Inspection on 13/03/07 for The Sidcup Nursing And Residential Centre

This inspection was carried out on 13th March 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Sidcup Nursing And... 11/12/08

The Sidcup Nursing And... 12/02/08

The Sidcup Nursing And... 29/11/05

The Sidcup Nursing And... 12/05/05

The Sidcup Nursing And... 24/11/04

The Sidcup Nursing And... 13/05/04

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Henry Nihill House

Birchwood

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Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE The Sidcup Nursing And Residential Centre 2-8 Hatherley Rd Sidcup Kent DA14 4BG Lead Inspector Lorraine Pumford Unannounced Inspection 13th March 2007 10:00 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 The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.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. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Sidcup Nursing And Residential Centre Address 2-8 Hatherley Rd Sidcup Kent DA14 4BG 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) 020 8300 7711 020 8300 7799 matthbev@bupa.com ANS Homes Limited Mrs Jane Brock Care Home 100 Category(ies) of Old age, not falling within any other category registration, with number (90), Physical disability (10) of places The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 71 beds for the general nursing care for people 60 years to include 10 beds for the physically disabled aged between 50-59 years 29 beds for the residential care of the elderly 1 place registered for named service user only under the age of 50 years. 1 place registered for named service user only under the age of 50 years for period of 6 weeks only. 29th November 2005 Date of last inspection Brief Description of the Service: The Sidcup Nursing and Residential Centre is owned by BUPA. The ground and first floors are for the general nursing care of 71 residents. The second floor provides residential care for 29 older people. All the bedrooms in the home have en-suite facilities and there are assisted bathrooms on each floor. There are communal sitting and dining areas and an enclosed garden. The home is very close to Sidcup High Street where there are a variety of shops and access to local buses. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Three inspectors spent approximately eight hours in the home. During that time the manager, a number of staff, residents and some visitors were spoken with. Prior to the inspection CSCI surveys were sent to a random sample of residents and relatives and their comments have also been incorporated into this report. During the inspection a number of documents, policies and procedures were examined and parts of the premises inspected. One other inspection has taken place in the last twelve months and this was to address concerns raised by a relative. Fees at present are residential £685 and nursing £895. What the service does well: What has improved since the last inspection? A requirement was made at the time of the last key inspection in relation to recruitment procedures and action has been taken to address this. A requirement and recommendation was made at the time of the last key inspection in relation to staff training and these have been addressed. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 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 The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A full and accurate assessment of need should be undertaken prior to admission to ensure the home can meet the needs of the residents. EVIDENCE: Staff stated that senior staff visit prospective residents at home or in hospital to assess their suitability for a place in the home and to ascertain if the home is able to meet the prospective residents needs. Some residents who completed CSCI surveys stated they had been given the opportunity to visit the home before moving in. The assessment format is comprehensive and covers key areas such as health, personal care and social history. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 9 Some issues arose in relation to two of the five assessments seen. In one instance records indicated a resident had short term memory loss and would need constant supervision, however the medication assessment had contradicting evidence stating the person was mentally alert and did not show any signs of mental confusion and would be able to manage her own medication. In another instance it was not possible for staff to locate a copy of an assessment for a resident admitted late in 2006.The only information regarding the persons needs at the time of admission was from a copy of the assessment carried out by the local authority prior to admission. Action needs to be taken to ensure that all residents benefit from a clear and accurate assessment prior to admission. This home does not provide intermediate Care. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 10 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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Medication practices need to be improved to safeguard residents further. Staff ensure residents receive appropriate support from health care professionals. EVIDENCE: Recording and practise in relation to care planning varied between units. There appeared to be some confusion over the right documents to use and staff were still completing document used by the previous provider along with the BUPA format and this had lead to some repartition. Care plans on the Knoll suite were particularly personalised and in addition to key information for staff regarding action to be taken to meet residents needs it was good to see there was additional information regarding service users likes and dislikes. The following observations were made on the units providing nursing care. