance safely, if this is their wish. What has improved since the last inspection? What they could do better: Staff must make sure that, as the new care plans are introduced, the current care plans where assessments and reviews need to be updated are given priority. The registered person must make sure that they continue to closely monitor and audit the medication system to help prevent errors occurring, and to make sure that service users receive the correct medication at the correct time. Steps must be taken so that information passed from one staff shift to another can be carried out in private, and in such a way that does not breach confidentiality. Care must be taken to make sure that the meals service meets the individual needs of service users, and that the flexible menu is offered as advertised, and to their satisfaction. Staff must make sure that they wear the protective aprons provided to them for use when they enter the kitchen area. They must also make sure that they lock the sluice rooms when they are unoccupied. DS0000027979.V327376.R01.S.doc Version 5.2 Page 7 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. DS0000027979.V327376.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 DS0000027979.V327376.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): 3 and 6. Quality in this outcome area is good. Prospective service users are assessed before they are admitted, to help make sure that the home will be able to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff at the home carry out a pre admission assessment for prospective service users before a decision is made as to whether it is a suitable placement to meet the service users’ needs. As part of the assessment, the manager said that staff also take into account the suitability of the room on offer. At the site visit, a service user was being moved to a ground floor room that they had been promised once it became free, and which would be more suitable to meet their needs. DS0000027979.V327376.R01.S.doc Version 5.2 Page 10 Staff also collect information from other professionals who have been involved in the care of the service user. For instance, the hospital or care manager. A telephone assessment is carried out in the case of emergency admissions. Staff use the information collected following admission, to develop a more detailed care plan. The service users spoken with could not recall being visited by staff before they were admitted. However, the manager gave assurance that every effort is made to make contact with them. If the prospective service user lives out of area, she stated that a member of staff from a BUPA home more local to them visit on behalf of the home. Of the six service users who returned their comment cards, some of which had been completed by relatives on their behalf, one stated ‘We were shown round on several occasions before deciding’. Another stated ‘Definitely the best’. One recently admitted service user said: ‘I am very happy here’. The manager said that the home does not provide intermediate care. DS0000027979.V327376.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): 7, 8, 9 and 10. Quality in this outcome area is good. The management takes proper action where shortfalls in care and medication practice are identified. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans looked at contained some good information for staff, and confirmed that the advice of community professionals, such as the General Practitioner (GP), mental health services, rehabilitation officer for people with visual impairment, and community matron are sought, where problems in meeting service users’ needs have been identified. Short-term care plans had also been included. This is good practice, as it provides staff with up to date information about new areas of need, and how they can best be met. Two comments made suggested that relatives sometimes had to instigate contact with the GP. From a record looked at where this had happened, contact had been made with the GP, and feedback provided to the family concerned. DS0000027979.V327376.R01.S.doc Version 5.2 Page 12 There is a physiotherapy room provided at the home, with regular physiotherapy input three days each week provided for those service users assessed as needing this service. Risk assessments are completed to check the risk from falls, tissue damage, nutritional problems and moving and handling difficulties. Discussion took place with the manager about two isolated care plans where these had not been updated. However, it did appear that the service users concerned were receiving the care that they required despite this shortfall. Confirmation was given at the second site visit that this shortfall in documentation was being addressed. In order to address this further, the manager is planning to introduce regular audits of the care plans so that shortfalls are quickly identified. Following training in care planning, the staff are now transferring information about service users’ current needs onto new care plan documentation. One looked at had been completed to a high standard. It gave clear information about needs and risks associated with the service user’s holistic needs, and how they were to be met by staff. If all plans are completed to this standard, staff will have very good information to follow when providing care. The manager stated that all care plans were due to be transferred onto new documentation within the next month. Discussion took place about the need to give priority to those care plans where reviews and assessments had fallen behind, so that current needs were clearly identified. This will ensure that the care that these service users’ receive is fully explained. Service users spoken with thought that they were treated with respect, and, during the site visits, care was provided in private. Comments included ‘Staff treat me with respect’, ‘Staff are excellent. Sometimes just not enough of them’, ‘the nurses are very good, but are overworked’. ‘Staff are nice’. ‘I am happy here’. ‘Sometimes we have a problem