Care Home: South Haven Lodge

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• St Vincents
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• The Maypole Nursing Centre
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What the care home does well The home`s records are generally well maintained and provide good levels of information to the staff on how to meet the needs of the service users. Health and Social care services are used to support the clients and maintain both their wellbeing and safety, with professional people telling us, via our (the Commission`s) surveys that: `the service works very well with the specialist `older persons mental health service`, `it requests assistance and advice in a timely manner, whilst retaining high levels of expertise amongst its staff`. The environment is well maintained and decorated to a good standard throughout, with evidence seen during the fieldwork visit of decorating being undertaken. Staff are provided in sufficient numbers and have access to good levels of training and development. People stating, via the surveys that: `the care home provides a safe, warm and caring environment for mum. The staff are caring and considerate and the home is extremely well managed. What has improved since the last inspection? Four requirements were made during the last inspection: one to update the `statement of purpose`, two to improve the handling of residents` medications, three to provide additional catering equipment and the fourth to consider the needs of the staff in relation to a rest area. The issue of the `statement of purpose` has been addressed with this and other sources of information about the home, brochure documentation, etc having been updated. Residents` medications are being appropriately handled and stored; and the records seen during the fieldwork visit accurately maintained. The kitchen facilities were visited during the tour of the premises and found to be in good working order, clean and tidy. Food storage was not a problem with both the kitchen and dry storage areas housing refrigeration / freezer units. The staff continue to have concern over the size of their rest room, which the manager acknowledges, however, he fails to see how the situation can be remedied due to the physical limitation imposed by the building. A new activities room has been created for the service users and the activities co-ordinator, which includes a computer system. What the care home could do better: People`s rights to privacy and dignity are being compromised by the homes` practice of leaving care records on display within their bedrooms. The information recorded within these documents often containing details of their personal care needs. CARE HOMES FOR OLDER PEOPLE South Haven Lodge 69-73 Portsmouth Road Woolston Southampton Hampshire SO19 9BE Lead Inspector Mark Sims Unannounced Inspection 24th March 2008 10:30 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 South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Haven Lodge Address 69-73 Portsmouth Road Woolston Southampton Hampshire SO19 9BE 023 8068 5606 023 8044 9092 southhaven@new-meronden.co.uk 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) New Century Care (Southampton) Ltd Mr Maximillian A H Whatman Care Home 46 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (0), Old age, not falling within any other category (0) South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users in the category of dementia (DE) must be at least 55 years of age. The home is not registered to take patients detained under the Mental Health Act 1983 - as amended. The home may accommodate up to 46 male and female service users in the categories DE, DE (E) and OP at any one time. A maximum of 10 service users within the category of MD(E) Date of last inspection Brief Description of the Service: South Haven Lodge is situated in the residential area of Woolston, within easy reach of local shops and facilities. There are good links to local transport systems. The home provides nursing care for older people, who may also have a diagnosis of dementia or mental disorder. It is owned by New Century Care (Southampton Ltd.), a company who have care homes in different parts of the country. Accommodation is provided in single and double rooms on two floors - ground and first floor. Some of these have en-suite toilet facilities. There are two passenger lifts for easy access between floors. The home has large, wellmaintained gardens at the rear of the property, and ample car parking at the front. The home has benefited from extensive refurbishment during 2006-7, so that it provides a pleasant environment for service users. Fees range from £430.50 to £800.00 per week, depending on the dependency levels and assessed needs of service users. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection was, a ‘Key Inspection’, which is part of the regulatory programme that measures services against core National Minimum Standards. The fieldwork visit to the site of the agency was conducted over five hours, where in addition to any paperwork that required reviewing we (the Commission for Social Care Inspection) met service users, staff and management. The inspection process involved pre fieldwork activity including gathering information from a variety of sources, surveys, the Commission’s database and the Annual Quality Assurance Assessment information provided by the service provider/manager. The response to the Commission’s surveys was good, with eight relatives responding on behalf of their next-of-kin, three health care and two care manager surveys returned, prior to the report being written. What the service does well: The home’s records are generally well maintained and