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 11 Two residents on Hatherley suite were case tracked. Both had an assessment and care plan, which identified their personal care needs and the action that staff should take to meet their needs. The content of care plans was variable. One care plan included specific information about the residents usual routine and preferences but was not reviewed regularly, the other plan was reviewed monthly but was a little vague in parts about the frequency that the resident should be repositioned or assisted to use the toilet. Records about wounds and pressure sores were good with clear information about the frequency of dressing changes and the appearance of the wound. Staff must ensure that care plans for wounds that have healed are removed and the wound care evaluation form is completed in full. There was no evidence that care plans were discussed with residents or their representatives this was confirmed by relatives who completed CSCI surveys. A comprehensive risk assessment is carried out for residents using bed rails. Risk assessments are also completed for residents that use lap belts however, the assessment are very basic and do not include strategies to reduce the risk of injuries to residents. Relatives and other professionals were consulted about the use of specialist equipment. The risk assessment for bedrails and lap belts stated that the assessment would be reviewed monthly. There was no evidence that this was taking place. Three care plans were viewed on Granville suite but only one in depth. The care plan assessed in depth had risk assessments completed and care plans prepared. Care plans were reviewed monthly. Bedrails and a seat belt were being used for the resident’s safety. Risk assessments were in place for these and were kept under review. The GP, a relative, the nurse and key worker were involved in the decision to use the seat belt. The resident had a history of being aggressive. A care plan had been prepared in relation to this but was not specific as to what action staff should take when the resident was aggressive. A behavioural record was kept but no entries had been made since October 2006. In June 2006 the resident was reviewed and found to have developed dementia. Two other care plans were viewed one in relation to management of aggression and one for a resident who had a pressure sore. The care plan in relation to aggression did not include what action staff should take and the behavioural record had no entries since October 2006. The resident with the pressure sore developed this when in hospital. The wound care plan gave details of the dressing used but did not include the frequency of dressings. A wound assessment chart was also in place and provided up to date information as to the condition of the wound. Staff felt the wound was not healing satisfactorily and had referred the resident to a tissue viability nurse for assessment. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 12 The GP attends the home on a weekly basis and residents see him as and when required, residents spoken with confirmed this. Care plans seen indicated residents receive support from a number of health care professionals and there was evidence people had received visits from a Physiotherapist, Neurologist, Tissue Viability Nurse, Chiropodist and Dentist. Staff assess residents nutritional needs using a recognised tool and where necessary residents with weight loss had been referred to the GP and Dietician Care plans for two residents with a poor appetite were examined these stated that they should be assisted to eat, given supplement drinks and be weighed weekly. Staff were seen assisting both residents to eat and offered the resident a supplement drink after the main meal. The residents weight was monitored but this was not taking place weekly as indicated in the care plan. A number of issues arose in relation to medication. Medication on Knoll suite is stored in a cupboard without ventilation. Staff have been recording the temperature and although the room was not adversely hot on the day, there were occasion during the summer months of 2006 when temperatures of 30, 31, 32 centigrade were recorded. Action is to be taken to ensure that medication remains at an appropriate temperature. Although it is good practice for a record of staff signatures to be maintained in relation to those staff responsible for administering medication, there were instances of staff using a signature on the MAR sheet which did not reflect that written on the specimen copy. Medication on Granville suite was assessed in detail. Medicine management policies and procedures were provided however the nurse was not sure where these were stored. Medicines supplies were received monthly and mainly in blister packs. Medicines were stored correctly and records kept for receipt, administration and disposal. A number of administration charts were viewed and gaps noted in recording. Staff had not brought forward medicine doses in stock to the new chart therefore it was not possible to complete an audit trail for some medicines. When staff transcribed medicine instructions on to the administration charts they had not written what was on the pharmacy label and had not signed these. There were instances of hand written entries made by staff on medicine administration charts these should be countersigned to reduce any risk to residents from transcribing errors. Homely remedy medicines were provided and agreed with the GP. The list of medicines in use included some topical applications. Records were kept for The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 13 these medicines and no inaccuracies were noted. Controlled drugs were managed safely and records checked were accurate. The supplying pharmacist removes unused medicines from the home and staff destroyed controlled drugs. Staff had made corrections to the returns record using correction fluid which is unsatisfactory. The GP completed a CSCI survey and stated in his opinion the care service sought advice from the practice appropriately. Staff address residents by their preferred name, for example some residents had chosen to be addressed formally as Mr or Mrs and this preference was respected by staff. Staff maintained resident’s privacy and dignity when undertaking personal care or when assisting residents to use the toilet. Staff ensured that residents clothing was protected during the mealtime. Some residents had adapted cutlery, which helped them to eat their meal independently. Residents said that staff were “helpful” and “cheerful”. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a varied nutritional diet. The home needs to ascertain the views of residents and provide more appropriate activities. EVIDENCE: Two full time staff were employed to manage activities. These staff stated they had a budget for activities and had adequate equipment provided. They had received training on moving & handling and had attended training with Age Concern on how to manage ‘chair exercising’. The majority of residents and relatives spoken with and a number who completed CSCI surveys stated that there were not enough activities provided. One resident when asked how he spent his day pointed to the television. Others stated there was not enough to do and people just watch TV all day. No activities were seen to take place on two suites. Although on Granville suite some residents were enjoying a flower arranging session in the morning and a quiz in the afternoon. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 15 Other activities listed as provided include bingo, quizzes, pat-a-dog, chair exercises, shopping trips using dial-a-ride and days out in the summer, additionally entertainers had been booked for sessions throughout the year. Despite all this it was difficult from documentation to see what activities individual residents participated in. Discussion took place regarding the current format used to record activities and consideration should be given to changing this so that there is evidence to support the activities provided. Care plans seen include very little information about resident’s social needs apart from stating that residents liked to watch television. Staff need to spend time with resident to ascertain their preferred social activities and include this in their care plans. Relatives spoken with said they were made feel welcome and were offered refreshments. Residents spoken with said they enjoyed seeing visitors and some enjoyed going out with relatives. A religious service takes place on Sundays and a local vicar attends the home on Friday to undertake Communion. All bedrooms seen were individually personalised. A resident spoken with stated staff had helped to arrange her room with photos and mementos when she first arrived. Lunchtime was observed on all three suites. All residents spoken with and those who completed CSCI surveys stated that the food provided was very good. Residents are provided with a choice of food at mealtimes and it was evident that residents can choose further alternatives and in addition to the cooked main meal. A number of residents had chosen to have jacket potatoes, salad or sandwiches. Staffs attention to detail was commendable with attention to presentation, individuals preferences in relation to portion size, little or extra gravy etc. There was a relaxed calm atmosphere on all three units, tables were appropriately laid and staff ensured residents had appropriate cutlery, plate guards and condiments so they could manage and enjoy their meal. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provider has a complaints procedure in place to address any concerns brought to their attention. EVIDENCE: The complaints policy and procedure were examined. In the last twelve months four complaints had been made to the manager about the service. Records seen included the original complaint, how it had been managed and the outcome. The record had been updated to include any complaints that may be made verbally to the manager. One of these four complaints was also brought to the attention of the CSCI and following concerns raised by a relative a Random Inspection was undertaken. The provider took action to address the requirements that were made at the time. All of the relatives and the majority of service users who completed CSCI surveys stated they were aware of the providers complaints procedure. Staff said they would report allegations of mistreatment or abuse to senior staff. Care staff spoken with understood the term whistleblowing and said they The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 17 had received adult protection training and domestic staff said they were told that they would be required to attend POVA training in 2007. Information provided at the time of the inspection indicates that staff have received in-house adult protection training as well as courses arranged by the London Borough of Bexley Adult Protection Coordinator. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident are provided with a clean, comfortable homelike environment. EVIDENCE: Residents benefit from single bedrooms with ensuite facilities. Residents spoken with stated they were happy with their bedrooms and had everything they needed. All communal areas were appropriately furnished and provided a comfortable homely environment. The home has an accessible, small but well maintained garden. It was apparent that the home lacks storage space and a number of bathrooms were being used to accommodate hoists, Zimmer frames, trolleys and boxes of incontinence pads. This not only detracts from a homelike environment but also is potentially hazardous to residents and staff using these areas. