This inspection was carried out on 28th June 2005.
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.
CARE HOMES FOR OLDER PEOPLE
Southlands Nursing Home 9 Ripon Road Harrogate North Yorkshire HG1 2JA Lead Inspector
Jan Dulieu Unannounced 28 June 2005 9:30
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southlands Nursing Home J53_J04_S27979_Southlands Nursing Home_V232043_280605_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Southlands Nursing Home Address 9 Ripon Road Harrogate North Yorkshire HG1 2JA 01423 526203 01423 504015 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Limited Mrs Susan Lesley Houghton Care Home 68 Category(ies) of Old age, not falling within any other category registration, with number (68) of places Southlands Nursing Home J53_J04_S27979_Southlands Nursing Home_V232043_280605_stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 17/1/05 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 accommodation in the home is situated on three floors and has recently been extensively refurbished to provide exceptional quality accommodation. Southlands Nursing Home J53_J04_S27979_Southlands Nursing Home_V232043_280605_stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection of the home was unannounced. Chris Baveystock the General manager of the home was present for the inspection. The inspection took place over three hours and focussed on the provision of care to service users and progress made in meeting the National Minimum Standards since the last inspection. What the service does well: What has improved since the last inspection?
The General manager has introduced newsletters for service users and staff and this is appreciated by them and has increased the level of morale overall. The programme of activities and events for service users has been maintained and continues to improve. Service users commented positively about the activities and a recent garden fete was particularly enjoyed. Staff are now receiving effective appraisal and supervision and the training for staff in NVQ,s is being maintained.
Southlands Nursing Home J53_J04_S27979_Southlands Nursing Home_V232043_280605_stage 4.doc Version 1.30 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. Southlands Nursing Home J53_J04_S27979_Southlands Nursing Home_V232043_280605_stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Southlands Nursing Home J53_J04_S27979_Southlands Nursing Home_V232043_280605_stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 3 Service users are given clear and helpful information about the home so that they can make an informed choice. Service user needs are assessed and are only admitted to the home after a needs assessment. EVIDENCE: Two service users explained how they had made the decision to come into the home. From their accounts it was clear they had been well supported with information prior to coming into the home and at the time of admission. Service users are carefully assessed prior to admission and their needs are clearly documented in their plan of care. Southlands Nursing Home J53_J04_S27979_Southlands Nursing Home_V232043_280605_stage 4.doc Version 1.30 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 Service users health care needs are outlined in their plan of care and they are met by caring and competent staff. EVIDENCE: A number of care plans were inspected and they included a range of assessment documentation, plans to meet service users needs together with evidence of review of the plans. Where appropriate the service users next of kin has signed the plans of care. The medication records for the service users on the first floor were inspected and these are well kept and include signatures for the administration of all medications given. Service users said that staff are kind and exceptionally helpful. Improvements in the times taken to answer the call bell are evidenced by the records kept, although service users continue to say that they wait longer than five minutes on some occasions. It is recommended that the manager of the home continues to monitor staff response times. Southlands Nursing Home J53_J04_S27979_Southlands Nursing Home_V232043_280605_stage 4.doc Version 1.30 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 standard(s) 12.13 and 15 Service users have access to a range of individual and group activities which are positively enjoyed. EVIDENCE: The home has a full programme of activities for all service users. They include outings to gardens, card games, flower arranging and wine tasting activities. Service users have recently enjoyed a garden fete to celebrate the garden landscaping with a ‘sensory’ planting scheme. Relatives have been invited to meetings to discuss any issues raised in the home and detailed minutes indicate that both service users and relatives are comfortable raising any concerns or issues they may have. Service users are consulted about all aspects of their care and staff demonstrated tact and sensitivity in the way they did this. Service users confirmed that staff make every effort to assist them. The food in the home was commented upon and service users said that the soups are particularly good. One service user said that they were able to request an omelette or anything that they would like if they preferred a different meal. One service user had been brought to the dining table in her own wheelchair but the height of the chair meant she was unable to access her meal easily. This should be addressed by the registered manager.
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The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Service users have confidence that their concerns are listened to and dealt with by the manager of the home. EVIDENCE: Service users said that they feel they can approach the manager or administrator with their queries and concerns and that action is taken if necessary. The home has not received any complaints since the last inspection and this is likely to be due to the approachability of the manager and her team. Also service users views are actively sought at meetings which service users value. Clear documentation is available about the services in the home which also supports this process. Southlands Nursing Home J53_J04_S27979_Southlands Nursing Home_V232043_280605_stage 4.doc Version 1.30 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 standard(s) 19,20,23 24,25 and26 Service users live in an attractive, clean and well-maintained environment. EVIDENCE: The environment of the home is beautifully decorated and maintained. Service users expressed satisfaction about the standard of housekeeping and service users particularly appreciate the Housekeeper. Service users are able to move rooms subject to the additional cost of different rooms. The garden has been landscaped and provides an attractive outdoor space to sit in. Two rooms on the first floor have internal glass shutters. It is recommended that a risk assessment is conducted to ensure that they do not present a hazard to service users in those particular rooms.
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The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Service users say that the home is short staffed although sufficient staff are on duty to meet their needs. The time taken to respond to the call bells continues to be raised by service users. EVIDENCE: The home is currently occupied by 41 service users. To meet their needs the home has a manager on duty supported by an administrator and receptionist. A housekeeper and cleaning team are employed together with a chef and catering team. An activities co-ordinator is also employed. A trained nurse is on duty on each floor during the day and evening and two trained nurses are on duty at night. In the morning two care assistants are on duty on each floor and at least one during the evening and night time. These numbers are clearly sufficient to meet service users needs and this is evident on inspection. It was not possible to accurately determine why a number of service users felt that the home is short staffed. On discussion with the manager we agreed that she would discuss this issue with service users and staff. It was also considered that the layout of the home may contribute to this perception because service users are unlikely to see staff unless they ring their call bell. Some service users commented that on occasions staff take longer to answer the call bell than they think is reasonable. The manager is already monitoring and auditing this and overall this situation has improved considerably since the last inspection.
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The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32 36and37 Service users are benefiting from the open and inclusive management style of the management team. EVIDENCE: The home has a registered manager in post Susan Houghton who is the Clinical Services manager. She is responsible for the delivery of care in the home and it is evident that service users are well cared for and that their care is clearly documented. The General manager Chris Baveystock is responsible for the overall running of the home and she has improved the levels of communication in the home together with the improved consultation with service users. Supervision and appraisal of staff is being conducted and this is having a positive impact on the care of service users. Service user plans of care kept on the nurses stations should be locked away appropriately. A recommendation has been made about this.
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This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 x 15 3
COMPLAINTS AND PROTECTION 3 3 x x 3 3 3 4 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 x x x 3 2 x Southlands Nursing Home J53_J04_S27979_Southlands Nursing Home_V232043_280605_stage 4.doc Version 1.30 Page 16 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement There are no requirements identified at this inspection. Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 10 15 37 19 Good Practice Recommendations The registered manager should continue to monitor the times taken to answer call bells and address issues arising from this. The registered manager should ensure that the servce user identified at the inspection is able to access the dining table properly. The registered manager should ensure that service users plans of care are stored in lockable facilities. The registered manager should ensure a risk assessment is completed to ensure the internal glass shutters in two first floor bedrooms are adequately safeguarded. Southlands Nursing Home J53_J04_S27979_Southlands Nursing Home_V232043_280605_stage 4.doc Version 1.30 Page 17 Commission for Social Care Inspection Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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