CARE HOMES FOR OLDER PEOPLE
SUMMERDYNE NURSING HOME Cleobury Road Bewdley Worcestershire DY12 2QQ Lead Inspector
Chrissy Presley Final - Unannounced Inspection 3 May 2005 10:35 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. SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Summerdyne Nursing Home Address Cleobury Road Bewdley Worcestershire DY12 2QQ 01299 403260 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) Frontsouth Limited Mrs Tuula Anneli Page Care Home with Nursing 27 Category(ies) of DE(E) Dementia (over 65) - 19 registration, with number OP Old Age - 27 of places PD(E) Physical Disability (over 65) - 27 SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: There are no more than twelve service users in the home with a primary diagnosis of dementia. Date of last inspection 21 October 2004 Brief Description of the Service: Summerdyne Nursing Home provides personal and nursing care for up to twenty-seven older service users who may have physical or mental fraility that requires continuing care. Accomodation is provided in seventeen single rooms, thirteen of which are ensuite. The remaining rooms are all ensuite double rooms. The home is situated on the outskirts of Bewdley town on a bus route. The home is an adapted house with a purpose built extension. Frontsouth Ltd owns Summerdyne and the registered manager is Mrs Tuula Page who looks after the day to day running of the home. SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place over six hours during the daytime. The inspection was carried out as part of the regular planned programme of inspections. A tour of the premises took place. Care records of three service users were examined. Health and safety documents and policies and procedures were also seen. Care staff on duty, three residents, one visitor and one visiting professional were spoken to during the course of the inspection. Time was spent with the registered manager. There have been no complaints to the home or the Commission for Social Care since the last inspection, which took place on 21st October 2004. What the service does well:
Summerdyne Nursing Home is a comfortable home that is clean and tidy. The registered manager visits all potential new residents to the home and will invite them to visit and have a meal before they make up their mind about a trial period in the home. Residents and visitors spoken to during the course of the inspection said staff always knocked before entering rooms and the visitor said she was always made welcome. Residents said the food was excellent and there was plenty of choice. The activities provided stimulated residents, these activities were either in groups or one to one, all residents were given the opportunity to join in. Residents said the registered manager and her deputy were approachable and they would not be afraid to complain. The registered manager managed the home well and was supported by a committed group of stable staff; this included all ancillary staff. SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 Page 6 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. SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.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 SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.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) 3 Residents needs were assessed by the registered manager or her deputy prior to admission to the home, the assessment document was appropriate and ensured nursing needs of new residents could be met. EVIDENCE: A resident spoken to was able to explain the assessment process and said the registered manager had visited her and explained about the home prior to admission. She was invited to lunch and had a look round the home. The assessment document was seen in the care plan and had been completed in a manner, which ensured the resident’s needs could be met. SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.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) 7,8,10, Care plan documents in the home contained enough information to ensure care needs of residents were met, in some cases these had not been evaluated monthly. Personal care and support is offered to residents to ensure their privacy and dignity is respected and independence is promoted whenever possible. EVIDENCE: Three care plans were inspected in detail during the inspection; these contained information that assisted staff to deliver care safely and in line with current best practice. On checking these documents it was noted that they had not been updated for two months, therefore all care plans were checked and a number had not been re-evaluated monthly, an immediate requirement was left with the registered manager requiring the documents to be updated within 24 hours. Records showed that the primary healthcare team and General Practitioners had regular input into resident’s healthcare needs. Residents spoken to during the inspection said they had seen their care plan.
SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 Page 10 Moving and handling risk assessments were seen and staff were seen carrying out moving and handling techniques in accordance with these documents. It was noted moving and handling risk assessments had not been updated in some care records. Residents spoken to said they were treated with respect and dignity, it was said that staff always knocked on their bedroom doors before entering. SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 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 standard(s) 12,13,14,15 Residents experience a stimulating life at the home. Activities are available according to the individuals needs. Residents dietary needs are well catered for with a balanced and varied selection of food readily available which meets their individual preferences. EVIDENCE: Residents spoken to said they had enough activities and residents were able to join in-group activities and for those residents not able to participate in these events; activities were offered on a one to one basis. Contacts with friends and family were encouraged and one visitor spoken to said she was always made welcome. Information about maintaining links with family and friends was seen in care plans. Residents were observed being spoken to by the cook who was asking them what they would like for supper. There was a wide choice of food offered to residents; food was nutritious and soft diets were offered to residents, which looked palatable. Residents said they enjoyed the food. SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 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 standard(s) 16,17,18 Residents and their families were given a good understanding of the complaints process. The registered manager made sure staff had the required level of knowledge and understanding of protection of the vulnerable adult and their responsibility. EVIDENCE: Policies and procedures regarding adult protection were concise and accessible to staff. Staff received training in this field and were fully aware of their responsibilities. There was evidence, those residents who were able to do so were planning to vote on Thursday. SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 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 standard(s) 19,20,21,22,23,24,25,26 Although there were a number of environmental issues which required addressing, residents were able to personalise their bedrooms. A comfortable standard of bedroom and communal accommodation is provided. EVIDENCE: The home was clean, warm and comfortable. Residents had personalised their bedrooms and had been able to bring in items from home. A tour of the premises highlighted the following;• The lawns and gardens were in need of attention. • The outside of the building required painting • Fire bells and emergency lighting was not being tested regularly • There was no rolling programme of maintenance and renewal • Furnishing ins some areas of the home were worn • Two of the four bathrooms were not in operation on the day of inspection (one bathroom was being used as a store for wheelchairs and hoists)
SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 Page 14 • • • • Window restrictors in some bedrooms were not working Fire doors did not close on rebates and some were wedged open. Residents did not have lockable storage space in their bedrooms Radiators that were guarded had not been painted and had loose tops making them unsafe SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 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 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) None of the standards in this section of the report were inspected at this visit. EVIDENCE: SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 Page 16 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 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) 38 The home is well managed but attention needs to be given to improving records of fire risk and maintenance. EVIDENCE: Safe working practices such as moving and handling were observed during the inspection. Staff had received training in fire safety however fire bells and emergency lighting had not been tested regularly. There was a first aider on duty at all times and staff had a good understanding of infection control policies, which were adhered to on questioning staff. Maintenance records for the equipment in the home, which included; the gas boiler, hoists, electrical safety checks and legionella were in order. The fire risk assessment and environmental risk assessment had been updated however the lack of a maintenance man did not ensure that rooms were checked regularly to ensure they were safe.
SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 Page 17 SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 3 1 2 3 2 2 3 STAFFING Standard No Score 27 x 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 3 3 x x x x x x x 2 SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 Page 19 yes 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. 2. 3. 4. 5. 6. Standard OP7 OP7 OP8 OP19 OP19 OP19 Regulation 15 15 15 23 23 23 Requirement Care plans must be reviewed monthly Risk assessments including manual handling and falls must be updated regularly Residents weight recordings must be reviewed and information acted upon The gardens must be cleared to enable residents to have safe access to them Fire bells and emergency lighting must be tested Fire doors must not be wedged open by the means of a wedge that does not comply with fire regulations Fire doors must close on rebates The outside window frames must be attended to and repainted The two bathrooms which had been de-commissioned must be in working order as per the immediate notice Sluices must be fitted with a key pad lock The bedroom identified during the inspection must be reE52 S4147 Summerdyne NH V221652 030505.doc Timescale for action Immediate and ongoing immediate immediate By 1st June 2005 and on-going immediate immediate 7. 8. 9. OP19 OP19 OP21 23 23 23 within 24 hours and ongoing 30/09/05 immediate notice 30/06/05 30/06/05 10. 11. OP23 OP24 13 23 SUMMERDYNE NURSING HOME Version 1.30 Page 20 12. OP24 12,13 13. 14. 15. 16. 17. OP25 OP10 OP10 OP19 OP38 13 12 12 23 13 decorated. Other areas in the home identified must be painted Residents must be provided with lockable storage space for medication, money and valuables and a key which he or she can retain (unless the reason for not doing so is explained in the care plan) Radiators must be safe guarded safely The practice of using a service bedroom for treatments must stop Care records must be secure; the office must be fitted with a key pad lock Worn furnishings must be replaced Window rectrictors must be in working order 30/09/05 immediate immediate within 7 days of inspection 30/09/05 immediate 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 OP19 Good Practice Recommendations a programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced and implemented SUMMERDYNE NURSING HOME E52 S4147 Summerdyne NH V221652 030505.doc Version 1.30 Page 21 Commission for Social Care Inspection The Coach House John Comyn Drive, Perdiswell Park Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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