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Inspection on 25/02/06 for Southwold Nursing Home

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

This inspection was carried out on 25th February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Southwold has a good staff team who understand conditions likely to be suffered by residents and the care required to meet the needs. Residents and visitors were positive about the staff team commenting, "the care was excellent". Good care plans and risk assessment help this. The home is of a good design to enable the home to meet residents needs and is well maintained and very clean. The home has good recruitment and training policies ensuring that not only appropriate staff are recruited but that they then receive ongoing training to enable them to undertake their role. The home provides a good setting for nursing students from Manchester University to learn fundamental nursing care.

What has improved since the last inspection?

The entrance and main staircase along with the dining rooms and all the lounges have been redecorated. All care plans are now regularly reviewed with a comment to state why they either still appropriate or need changing.

What the care home could do better:

Ensure that the right numbers of registered nurses are on duty and if they want the assistant practitioner to take the place of a registered nurse they must get the Commissions approval to do this. Ensure that locks are fitted to bedroom doors to enable residents to have privacy if they want this.

CARE HOMES FOR OLDER PEOPLE Southwold Nursing Home Southmoor Road Wythenshawe Manchester M23 9NR Lead Inspector Leslie Hardy Unannounced Inspection 25th February 2006 11:00 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 Southwold Nursing Home DS0000021658.V278925.R01.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. Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Southwold Nursing Home Address Southmoor Road Wythenshawe Manchester M23 9NR 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) 0161 945 6367 0161 945 9002 Anchor Trust Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (37), Physical disability (3) of places Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users aged over the age of 60 requiring nursing care shall be 37. 3 named service users are currently accommodated who are below 60 years of age and require general nursing care. 8th November 2005 Date of last inspection Brief Description of the Service: Southwold is a home with 40 beds providing personal care with nursing. The Home was purpose built for the specific resident group in the early 1990’s, initially to provide a better care setting for people on long stay wards within the NHS. It is built on two floors and has a passenger lift. The home is on the edge of the Wythenshawe Hospital site. It is close to a major motorway network and public transport provides very frequent services to Manchester, Stockport and Altrincham. These services are situated very close to the entrance to the home. Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection, which was unannounced, was carried out on Saturday 25 February 2005, starting at 11 am and lasted for 4 hours. During the inspection, 15 residents, 8 visitors and 8 staff were spoken with. Care records were seen and a tour of the building took place but time was also spent with residents and visitors to enable a picture to be gained of how they viewed the home and what it was like to live there. Of the two recommendations one had been implemented and action on the other was programmed. The home is an appropriate building to deliver the care that residents needed and it is kept well maintained, clean and tidy. Residents and visitors spoke highly of the care given by well-motivated staff in the home, using phrases like “they are very good”, “I have never had any concerns” “if I have concerns they are dealt with”. The home had been without a permanent manager since April 2005 when the manager was promoted to area manager within Anchor. A temporary manager had been running the home since October and the inspector was told that a permanent appointment had just been made. The temporary manager was clearly seen by residents and relatives to be having a positive effect. During this inspection only a selection of key National Minimum Standards were assessed therefore to gain the full picture of how the home meets the needs of residents, this report should be read in conjunction with previous reports. What the service does well: Southwold has a good staff team who understand conditions likely to be suffered by residents and the care required to meet the needs. Residents and visitors were positive about the staff team commenting, “the care was excellent”. Good care plans and risk assessment help this. The home is of a good design to enable the home to meet residents needs and is well maintained and very clean. Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 6 The home has good recruitment and training policies ensuring that not only appropriate staff are recruited but that they then receive ongoing training to enable them to undertake their role. The home provides a good setting for nursing students from Manchester University to learn fundamental nursing care. 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. Southwold Nursing Home DS0000021658.V278925.R01.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 Southwold Nursing Home DS0000021658.V278925.R01.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): None of these standards were assessed at this inspection. EVIDENCE: Southwold Nursing Home DS0000021658.V278925.R01.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): 7 8 and 10 Residents with treated with respect and their dignity maintained, by staff who used good care plans and risk assessments to deliver good care that met the residents needs. EVIDENCE: All residents had care plans that covered their ongoing, as well as any acute, needs. Care plans were reviewed monthly with a comment on why the plan was still appropriate or why it needed changing. The needs identified by external assessments, including for funded nursing care, together with the homes own assessments and risk assessments were used as the basis for the plans. The home used a number of recognized risk assessments including for pressure ulcers, manual handling and the use of bed rails. Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 10 Though all risk assessments were updated on some occasions it was found that there were 6 months between these. If this is because a low risk was previous identified and factors had not changed. This is acceptable if at the previous assessment a time scale had been set for the next risk assessment along with factors that would trigger an earlier reassessment. It is recommended that this practice be implemented. The care plans for each resident were known by staff who used them to deliver care to residents as individuals. Residents and staff knew each other well with staff understanding residents needs and likes. Residents were well dressed with short clean nails, clean eyes and moist clean mouths. Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed at this inspection. EVIDENCE: Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 12 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): None of these standards were assessed at this inspection. EVIDENCE: Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 13 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, 24 and 26 The home is clean, well maintained, with appropriate infection control techniques used. EVIDENCE: Southwold is well maintained and suitable for its use. The home is totally accessible to wheelchair users and a range of adaptations and aids to meet the needs of all residents are available and used. Since the last inspection the entrance hall, main staircase, main dining room and all the lounges have been decorated. Bedrooms all contain a lot of the residents personal effects, these range from large numbers of pictures and photographs to items of furniture. As one resident said “its difficult to get in my room for all the stuff”. Bedrooms are not fitted with locks and that has been a requirement in previous reports. Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 14 Though the timescale given in that report, the 31 March had not been reached, the acting manager confirmed that this was programmed for the next financial year, so the requirement is reiterated. This would ensure that residents were able to maintain privacy if they wanted to. The home was found to be very clean, with no odour. Procedures to control cross infection were seen to be in place and maintained by staff. Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 15 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): 27, 28, 29 and 30 A well-trained staff team deliver appropriate care to residents. The homes recruitment policies ensure that staff were not employed who could be a risk to residents. EVIDENCE: The home was found to be normally staffed to at least the staffing notice currently in force and is frequently staffed above this. The home employ an assistant practitioner who is a member of staff who has undertaken a foundation degree at Manchester Metropolitan University along with a number of associated qualifications. It appears that this staff member is on some occasions used as a replacement for a registered nurse. This means that on the occasions this happens the homes staffing levels are outside of the current staffing notice. If this reflects how the home formally wish to use this individual then the registered person must use the correct procedure by submitting the change as a variation so that the Commission can review the request formally. The home currently has 44 of its care staff (excluding registered nurses) with a National Vocational Qualification at level 2. Further staff should finish a course shortly to take the number over 50 , which is the minimum required by the National Minimum Standards (NMS). Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 16 The home was found to be committed to ongoing staff training with all care staff having a training record with a requirement to do mandatory training including fire safety and moving and handling at regularly stated intervals. Staff did have the knowledge and skills to care for the resident group. Discussion with the link tutor from Manchester University who place student nurses at Southwold as part of their training showed that students were complementary about the home, the care given, how they were treated and what they learnt. From the residents view this was positive because not only was it an outsiders view of the home it could mean that once qualified these students saw care with nursing homes as a positive place to work. A review of staff files showed that good pre employment checks were in place with a record kept of the main points discussed at interview, but also a pre interview form was used to get a feel of the candidates views on the job they were applying for. New staff undertook induction and foundation training which met the appropriate training organisations standards currently in force. Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 17 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): 33 and 35 Good systems are in place for finding out residents and staff views of the service and those systems in place for handing residents money reduce the risk of inappropriate transactions taking place. EVIDENCE: Residents and relatives commented positively on how the temporary manager had introduced regular meetings to provide a forum for them to comment on how the home was meeting needs and to raise any concerns. The home has a good system in place for the handling of residents’ finances. These are regularly checked internally and reconciliation of two accounts by the inspector showed that these were in order. Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 18 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 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 3 X X X X 2 3 X STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 19 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 OP24 Regulation 23 Requirement Locks suited to service users capabilities and accessible to staff in an emergency must be fitted to all bedroom doors. (previous timescale of 31/03/06 not likely to be met). The home must staff to the staffing notice currently in force, and if they wish to use the assistant practitioner to replace a registered nurse a variation must be submitted and agreement or otherwise obtained from the Commission. Timescale for action 31/03/07 2. OP27 18 30/06/06 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 OP8 Good Practice Recommendations If some risk assessments are to be reviewed at less than monthly intervals the reason for this must be stated on the appropriate risk assessment. Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Southwold Nursing Home DS0000021658.V278925.R01.S.doc Version 5.1 Page 21 - 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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