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 19 Overall the home is well maintained. On the day the inspection some work was required in the ground floor shower room to repair chipped tiles and worn paintwork and the outer wall and area around the shower and washbasin was damaged and needed re-plastering and repainting. This was discussed with the manager who stated the matter would be addressed promptly. There was an offensive smell coming from the sluice on the first floor which may have been caused by a number of filled yellow foul waste bags being stored in the area. Staff need to remove these bags promptly to appropriate outside storage areas to reduce the risk of odour and the possible spread of inspection. Hand washing facilities were appropriately sited and soap and hand towels were replenished regularly. There were adequate supplies of gloves and aprons. The laundry and laundry service was extremely well organised. All resident’s personal clothing and the home’s linen and towels are laundered on site. There are three washing machines and two tumble dryers all the machines were in working order and the washing machines had a 90-degree cycle appropriate to deal with soiled items. Three staff are on duty every day in the laundry and the housekeeper said that adequate hours were provided to manage the laundry. Staff said they had received training on COSHH, moving & handling and infection control. Staff also said they were provided with adequate supplies of protective clothing to do their work. The laundry was clean, tidy, well organised and had water permeable flooring. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by sound recruitment procedures. Staff are appropriately qualified and trained to care for residents. EVIDENCE: Staff spoken with stated they felt there was enough care staff employed to meet the needs of the residents. Staffing levels were satisfactory on the day of the inspection however a relative and a member of staff spoken to on one unit stated there were occasions when the unit did not have the agreed number of carers. The majority of residents who completed CSCI surveys when asked are staff available when you need them replied usually. The only additional comments made by two residents were that due to the number of people there were occasions when they had to wait a while for assistance. The majority of relatives who completed surveys stated they felt residents were always given the care expected. One visitor said there had been a delay in getting help for his relative to use the toilet because staff were supporting other residents or attending meetings. The majority of relatives stated that the care staff have the right skills and experience to look after people properly. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 21 At present the home employs twenty registered nurses and forty-two carers. 38 of the carers have attained an NVQ 2 or above qualification in care. Three members of staff were currently undertaking a course and six are due to commence shortly. A requirement was made at the time of the last key inspection that two references must be taken up on all staff working in the home. Records were examined in relation to four members of staff recruited to work in the home since the last inspection and action had been taken to address this issue. In addition there was evidence that checks on employees identity had been undertaken, CRB/POVA checks and confirmation of employees health status had also been undertaken. The home benefits from having a training co-coordinator. Records seen indicate that staff have a comprehensive induction when commencing employment and are also provided with statutory training, such as fire, food hygiene and basic health and safety. Staff attend additional training courses relevant to caring for older people. BUPA provide in house training for care staff in relation to working with people who have dementia. Staff spoken with felt they were provided with good training opportunities. A requirement was made at the time of the last key inspection that all nursing and care staff should be provided with manual handling training and action has been taken to address this. A recommendation was made at the time of the last inspection in relation to palliative care training and action has been taken to address this. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.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): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are comprehensive systems in place to monitor the quality of care and service provided in the home. Staff ensure that the home is safe and well maintained. EVIDENCE: The person who manages the home on a day-to-day basis has a number of years experience in the nursing and care profession and is suitably qualified for the post. Staff spoken to stated they receive supervision on a regular basis to discuss practice, training and development issues. From discussion with staff it is apparent that some staff responsible for undertaking this have not received appropriate training and action is required to address this issue. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 23 All staff receive an annual appraisal. There is a system in place for managing residents personal allowance held by the home for safekeeping. All money is held collectively, staff stated that they printed off information for residents or their representatives upon request. At present all information regarding residents money is recorded on one sheet and discussion took place regarding the need for information to be held separately to maintain resident confidentiality. Discussion also took place regarding the need for there to be individual receipts to be used for residents or their representatives depositing money with the home. Work was in progress to implement BUPA’s quality assurance programme. Training was planned and some audits were already taking place. Staff had carried out medication, record keeping and infection control audits in recent months. Concerns identified during audits were recorded and action plans were developed to address issues. A new system for obtaining regular feedback about the service