provide good levels of information to the staff on how to meet the needs of the service users. Health and Social care services are used to support the clients and maintain both their wellbeing and safety, with professional people telling us, via our (the Commission’s) surveys that: ‘the service works very well with the specialist ‘older persons mental health service’, ‘it requests assistance and advice in a timely manner, whilst retaining high levels of expertise amongst its staff’. The environment is well maintained and decorated to a good standard throughout, with evidence seen during the fieldwork visit of decorating being undertaken. Staff are provided in sufficient numbers and have access to good levels of training and development. People stating, via the surveys that: ‘the care home provides a safe, warm and caring environment for mum. The staff are caring and considerate and the home is extremely well managed. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. South Haven Lodge DS0000059970.V359451.R01.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 South Haven Lodge DS0000059970.V359451.R01.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, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. EVIDENCE: The service tells us, via their AQAA that: ‘Residents and their representatives are given all relevant information and are encouraged to visit prior to making decision on admission to the home. If a prospective resident is unable to attend the home for a viewing photographs are provided of the important areas including the bedroom from all angles. Each individual resident has a pre admission assessment at their own home or in other locations and careful consideration is given to this assessment before South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 9 agreeing admission to the home, therefore ensuring that staff are qualified and skilled to meet the needs of the prospective resident. A written letter of confirmation is then sent to confirm assessment and ability to meet assessed needs, a statement of purpose, welcome pack and written contract is given to all residents during the admission stage. Trial period of 4-6 weeks with review and final decision’. Feedback taken from the care managers surveys indicate that the service undertakes assessments and ensures that accurate information is gathered prior to agreeing and/or offering accommodation. Additional comments included: ‘this nursing home takes a number of new residents from specialist wards in Moorgreen Hospital. The manager always carries out his own assessment and makes appropriate use of ward based and social worker assessments’. The assessment process for the person most recently admitted to the home was reviewed during the fieldwork visit, with their care plan found to contain both a professional summary of care and an in house assessment completed by the manager. In discussion with a relative the admission, to the home, of her next-of-kin was discussed, the relative stating that the family had visited the home on behalf of the resident and had been impressed by the way the staff conducted themselves throughout and that they had been provided with an information pack about the facilities and amenities of the home. The home does not provide an intermediate care service and so this standard is not applicable. South Haven Lodge DS0000059970.V359451.R01.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 7, 8, 9 & 10: The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The service tells us, via their AQAA that ‘Each resident has a robust care plan and risk assessments which is regulary reviewed and provides good information for the care team to implement high quality care to meet residents’ needs. Residents are consulted on their care plans and contribute as much as practical on a daily basis. Quality assurance audits are carried out’. Five ‘service user plans’ were reviewed during the fieldwork visit and found to contain a variety of assessment tools, including: dependency assessments, oral assessments, moving and handling assessments, waterlow scores, night South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 11 care assessments, side rail consent forms, food profiles, social histories and advance needs and/or death management plans. The care plans and the pre-admission assessments, which are the working documents, were both based on the ‘Activities of Daily Living’ (ADL) a model of care used within the nursing profession. The plans contained detailed information about the residents’ and the care and support they require on a day-to-day basis. The staff also used the running records to communicate and record any short-term changes in a persons’ condition and/or care. One person’s records advising staff that the resident had been unwell the preceding day and restless overnight and therefore they had requested to remain in bed that day. On touring the premise we (the Commission) met the person referred to above and their relative, who confirmed they had been under the weather recently and that they had requested to remain on bed rest. It also became apparent that this occurs from time-to-time and that the staff are happy to support the person to remain in bed and deliver care accordingly. The view of the professionals who visit the home is clearly that the service provides good levels of both health and social care, people remarking via the surveys that: ‘care for the individual person, high standard of nursing care’, ‘staff attempt to meet both physical and psychological needs’ and ‘I have always found this nursing home to be very flexible and responsive to the individual needs of both the resident and the residents’ immediate family’. The relatives inform us (the