understanding one or two of the overseas carers,’ ‘The overseas carers are very kind’, ‘Very satisfied’, ‘Very helpful and supportive’. Relatives’ comments included: ‘Clearly my relative is in very good hands’, ‘(my relative) always looks clean, tidy and well cared for’. Staff have limited handover time between shifts, and on the first and second floor there is nowhere for this to be carried out in private. One floor has overcome this problem by completing a written handover which staff read before they begin their shift. However, this results in collective records being kept, and does not properly protect the confidentiality of service users. This was brought to the attention of the manager, who is looking at ways in which the handover time can be extended, and information passed on in private. There is a separate medication trolley for each floor of the home. There is one controlled drugs cupboard, which is situated on the middle floor of the building. This means that staff working on other floors leave the floor on DS0000027979.V327376.R01.S.doc Version 5.2 Page 13 which they work to obtain the medication, the administration of which is witnessed by a second nurse. Medication kept for service users is signed in upon receipt, and destroyed medication returned to the contractor is accounted and signed for. A record is kept of the medication kept by service users who choose to self medicate, so that staff have up to date information about what they are prescribed. There have been five medication errors reported to the Commission for Social Care Inspection by the home during the period since the last inspection. The majority of these occurred following a considerable rise in occupancy at the home. The manager has taken these matters seriously, resulting in disciplinary action where required. A comment received during the site visit that the number of tablets given to a service user are always checked by them because of previous errors was passed onto the manager. Staff have been instructed by the manager that they must not be distracted when administering medication. From discussion with one staff member, it was clear that this has been taken seriously. There have been no further errors reported by the home to the Commission since the beginning of December 2006. Service users who choose to self medicate are assessed initially to check that it is safe for them to do so. But it is important that subsequent informal assessments are documented within the written risk assessment, which should be regularly reviewed and updated in all cases. The second floor of the home has just been provided with a medication fridge. Staff need to make sure that the temperature of the fridge is checked and recorded on a daily basis to make sure that the medication is being stored at the appropriate temperature. Staff do not currently sign when ‘when required’ (prn) medications are not given. This could lead to avoidable errors. Advice was provided to staff about ways to improve upon the recording. Whilst firm action has been taken by the manager, the medication system, and the staff who are responsible for it, must continue to be closely monitored, to prevent further errors occurring, and to make sure that service users receive the correct medication at the correct time. DS0000027979.V327376.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): 12, 13, 14 and 15. Quality in this outcome area is good. Social opportunities are provided, and service users can maintain important contacts with their families and friends. But further attention needs to be given to the individual needs and choices of service users to make sure that they are met to their satisfaction. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a range of activities for service users to join in with if they wish to. A dedicated activities organiser provides them. Each service user is given a copy of the activities programme for the forthcoming week, so that they have the opportunity to decide what they would like to attend in advance. Activities also take place out of normal hours. For example, a ‘Burns night’ was advertised. Activities were also organised to take place on a Saturday. Comments from service users included: included: ‘Lots of activities available’, ‘There are activities, but I am not really interested’, ‘Activities are so, so’. Discussion took place with the manager about the needs of those with sight problems, and feedback received which suggested that the opportunities open to them were sometimes limited. It is recommended that is looked into DS0000027979.V327376.R01.S.doc Version 5.2 Page 15 further by the manager, to see whether any further social input could be offered for these service users. A letter of commendation has recently been received, which especially praises the work that the activities person does at the home. Staff and service users spoken with confirmed that, although their time was limited, the activities organiser tries to visit service users in their own room when they are unable to join in the group activities, which take place on the ground floor of the home. A relative commented ‘Sometimes more contact with staff for other than essential care would be appreciated’. Visits take place from local priests, and a church service is held at the home. This helps to meet service users’ spiritual needs. Visiting arrangements are flexible, and service users were receiving visits in the privacy of their own room. Choice for service users is considered. Those spoken with were satisfied that the routine of the home did not place restrictions upon their right to choose how they wished to spend their time. One staff member explained how the flexibility of the home allowed for service users living on this particular floor to have a bath whenever, and as often, as they wished. The chef explained that the mealtimes were flexible. The manager explained that the menu has now been nutritionally assessed, and that the kitchen staff receive a memo when service users first arrive at the home, so that they know whether