was about to be introduced which will enable staff to identify and address residents concerns in a timely manner. A satisfaction survey was undertaken in 2006. The results indicated that residents were satisfied with most aspects of care, however wanted more outings and activities such as art, pottery, craft and quizzes. Records seen indicate that regular resident meetings are taking place, however the name or number of residents attending was not recorded. From the minutes it was evident that residents felt able to raise issues. To improve these meetings the names of residents attending should be recorded and any queries raised by residents at a meeting should be replied to at the next meeting to evidence that residents views are taken seriously and appropriately acted upon. Staff spoken with said they had attended regular meetings and felt their views and comments were heard at these. A representative of BUPA attends the home on a regular basis to monitor the care and service provided. Copies of reports are appropriately forwarded to the CSCI. A sample of health and safety records was examined. All of the records seen were up to date. The home employs a full time maintenance person to carry out regular health and safety checks, undertake routine repairs and redecorate bedrooms. Plans were in place to recruit an additional maintenance person to support the existing employee and maintain the garden. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 24 Fire safety arrangements were good. Regular checks are undertaken to ensure that the fire alarm system, emergency lights, fire extinguishers and fire doors are in working order. Fire safety equipment is serviced regularly and staff received fire safety training and attended fire drills. The home’s system of recording accidents was examined. Staff complete two accident forms which are forwarded to the manager. It was unclear why two almost identical forms were being completed and the manager said that this was due to the change of registered provider for the service. Accident forms were well completed and included relevant details about the event. A system was in place to report accidents to other agencies where needed. Equipment such as bedrails and wheelchairs are checked regularly to ensure that they are fitted correctly and safe for use. Moving and handling guidelines were displayed in resident’s rooms and kept on their file for staff to refer to. Staff were observed assisting residents to stand and walk and transfer into a wheelchair using a hoist. Staff provided support and reassurance for residents that lacked confidence when moving. A number of staff hold current first aid certificates and one member of staff is due to commence training in the near future. The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.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 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 2 2 2 3 The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement The registered person must ensure that a full and accurate assessment of residents needs is undertaken prior to admission. The registered person must ensure that the resident and where appropriate their representative are involved in reviewing care plans. The registered person must ensure care plans include details as to what action staff take to manage resident aggressive behaviour. The registered person must ensure wound care plans include full details of management including frequency of dressings. The registered person must ensure medicines are safely managed, stored and recorded. The registered person must as far as possible eliminate unnecessary risks to the health and safety of residents in this instance ensure that the risk assessment in relation to lap belts include strategies to reduce the risk of injuries to residents. DS0000006769.V326712.R02.S.doc Timescale for action 31/05/07 2 OP7 15 31/07/07 3 OP7 15 31/05/07 4 OP7 15 31/05/07 5 6 OP9 OP38 13 13 31/05/07 31/05/07 The Sidcup Nursing And Residential Centre Version 5.2 Page 27 8 OP36 18 The registered person must ensure that all staff responsible for the formal supervision of staff are appropriately trained to perform the task. 31/07/07 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 OP7 OP9 OP9 OP12 Good Practice Recommendations Staff should follow action stated in residents care plans. If it has been assessed as necessary to weigh a person weekly this should be taking place. For the purposes of auditing medication staff should use the same signature on the MAR sheet as that written on the specimen document. Hand written entries made by staff on medicine administration charts should be countersigned to reduce any risk to residents from transcribing errors. The registered person should ensure the activities provided are suited to the residents. In view of the comments made about activities management should review activities with residents i.e. by holding a resident meeting, and further keep a more detailed record of activities that residents are participating in. Staff should find more appropriate places to store aids and equipment when not in use. Staff need to remove foul waste bags to appropriate outside storage areas to reduce the possibility of odour and the possible spread of inspection. In order to meet the providers policy risk assessment for residents requiring lap belts and bed rails should be reviewed monthly. The registered person should safeguard residents’ confidentiality regarding service users money. Residents or their representative should be issued with a receipt when depositing money with the home for safekeeping. Correction fluid had been used on some records. Staff need to be reminded of the appropriate way of amending a written error. 5 6 7 8 OP19 OP26 OP38 OP35 9 OP9 The Sidcup Nursing And Residential Centre DS0000006769.V326712.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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