Care Home: Southdown Nursing Home

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What the care home does well The majority of people who live in this home are very frail and find it difficult to tell us about their opinions of the home, but those that can say that they find it a nice comfortable place to live in and it suits their needs. Both they and their visitors are very appreciative of the staff and they told us that they are very kind and caring. The feedback gained from the "expert" about her initial impression of the home was that "a great many of the residents suffer from incontinence and a number need help with feeding. These requirements place heavy demands on the staff but, for me, there was no sense that staff felt pressurised by their commitments. Rather, the overall impression I gained was of a calm, homely atmosphere. Most residents I spoke to were a little confused but I was able to gather a general sense from them that they were happy in this home and felt that the staff were kind". Residents looked clean, well cared for and comfortable and a regular toileting regime ensures that the home is generally free from any malodour once everyone is up and dressed in the morning. Menus are varied, particular preferences and dietary needs are catered for and people say that they like the food that is served to them. Staffing levels appear to be sufficient to meet the care needs of residents and many of the staff have received some training in caring for residents with dementia. Staff turnover is very low, enabling continuity of care to be provided and more than 50% of carers are educated to NVQ level 2 and above. A comprehensive pre-admission assessment is undertaken and this, in addition to the one from the care manager, ensures that the healthcare needs of residents will be met. These then form the basis of care plans that accurately reflect the care that is currently being delivered and the support that residents need. These plans are regularly reviewed and advice is gained from other healthcare professionals as required. Their frailty means that residents are often not able to contribute to these plans however, input is encouraged from their relatives who sign to say that they agree with them. Some organised activities, suitable for the needs of the residents, are provided. Staff also recognise the importance of any form of interaction and communication and spend time chatting with people and involving them in various pastimes. What has improved since the last inspection? Since the last inspection, a new management structure has been developed within the home and a great deal of work has been done in order to improve the outcomes for the people who live there. Much of the home has been redecorated and looks fresher and brighter. Pretty quilts and curtains have been put into the bedrooms, furniture has been replaced and bathrooms have been upgraded. A handyman is now employed on a permanent basis to help with the maintenance. There is new garden furniture and chairs and tables in the lounge have been rearranged to give residents more room to walk around. New equipment including a hoist, wheelchairs, over bed tables and adapted feeding utensils have been purchased and there is a new television in the sitting room. The management team are trying to encourage both residents and their families to become more involved in the running of the home. There are regular meetings and a newsletter is published so that everyone is aware of any new developments. Opinions are being used to influence service provision, one example being the increase in visits from the hairdresser which is something that was asked for. Some relatives have been helped to register with the Dial-a-Ride scheme so that it is easier for them to visit and an exceptionally large number of them came to the party that was held to celebrate Christmas. Policies and procedures are being developed in the home. There is a New Statement of Purpose, which explains the aims and objectives of the home and a new Service User Guide. A copy of this booklet, which describes all of the facilities that are provided as well as other useful information, has been put into each resident`s room. Work is also being undertaken, with picture prompts and useful phrases, to help staff to communicate with people for whom English is not their first language. Staff supervision is now happening, on a regular basis, so that all staff are able to discuss the way that they work and any training needs that they may have for the future. Also training sessions are being planned for all staff for the coming year to ensure that they will have the necessary skills to help them meet the needs of those people who live in the home. What the care home could do better: It is acknowledged that all of the issues of concern from the last inspection have been addressed. It is recommended that The New Service User Guide could be made a little easier for residents and their relatives to read next time that any are produced Currently the print is very small. Care must be taken to ensure that all of the information, that is required to be obtained as a part of the recruitment procedure, is always complete, prior to any new staff member beginning work. One omission was noted at the time of the inspection.There had been one adverse incident that had occurred in the home. Although this had been dealt with, by the manager, there must be a robust process put in place to ensure that notifications are sent to the relevant people including the placing authorities and The Commission for Social Care Inspection. CARE HOMES FOR OLDER PEOPLE Southdown Nursing Home 5 Dorset Road Cheam Surrey SM2 6JA Lead Inspector Alison Ford Key Unannounced Inspection 10:30 17th January 2008 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 Southdown Nursing Home DS0000019123.V356562.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. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southdown Nursing Home Address 5 Dorset Road Cheam Surrey SM2 6JA 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 8643 1639 020 8642 1369 wij@ceylonsatphiers.co.uk Melba Rosario Wijayarathna Melba Rosario Wijayarathna Care Home 25 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (0) of places Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users admitted with a diagnosis of dementia does not exceed 10. A Registered Mental Health Nurse or Registered General Nurse who holds a recognised Dementia training certificate is always on duty. All staff must have dementia awareness training. Date of last inspection 31st May 2007 Brief Description of the Service: Southdown is a converted and extended house, registered with The Commission For Social Care Inspection to provide nursing care for up to 25 elderly people, including up to ten that may suffer from dementia. The home is situated in a residential area of Cheam and is close to public transport links. There are fifteen single and four double bedrooms arranged over two floors. Fourteen of the single rooms have en-suite facilities. A shaft lift provides access to the lower first floor with a stair lift serving those rooms on the upper first floor. In addition to the dining room there are two communal lounges. There is pleasant back garden, which can be used by residents, and car parking is available at the front. At the time of this inspection fees range from £490 - £540 per week. Any additional charges that might be payable for personal items or services such as hairdressing would be discussed prior to admission. Copies of the homes Statement of Purpose and the latest inspection report can be obtained directly from the home or, in the case of the latter, from the Commission for Social Care Inspection via the internet. Southdown Nursing Home DS0000019123.V356562.