they have any particular likes, dislikes or nutritional needs. The chef was satisfied that they receive sufficient information. There is a ‘night bite’ menu, which means that there is a meals service available twenty-four hours a day. Not all service users spoken with were aware of this. One said that they were told by staff that the kitchen was locked, and another that the basic food they had requested was not available. Comments were also made that food was not offered at suppertime, but that it had to be requested. They included: ‘Night staff don’t always offer us sandwiches. We have to ask for them. They say they don’t know where they are’. ‘I think I can have supper if I ask for it, but none is offered’. The manager confirmed that supper is always available. Rather that service users having to request supper, it was recommended that it be offered. One service user commented that they were sometimes missed when teatime drinks were offered. They had been told by staff that they had been too busy so ‘did not do drinks’. The manager took these matters seriously, and has already spoken to the staff concerned. She intends to monitor this further. The menu provides a choice at each mealtime. Comments from service users about the food included: ‘The food is marvellous’. ‘The food is sometimes cold when it reaches the first floor’. ‘Teas are variable – sometimes we have a full dinner. Sometimes a toasted teacake and a bit of cake’. ‘The food is variable’. One relative stated ‘Occasionally they forget to give (my relative) a dessert’. DS0000027979.V327376.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): 16 and 18. Quality in this outcome area is good. Complaints are taken seriously, and are looked into. Service users are protected by staff that will report matters affecting their vulnerability. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a copy of the complaints procedure in the main reception. The procedure is clear, and gives contact details for the Commission for Social Care Inspection. One person commented that sometimes on weekends and evenings, the relevant people to whom they would complain were not available. This was discussed with the manager, who explained that ways of overcoming this issue were being looked into. A letter of commendation was seen which was sent from the relative of a service user whom the home had cared for. During the site visit, a service user had requested a thank you card to complete for the staff. Comments from service users included: ‘I would grumble if I needed to’, ‘I would complain if I had any problems’, ‘I have never had a reason to complain’. There has been one complaint made direct to the home, which was in the process of being investigated at the time of the site visit. The records seen suggested that contact had been maintained with the complainant, and the DS0000027979.V327376.R01.S.doc Version 5.2 Page 17 opportunity given to them visit the home to discuss the elements of the complaint. The manager explained that, should the complainant not be satisfied, the matter would be referred to the responsible individual for further consideration. A professional who visits the home raised a concern with the Commission for Social Care Inspection during the period since the last inspection. This is discussed within outcome group ‘Staffing’. The matter was referred to the responsible individual for the home, who investigated the matters raised, and provided satisfactory feedback to the Commission as requested. There has also been one anonymous complaint made to the Commission for Social Care Inspection following this site visit. This is also outlined in outcome area ‘Staffing’. From previous experience, it is considered that BUPA Care Homes take complaints made to them seriously. On this basis, the complaint has been referred to the responsible individual for investigation, who has been required to report back following the outcome of their investigation. This will be dealt with separate to this report. Staff spoken with understood the importance of passing on their concerns should they suspect that a service user was being abused. They understood that they were not able to keep secrets where they had any concerns. The manager understands the role of the local authority as lead investigator in safeguarding adults’ issues. She makes sure that any such matters which may need to be considered by the local authority are referred to them. DS0000027979.V327376.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): 19 and 26. Quality in this outcome area is good. Service users live in a clean, pleasant and well-maintained environment, with which they are satisfied. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All areas of the home were immaculately clean and tidy, and a credit to the cleaning staff. There is a choice of communal social areas, all of which are all located on the first floor of the home. These include a large dining area, a bar, coffee lounge, large library with seating, and a smaller sitting area with television. There are ramps and passenger lifts to allow easier access to all areas of the home for those with limited mobility. One service user stated about their room ‘I am very happy with it’. Another stated ‘I have a nice clean room with pleasant surroundings’. DS0000027979.V327376.R01.S.doc Version 5.2 Page 19 There is a maintenance man employed at the home, who makes sure that they keep the facilities well maintained. He also keeps track of when outside contractors are due to visit. This makes sure that essential planned safety services are not overlooked. The heating has now been repaired to one ground floor bathroom. This provides service users with additional choice of facilities available to them. Staff were satisfied that the laundry has sufficient equipment to meet demand. There is a system in place to make sure that soiled linen is received separately, so that laundry staff are protected from the risk of infection. They said that they have an abundance of protective clothing. DS0000027979.V327376.