Commission), via their surveys that ‘the care home provides a safe, warm and caring environment’, ‘I find everything is done extremely well and my relative could not be in a better care home’ and ‘ they look after the people in their care’. The relatives also informed us both during the fieldwork visit and through the surveys that they are kept up to date with any changes in their next-of-kin’s health and that when the need to involve health or medical professionals in their next-of-kin’s care arises they are informed. Six of the eight surveys returned ticked ‘always’ in response to the question: ‘are you kept up to date with important issues affecting your friend/relative, for example if they have been admitted to hospital or had an accident, etc’, one of the person ticked ‘usually in response to the same question and the seventh person commented: ‘never been to hospital since being in the care home’. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 12 The professional view is that the home both identifies and meets people’s health care needs, all five people tick ‘always’ in response to the related question, the three health care professionals also indicated the home seeks advice and acts upon it to manage and improve individuals’ health care needs. The service tell us, via their AQAA that ‘Residents have access to other health professional services as and when needed. Preference of General Practitioner (GP) is respected where possible. All staff have access to training and professional research and literature’. The ‘service user plans’ reviewed during the visit contained specific health and social care records, which document the service users’ involvement with any professional service. People’s files also contain copies of correspondence from the professional health and social care services, which confirmed outcomes of clinic visits or appointments. The service has also created a visitors’ and/or quiet lounge/room, which can be used by the resident to entertain health and social care professionals, should they not wish to use their bedroom during visits. This facility can also be used to entertain families or friends and provides a private area away from the rest of the home during visits. The service states, via the AQAA that ‘Staff respect the residents privacy and dignity by knock on doors and wait to enter and call residents by their preferred name of address, which is documented’. The latter two statements were confirmed during the fieldwork visit with staff noticed knocking on people’s bedroom door (if closed) and on toilet and bathroom doors before entering. The residents preferred term of address was also document on their ‘service user plan’ and the interaction between the staff and the residents and the staff and the visitors noted to be appropriate and respectful. Relatives commenting, via the surveys, stated that ‘our relative could not have better care anywhere, nothing is too much trouble’ and ‘ staff talk and laugh with my relative even though they get little back or no response, always friendly’. Two people also commented on how their relative is always kept clean and tidy, which for many people is an important and essential aspect of their care, which promotes self-esteem and dignity. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 13 The environment is designed to provide a degree of privacy for the residents’ with communal facilities fitted with appropriate locks, which can be operated by people with both physical and cognitive impairments. Bedrooms are either single occupancy or shared, with the shared rooms fitted with screening to provide privacy during the delivery of personal care. All toiletries, etc were stored separately to prevent sharing. The views of the professionals, is generally that the service respects and promotes privacy and dignity for the service users, with four people ticking ‘always’ and the fifth ‘usually’ in response to the question: ‘does the care service respect individuals’ privacy and dignity’. However, the placing of the residents’ care records in their bedrooms, to promote use and ease of access, was discussed with the manager, as the information contained within those records can be very personal and private and therefore should not be readily accessable to anyone visiting the residents room. The manager has undertaken to review the practice and make changes accordingly. The service tell us via the AQAA that ‘There is a comprehensive procedure for the administration of medicines and these are well adhered to’. A review of the home medication storage established that all medications are correctly held and secured. The medication administration record (mar sheets), were generally well maintained, although on occasions staff had either used the wrong code or not specified the appropriate code, when omitting a medication. It was also noted that at the time of the fieldwork visit the medications in use had not been appropriately accounted for or checked into the home, although the manager was able to demonstrate that this was a one off issue, with previous mar-sheets providing evidence of how the home usually booking medicines into the home. One of the surveys completed and returned to the Commission, came from the home’s pharmist, who felt the home communicated well and sought appropriate medicines advice. Medication stocks are kept to a minimum and records indicate that the home’s medication fridge is checked on a daily basis to ensure it operates within safe and acceptable parameters. Staff observed administering medicines did so safely and appropriately, taking the medication to the service user, administering the medicine and then returning to sign the medication record. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 14 No service users self-medicate, as a result of their physical and cognitive health care needs. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 14 & 15: People who use services are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities could be improved to better meet individual’s expectations. EVIDENCE: The service employs an activities co-ordinator, who would normally be responsible for planning and delivering activities and entertainments to the residents’. However, during the fieldwork visit the manager explained that the activities co-ordinator has been off on long-term sick and that her absence has had a detrimental impact on the home’s activities schedule, with the care staff providing alternative in house entertainments were possible, whilst external entertainments remain largely unaffected. The manager did say that the activities co-ordinator is expected to return to work shortly and that in her absence an activities room has been created for South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 16 arts & crafts, small group work and for people to learn new skills like how to use the computer supplied. Generally, the views of the residents’ relatives, is supportive of the day-to-day activities provided at the home with five of the eight people ticking ‘always’ and one ‘usually’ in response to the question: ‘does the care service support people to live the life they choose’, the other two people opting not to reply to this question. However, both relatives to abstain from answering this question did indicate or comment that: ‘more stimulation for the patients with dementia’ could be provided. Comments provided by other relatives included: ‘staff always make sure he is okay – talking and laughing with him’ and ‘staff spend time with people in their care’. Information taken from the professional surveys is also supportive of the efforts made to support people lead or live the life style they would choose, four of the five respondents ticking ‘always’ in reply to a question on this subject, the fifth person did not answer the question. The service, via their AQAA, tell us that: ‘activity coordinator seeks the views of the residents in order to promote a variety of daily activities, these plans are regulary reviewed and can be changed to meet individual needs; information of community events and activities are displayed through out the home; regular trips into the community and community based involvement’. During the fieldwork visit we saw no activities being undertaken with the residents, however, as stated by the relatives the staff were observed in conversation with residents’ and at mealtimes the one-to-one interaction whilst supporting people with their dinners was good. The home provides access to the day-to-day entertainments you would expect to find in most people’s homes’ with televisions and radios in evidence both in communal areas and people’s bedrooms. Records support the manager’s claims that prior to the absence of the activities co-ordinator, through sickness, the range of activities within the home were good and that these were provided both on a one-to-one level and group setting. Copies of the schedules devised by the co-ordinator were also still available for viewing and these provide further evidence of the work undertaken to provide adequate stimulation for residents. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 17 The service tells us, via their AQAA that they have an: ‘open visiting policy where visitors are welcome anytime and facilities are available for them to have a drink or a meal with the resident’. The above statement was confirmed during the fieldwork visit when we arrivied at the home at the same time as a visitor who discussed their regular visits to see their relative, who was visited during the tour of the premise and who was later observed in the dining room eating diner. Other visitors were observed coming and going throughout the fieldwork visit and every person seen signed into and out of the home via the visitors book. In conversation with another relative it was established that a member of their family visits everyday to support their next-of-kin with their meal, which increases the interactive element of their visits. Feedback provided via the relative surveys is a little mixed with four people indicating that the home supports their relative/friend to keep in touch, whilst the remaining four people all felt the question did not apply due to their relative’s dementia. As mentioned earlier, within the report, a quiet lounge or visitors room has been created for the use of the residents’ and their relatives, which provides additional privacy during visits should they require. The home’s visiting arrangements are detailed within the ‘service user guide’ and/or ‘statement of purpose’ documentation. Copies of these documents were available within the home’s reception hall/main corridor area. Information already taken from the relatives and professionals surveys has established that people generally feel the home provides an environment, which ‘support people to live the life they choose’. Observations made during the fieldwork visit tend to support this view, with one person’s request to remain in bed respected and documented for other carers to note, a persons’ request for an alternative lunchtime meal appropriately addressed by staff, people’s preferred terms of address documented and used by staff and people witnessed choosing which lounge to visit depending on what is occurring within that area at the time. However, the degree to which people are able influence their day-to-day lives is often hampered by their general health care needs, both physical and cognitive’, as implied by one professional respondent who in reply to the question: ‘ does the care service support individuals to live the life they choose’, wrote ‘strange question as most need fulltime nursing care’. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 18 However, the manager and the staff did appear, during the visit, to be encouraging people to make decisions for themselves, as indicated above and on a wider scale through residents’ surveys, which enable relatives, if required, to support the residents to comment upon the service provided at the home. Feedback provided via the most recent survey indicating that more outings would be appreciated, as part of the activities schedule/programme. The tour of the premise enabled us to visit the kitchen, dining room and food storage facilities, where time was taken to speak to the catering staff. Two catering staff were on duty during the visit and both confirmed that they had completed basic food hygiene training courses. They also discussed the menus and showed us the records they maintain in respect of the food served and the equipment checks undertaken. The food storage facilities were appropriate and provided sufficient dry, cold and frozen food stores and there was a range of catering and/food items available. Observations made during breakfast and lunchtime, established that mealtimes are social occasions and that sufficient staff are around to support the service users to eat their meals. The catering staff also demonstrated an awareness of how meals should be served and presented with soft/liquidised meals looking appealing and well presented. The observations also suggested that the people eating the meals were enjoying what they were served, as people required little or no prompting to eat their food, although the staff interactions with residents were positive and appropriate throughout. Relatives were also noticed to be involved with assisting their next-of-kin with their meal, as reported earlier and at least one relative was seen eating with the residents in the dining room. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 16 & 18: People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, and are protected from abuse, and have their rights protected. EVIDENCE: The service tells us via their AQAA that: ‘the complaints procedure is widely distributed and available. Outcomes of complaints are managed in an effective and sensitive manner. Complaints resolved quickly and efficently involving agencies as needed. Feedback to concerned parties. stringent disciplinary procedures. Excellent documentation. Staff training in the handling of complaints. Open door policy. Clear learning, and changes to services and procedures take place. Polices and procedures are regularly reviewed and updated. The rights of the residents are safeguarded through staff training, supervision and continuous quality monitoring audit processes’. The dataset, which forms part of the AQAA documentation, establishes the existence of the home’s complaints and concerns procedure and that this was last reviewed in the June of 2007. The dataset also contains information about the home’s complaints activity over the last twelve months: No of complaints: 1. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 20 No of complaints upheld 0. Percentage of complaints responded to within 28 days: 100 . No of complaints pending an outcome: 0. The evidence indicates that people’s complaints are being appropriately handled, with written responses, where appropriate, being dispatched by the manager, a complaints logging system documents all activities associated with a complaint. Details of the home’s complaints process are on display around the home and made clear to people via the ‘service users guide’ and ‘statement of purpose’, which are also accessible around the home. The indication, from the survey respondent is that people are generally aware of the home’s complaints process and when service users have raised concerns these have been appropriately handled. During the visit the deputy manager produced copies of the homes training matrix, which indicates that all staff have completed ‘safeguarding adults’ training, this corroborated the information contained within the AQAA, which states that staff have undertaken ‘adult protection training’. The homes tells us, via their AQAA and dataset, that policies on the protection of service users are in place, ‘Safeguarding adults and the prevention of abuse’ and ‘Disclosure of abuse and bad practice’, both policies updated/reviewed in the June of 2007. The dataset also establishes that over the last twelve months no safeguarding referrals have been made to the Local Authority, a statement support by a review of our database, which established that no alerts had been brought to the Commission’s attention during this period. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 19 & 26: The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The service states via the AQAA that: ‘the home offers a good selection of equipment, including a specialist care bed and is adapted to meet the individual residents needs. All staff are trained in their use. The home meets the requirements of the Disability Discrimination Act and all rooms have ensuite facilities. 