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): 27, 28, 29 and 30. Quality in this outcome area is good. Service users are cared for by staff that receive a variety of training to help them provide good care. However, further enquiries need to be made to make sure that service users are satisfied with the way that staff are made available to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Comments from service users and staff about the numbers of staff available differed. They included: ‘Staff are excellent. There are sometimes just not enough of them’, ‘I am satisfied. The staff are nice’, ‘Nurses are very good but overworked’, ‘there is always someone close by’, ‘sometimes I have to wait when needing the toilet’. One commented that they sometimes missed their teatime drink. They had been told by staff that they had been too busy so ‘did not do drinks’. Staff comments included ‘There are enough staff, and nurses get supernumerary time as well’, ‘there is always a trained member of staff on each floor’, ‘we are sometimes short staffed’. Other comments included: ‘Generally the home is fine, but the staffing levels can sometimes not be of a satisfactory level’, ‘Weekend cover can be quite low’, ‘It would be nice if there were enough staff to allow them to sit and chat with residents occasionally instead of only having time to attend to essential care needs’. One member of staff spoken with thought that there were enough staff provided to take DS0000027979.V327376.R01.S.doc Version 5.2 Page 21 account of the recent increase in occupancy. The chef said that previous problems with perceived short staffing in the kitchen were now resolved. The responsible individual has agreed to look into this conflicting evidence by seeking the views of service users by way of an additional satisfaction survey. There has been one concern raised by a visiting professional to the Commission for Social Care Inspection during the period since the last inspection. Following the transfer of a number of service users from another home owned by BUPA Care Homes, they were concerned about whether there had been sufficient staff provided to cope with the increase in service user numbers, including the provision of trained staff. The home provided evidence, which suggested that this had been taken properly into account. There has also been one complaint made to the Commission for Social Care Inspection anonymously since the site visit relating to this report was carried out. It alleged that there were insufficient staff available to meet service users’ needs. This has been referred to the responsible individual for BUPA Care Homes for investigation. They have been instructed to provide the Commission with details of the outcome of their investigation. Care staff confirmed that they receive supervision, and a range of statutory training that is updated on a regular basis. Training includes an NVQ programme onto which staff are encouraged to enrol. Nursing staff are assisted in updating their knowledge with training specific to the work that they do. They have also forged links with community specialists, who give them advice in areas such as palliative care and tissue viability. Specific members of staff have their own designated responsibilities. For instance, the head of domestic services explained that she appraises the domestic staff. Staff said that they have meetings where they are able to air their views. From the recent recruitment files, it could be evidenced that staff are properly vetted before they begin to work at the home. A recently recruited member of staff explained that, prior to working at the home, they were interviewed, but were not allowed to work at the home until such time that their Criminal Records Bureau check was returned. Following recruitment, they confirmed that they underwent a period of induction with which they were satisfied. The manager explained that she has carried out an audit of the staff recruitment files since taking up post. For staff who had been employed by BUPA Care Homes, but who had been transferred from another home, and for whom she has not seen copy of the CRB applied for by the home at the time, she has obtained the staff members’ copy as evidence that the CRB was obtained. She has made the decision that this provides sufficient evidence that these staff have been properly vetted, and are fit to work in a care setting. Staff from overseas who commenced work at the home before their CRB was returned were subject to a POVA First check. They also provided a police check from their country of origin. This helps to protect service users from unsuitable workers. DS0000027979.V327376.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): 31, 33, 35 and 38. Quality in this outcome area is good. An enthusiastic manager who is well supported by BUPA Care Homes runs the home. Service users may benefit further from her input once she has been relieved from her extra managerial duties. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has made application to the Commission for Social Care Inspection to become registered. She will replace the clinical nurse manager, who wishes to step down from the position of registered manager. The application is not yet completed. The clinical manager now works supernumerary and will continue to provide clinical support to the manager, DS0000027979.V327376.R01.S.doc Version 5.2 Page 23 who is not a qualified nurse, but who has good management experience, and a relevant management qualification. The manager receives regular support and supervision from the responsible individual for BUPA Care Homes, and has just received an outstanding appraisal for the achievements she has made since she was deployed to work at the home in February 2006. She is enthusiastic, and has also obtained a nationwide award from BUPA in recognition of her commitment. She holds regular staff meetings. She explained that a staff survey carried out recently identified that staff were very satisfied with the input that she made at the home. Staff comments