4 communal areas and 1 garden area are available to ensure that residents have a choice to sit quietly, meet with their families or engage in activities with other residents. Smoke free environment. Regular maintenance audits are carried out and appropriate records are kept. All rooms are maintained to a high level and room personalisation is encouraged. There is a proactive infection control policy in place to ensure that infections are South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 22 minimised. Clinical waste is properly managed and stored. The home offers a clean and odour free environment’. The tour of the premise confirmed much of the information provided via the AQAA and re-plastering and redecoration of one of the corridors was in hand during the visit. The new activities room is now in place and generally the communal facilities were well decorated and furnished. Many of the bedrooms visited during the tour of the premise, contained items of an individual nature, pictures, ornaments, pieces of furniture, etc, which had been used by the occupant to personalise their room or side of a room if shared. Comments obtained via the surveys include: ‘the care home provides a safe, warm and caring environment for my relative’ and ‘kept warm and very comfortable, everything that he needs is well catered for, it is a very happy home’. The home employs domestic, laundry and housekeeping staff, who were observed during the visit undertaking their duties. The home was noted to be free from odours and very clean and tidy throughout, with the housekeeping staff discussing how well looked after the premises are and that the employment of so many ancillary ensures the care staff are free to care. The AQAA also tells us that staff receive access to training on the management and control of infections and that policies and procedures are available, these were last reviewed and updated in the June of 2007. Communal toilets and bathrooms were noted to contain liquid soaps; paper towels and bins for the disposal of waste and all chemicals were stored in accordance with the ‘Control Of Substances Hazardous to Health’ (COSHH) regulations. The laundry, which is located within the main building, is the responsible of the laundry personnel who laundering residents clothing and returning them to the clients room. Clothes are labelled to reduce the possibility of lose or the item being returned to the wrong person, although the laundry operative did say that if people bring in new clothes and forget to label them or inform staff this can lead to delays in returning items. During conversations and via the surveys, no issues or concerns regarding the cleanliness of the home or the undertaking of people’s laundry were identified. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 27, 28, 29 & 30: Staff in the home are trained, skilled and provided in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: The service tells us via the AQAA that: ‘The home is staffed efficiently to meet the needs of the residents’. Copies of the home’s duty roster were seen during the fieldwork visit and seemed to indicate that sufficient staff care, domestic and ancillary staff were on duty to meet the needs of the residents’. Sufficient staff were also observed around the home during the visit, with this most noticeable during lunchtime, when staff were available to help people in the dining, the main lounge (where the majority of the residents require feeding) and to take meals to people who decided to remain in their bedrooms. The indication from the relative surveys is that people the staff are available in sufficient numbers to meet the needs of their next-of-kin, with people commenting: ‘I find everything is done extremely well and my relative could not be in a better place’, we are extremely happy with the daily running of South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 24 South Haven Lodge’ and ‘the staff are caring and considerate and the home is extremely well managed’. The relatives surveys also indicate that seven out of the eight people responding feel the staff have: ‘the right skills and experience to look after people properly’, the eight person ticking ‘usually’ in response to the same question and adding: ‘my observations on visits suggest that the care staff are competent in what they do’. The professional health and social care survey respondents also feel the staff have the right ‘skills and experience to meet the needs of the residents’ with all five tick ‘always’ in response to the question raised about staff training, one professional adding: ‘staff attempt to meet both physical and psychological needs’. Details of the home’s staffing arrangements and the skills and experience of the staff are set out within the ‘statement of purpose’ document, which as mentioned is accessible to people within the home. The deputy manager is responsible for identifying, planning and arranging the training programme for South Haven Lodge. During the visit she provided us with sight of the training matrix, which showed over the last twelve months that staff had completed moving & handling, health & safety, first aid, food hygiene, COSHH (one of course, which is only updated if changes in chemicals used at the home occur), infection control – level 2 Vocational Infection Qualification, hand washing (annually), fire training (twice annual day staff and four times a year for night staff), Protection Of Vulnerable Adults. The records maintained and the training folder available also evidence that deputy manager arranges a number of external training courses, which have recently included: ‘bereavement, challenging behaviour, Malnutrition Universal Screening Tool (information pack), nutrition, MRSA awareness, ASET (a training body) level 2 in dementia and Palliative care another course devised by ASET both of which are to be delivered in house. The service tells us, via the AQAA that: ‘all support staff have or are undertaking National Vocational Qualifications (NVQ) 2 or above training or equivalent’. Information taken from the dataset and confirmed with the manager, indicates` that currently the home employs twenty-nine care staff. Thirteen of the twenty-nine care staff have completed a National Vocational Qualification (NVQ) at level 2 or above and this provides the home with a ratio of 45 of its care staff possessing an NVQ at level 2 or above. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 25 The dataset also indicates that a further eleven staff are currently undertaking their NVQ and once these staff have completed their course the homes’ ratio of staff possessing an NVQ could rise to 96 . Information contained within the dataset establishes that a recruitment and selection strategy/procedure exists to support the manager when employing new staff. It also indicates that all of the people commencing work within the home over the last twelve months have undergone satisfactory pre-employment checks. On reviewing the files of the two most recently recruited staff all of the required checks were in place, Criminal Records Bureau (CRB) checks, Protection Of Vulnerable Adults (POVA) checks and two references. The files also contained completed application forms, work permits, health declarations, photographs of the employee, interview summaries, personal information and information used to support the CRB application process. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 26 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 31, 33, 35 and 38: The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The service tells us via their AQAA that ‘the registered manager has the appropriate qualifications and relevant experience’. In conversation with the manager he confirmed that he possesses a professional nursing qualification and has completed appropriate managerial qualifications. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 27 The Service also state via their AQAA that: ‘a business plan is in place and that the home enjoys financial stability. As part of the healthcare group the home enjoys company accounting and auditing facilities and bi-weekly support visits by Senior Management are undertaken’. Information taken from the relatives surveys indicate that they feel the home is well run and organised with people commeting: ‘when we first met Max the manager we liked him immensley, to us, as a family, the saddness of our relatives illness was fully understood by Max and his wonderful team of staff’. The above view also seems to be shared by the professional visitors with comments including: ‘I have great confidence in this home and in particular in its manager, his leadershio is the key to this homes’ success’ provided. The home’s approach to quality assurance is reasonable with residents meetings and survey used by the manager to gauge people’s satisfaction with the service. The service tells us, via their AQAA: ‘There is a comprehensive quality assurance process in place. Residents surveys are carried out at least annually’. A comments and compliments folder has been established and is accessible within the home to visitors and included recent remarks, such as: ‘the home is clean, staff approachable and willing to discuss issues, attitudes good’, ‘we have been very grateful to Max and the team for allowing my father to die with dignity with familiar people around him’, ‘would recommend SH to any family who find themselves in the dilemma we were faced’ and ‘Thank you for making our dear dad 90 birthday so special thank you for his lovely cake, you are all so caring’. Care plans and risk assessment documents are being reviewed and updated accordingly and other records, like those relating to the receipt of medication, and training and development matrix, etc, normally accurately maintained. The service tells us, via the AQAA and dataset information that health and safety policies and procedures are made available to the staff and that domestic appliances and personal equipment is regularly maintained and serviced. Residents’ monies are individualised and not pooled and appropriate records are kept, which account for expenditures, etc. The dataset establishes that policies and procedures are available to support the management and/or staff manage clients’ valuables and monies and that these were last updated in the June of 2007. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 28 In conversation with relatives and via the surveys no issues relating to the homes’ management of peoples’ monies or maintainance of their personal items/valuable were raised. Health and safety training is being made available to staff, with the training matrix and plan providing evidence of the courses attended and those to be attended by staff, including: health and safety, infection control and moving and handling, etc. The tour of the premise identified no immediate health and safety issues, and the environmental risk assessments do consider both potential areas of harm and how these can be managed, as highlighted by the service’s decision to improve the ramped access at the front of the home. Generally the service users and their relatives are satisfied with the service being provided at the home and raised no concerns in relation to either Health or Safety issues. South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 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 3 X X 3 South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 30 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. Standard Regulation Requirement 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. Refer to Standard Good Practice Recommendations South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI South Haven Lodge DS0000059970.V359451.R01.S.doc Version 5.2 Page 32 - 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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