included: ‘I can see the manager at any time. She operates an open door policy’. ‘The management are good’. They agreed that there are plenty of meetings held so that they are able to pass on their views about the running of the home. The manager is currently responsible for overseeing the management arrangements in one other BUPA care home in the area, and, previous to that, a second. Subsequently, she has not spent as much time at Southlands as she would have wished. One service user commented that they ‘don’t see much of the management’. Another stated ‘we don’t see a lot of the manager. She has three homes to run’. The company has a robust quality assurance system in place. An annual survey is carried out, which seeks the views of service users, relatives, staff and professionals who have an interest in the home. The manager stated that feedback from the surveys is provided to service users, staff and relatives during meetings, where each head of department will discuss what is happening in their particular area. The responsible individual for BUPA Care Homes carries out regular visits to the home, after which they complete a report and action plan for the manager. A copy of the report is sent to the Commission. This means that activity at the home can be monitored. The home can look after service users’ personal allowances if this is their choice. Monies are held in an umbrella account which accrues interest, and which is apportioned fairly between the service users concerned. Service users’ affairs are generally managed by their families. Should service users wish to manage their own affairs, they would be supported in doing so. Rooms have lockable facilities so that service users are able to safe keep small amounts of money and valuables. The company takes proper care where they have been made appointee on behalf of a service user, who receives their allocated personal allowance. The home keeps a small float available, so that service users have access to cash on request. The records and certificates looked at confirmed that the home is kept regularly maintained. DS0000027979.V327376.R01.S.doc Version 5.2 Page 24 Action has been taken to meet requirements made following the previous inspection: The kitchen area was clean, and records seen were kept up to date. This provides evidence that food is stored and served at the right temperatures, and that cleaning schedules are kept up to date. Bed rails are now checked by the maintenance man on a monthly basis, and a record kept confirming that they are safe for use on service users’ beds. The following matters were raised with the manager during this site visit: Staff are provided with aprons for use when they enter the kitchen. However, two members of staff were seen entering and leaving the kitchen area having not used these. The fire door into the physiotherapy room was hooked open. The manager thought that the door was fitted with a magnetic closer. By the second site visit, the hook had been removed, and a magnetic closer fitted. Bolts have now been fitted to sluice room doors to reduce the risk from service users accessing these rooms. However, two were left unbolted at this site visit. These were locked immediately, and the manager informed. DS0000027979.V327376.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 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 X X 2 DS0000027979.V327376.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13,15 Requirement Priority must be given to the update of those care plans where risk assessments have not been completed, and where review has fallen behind. The registered person must closely monitor and audit the medication system, to help prevent further errors occurring, and to make sure that service users receive the correct medication at the correct time. Risk assessments for those service users who self medicate must be kept updated and reviewed regularly. The temperature of the medication fridge must be checked daily, and the temperature recorded, to make sure that medication is being stored at the correct temperature. 3 OP10 12,17 Suitable arrangements must be put into place to make sure that handover is not undertaken in a public area. DS0000027979.V327376.R01.S.doc Timescale for action 28/02/07 2 OP9 13,15 28/02/07 28/02/07 Version 5.2 Page 27 Collective records must not be kept. 4 OP15 12 The registered person must 28/02/07 make sure that the meals service meets the individual needs of service users, and that the flexible menu is offered as advertised. Staff entering the kitchen area must wear suitable protective clothing. Previous timescale of 24/01/06 not met Staff must make sure that they lock sluice rooms when left unattended. 24/01/07 5 OP38 13 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP9 Good Practice Recommendations Care plans should be reviewed on a monthly basis. Where service users are able to tell staff when they need their ‘when required’ (prn) medication, this should be recorded in the care plan. The medication records should then be signed when the medication is actually administered. Where the service user is not able to decide, and staff are making a decision on their behalf about whether or not they need their medication, then the home should record on each occasion why the medication has, or has not, been administered. 3 OP12 The registered person should check that there are no shortfalls in the range of activities available to service users with visual impairment, and look at ways in which DS0000027979.V327376.R01.S.doc Version 5.2 Page 28 these can be provided if necessary. 4 OP27 As part of the quality assurance programme, the registered person should review the staffing arrangements at the home to make sure that staff are deployed so that service users’ holistic needs are met to their satisfaction. DS0000027979.V327376.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 DS0000027979.V327376.R01.S.doc Version 5.2 Page 30 - 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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