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 star. This means the people who use this service experience good quality outcomes. This was the homes second visit as part of the inspection process for the year 2006/2007 and was unannounced. It was undertaken by one inspector and “An Expert By Experience”. This is a person who, because of their previous experience of using similar services, visits with an inspector to help them a get a picture of what it is like to live in the home. In this instance the expert had been a healthcare professional whose relative had lived in a home for older people. When writing the report, consideration has been given to comments made by residents and their relatives and to notifications received about the service during the year including any information we have about how well they have managed any complaints. The homes manager has also completed an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. A partial tour of the premises was undertaken and a sample of care plans, records and documentation relating to the health and safety of residents was seen. There were twenty residents living in the home at the time of this visit, and several were spoken with, also the members of staff on duty at the time and three relatives who were visiting. Since the last inspection The Registered Provider, has become the Registered Manager of the home and she and all of her staff are thanked for their help during the inspection. The Commission has not received any complaints about this service since the last inspection. What the service does well: The majority of people who live in this home are very frail and find it difficult to tell us about their opinions of the home, but those that can say that they find it a nice comfortable place to live in and it suits their needs. Both they and their Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 6 visitors are very appreciative of the staff and they told us that they are very kind and caring. The feedback gained from the “expert” about her initial impression of the home was that “a great many of the residents suffer from incontinence and a number need help with feeding. These requirements place heavy demands on the staff but, for me, there was no sense that staff felt pressurised by their commitments. Rather, the overall impression I gained was of a calm, homely atmosphere. Most residents I spoke to were a little confused but I was able to gather a general sense from them that they were happy in this home and felt that the staff were kind”. Residents looked clean, well cared for and comfortable and a regular toileting regime ensures that the home is generally free from any malodour once everyone is up and dressed in the morning. Menus are varied, particular preferences and dietary needs are catered for and people say that they like the food that is served to them. Staffing levels appear to be sufficient to meet the care needs of residents and many of the staff have received some training in caring for residents with dementia. Staff turnover is very low, enabling continuity of care to be provided and more than 50 of carers are educated to NVQ level 2 and above. A comprehensive pre-admission assessment is undertaken and this, in addition to the one from the care manager, ensures that the healthcare needs of residents will be met. These then form the basis of care plans that accurately reflect the care that is currently being delivered and the support that residents need. These plans are regularly reviewed and advice is gained from other healthcare professionals as required. Their frailty means that residents are often not able to contribute to these plans however, input is encouraged from their relatives who sign to say that they agree with them. Some organised activities, suitable for the needs of the residents, are provided. Staff also recognise the importance of any form of interaction and communication and spend time chatting with people and involving them in various pastimes. What has improved since the last inspection? Since the last inspection, a new management structure has been developed within the home and a great deal of work has been done in order to improve the outcomes for the people who live there. Much of the home has been redecorated and looks fresher and brighter. Pretty quilts and curtains have been put into the bedrooms, furniture has been Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 7 replaced and bathrooms have been upgraded. A handyman is now employed on a permanent basis to help with the maintenance. There is new garden furniture and chairs and tables in the lounge have been rearranged to give residents more room to walk around. New equipment including a hoist, wheelchairs, over bed tables and adapted feeding utensils have been purchased and there is a new television in the sitting room. The management team are trying to encourage both residents and their families to become more involved in the running of the home. There are regular meetings and a newsletter is published so that everyone is aware of any new developments. Opinions are being used to influence service provision, one example being the increase in visits from the hairdresser which is something that was asked for. Some relatives have been helped to register with the Dial-a-Ride scheme so that it is easier for them to visit and an exceptionally large number of them came to the party that was held to celebrate Christmas. Policies and procedures are being developed in the home. There is a New Statement of Purpose, which explains the aims and objectives of the home and a new Service User Guide. A copy of this booklet, which describes all of the facilities that are provided as well as other useful information, has been put into each resident’s room. Work is also being undertaken, with picture prompts and useful phrases, to help staff to communicate with people for whom English is not their first language. Staff supervision is now happening, on a regular basis, so that all staff are able to discuss the way that they work and any training needs that they may have for the future. Also training sessions are being planned for all staff for the coming year to ensure that they will have the necessary skills to help them meet the needs of those people who live in the home. What they could do better: It is acknowledged that all of the issues of concern from the last inspection have been addressed. It is recommended that The New Service User Guide could be made a little easier for residents and their relatives to read next time that any are produced Currently the print is very small. Care must be taken to ensure that all of the information, that is required to be obtained as a part of the recruitment procedure, is always complete, prior to any new staff member beginning work. One omission was noted at the time of the inspection. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 8 There had been one adverse incident that had occurred in the home. Although this had been dealt with, by the manager, there must be a robust process put in place to ensure that notifications are sent to the relevant people including the placing authorities and The Commission for Social Care Inspection. 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. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 9 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 Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 10 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): Standards1, 3,6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who use this service can expect that a pre admission assessment will be carried out to ensure that the home and the services that it provides will meet their needs. Written information is now available, describing the home and the services offered , to help people decide if it will suit them. This home does not offer intermediate care. EVIDENCE: The local authority funds the majority of the current residents and the care manager’s assessments, determining the level of support that is required were seen in care plans that were assessed. In addition a senior member of the homes staff will visit potential residents to make certain that their needs can be met. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 11 In response to a requirement issued at the last inspection, a new Statement Of Purpose has been developed. This is a full and comprehensive document, which meets the requirements of the regulations and provides a detailed explanation as to how the people who use the service will be supported and cared for. A Service User Guide has also been developed and it provides a useful reference tool for residents and their relatives. A copy is available to all of the residents in the home and it is left in their bedrooms for people to refer to. It is recommended that consideration should be given to producing the book in larger print to help those people for whom it is intended. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 12 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): Standards7,8,9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who use this service consider that they are always treated with respect and dignity. Their care plans accurately reflect their assessed healthcare needs and appropriate interventions and support are given to ensure that these are met in the way which they prefer. Medication policies and procedures are in place to ensure their protection. EVIDENCE: A sample of three care plans was inspected at this inspection. These are reviewed monthly to ensure that they reflect the care that is currently being provided and relatives are invited to participate in the process. Input is gained from other healthcare professionals as required. There was evidence that many of the problems that might be associated with this client group have been considered and appropriate interventions put in place. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 13 Residents and their relatives that were spoken with consider that outcomes for them with regard to their personal care are good. They are supported in the way that they wish and their views are taken into account. Of particular note is the way in which a home worked closely with one resident and supported them so that they have now been able to leave the home and return to live with their family. Since the last inspection work has continued to produce “life histories” of residents outlining their previous lives and achievements. This has allowed staff to gain a better understanding of the people that they are caring for. Two of the residents in the home have a limited ability to speak English and a selection of useful phrases in their particular languages have been put up to help staff to talk with them. Staff were observed treating people with respect and everyone spoken with agreed that they were always kind. Personal care is delivered in resident’s own rooms and screening is provided in shared rooms. Medication records and storage were in order. Southdown Nursing Home DS0000019123.V356562.R01.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): Standards 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. The people who use this service would be encouraged to make choices within their limitations in order to preserve their independence, and their visitors are always welcome. Meals that are served in the home are nutritious and generally suited to resident’s preferences, and a there is a limited range of activities provided in the home to offer them stimulation and interest. EVIDENCE: The majority of residents in this home are very frail and have limited capabilities although they are encouraged to make choices in their lives as much as they are able. Some of them have requested to get up later in the morning and they are able to choose the clothes that they wear and the meals that they eat. Visitors are always made welcome and the expert by experience spoke with three of them who were visiting at the time. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 15 All of them said the staff did an excellent job adding “you can’t fault them for the care they provide” and “ we are very satisfied with the way they look after our relative”. She observed the lunchtime meal, which she thought was nicely presented, and she was told a choice was available if required. She was concerned that there seemed to be little home cooking, rather, ready prepared foods such as packs of vegetarian sausages and pre-sliced meat were used, and the lunch she saw didn’t look very appetising. Indeed a number of people left theirs though others told her it was very nice and said they generally enjoyed the food they were served. Fresh table napkins were provided for all those able to use them. Residents needing help were fed either at the table or in their armchairs. It is recommended that some work should be undertaken to try and find out residents food preferences and revise the menus accordingly with a greater emphasis placed on providing fresh produce whenever possible. This will be monitored at future visits. Picture menus are currently being developed to help them to make their choices. There is a daily timetable of activities provided by the staff and once a week an activities co-ordinator visits. The expert by experience, who spent most of her visit with the residents, thought that it would be useful if she could visit more frequently, not only freeing up staff to spend more time with those unable to participate but also to offer specialised input for these residents who otherwise seem to spend their days just sitting around. When she is not in the home carers organise various pastimes with people such as arts and crafts. It is recommended that consideration should be given the idea of having more professional input. Of particular note is the fact that the senior nurse in the home has helped some visitors to register with Dial-a-Ride so that they can come to the home more often. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 16 Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 17 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): Standards 16,18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who use this service have access to an appropriate complaints procedure, which ensures that their concerns would be listened to, and acted upon promptly. Policies and procedures are in place to protect them from abuse. EVIDENCE: There is a complaints procedure, which is displayed in the hall. It also in the Service User Guide, which has been distributed to all of the residents. The complaints book was seen and any concerns that had been raised had been addressed appropriately. One issue was highlighted during the inspection where, although an incident had been dealt with by the home, it had not been reported to The Commission. This was discussed with the Registered Manager and is now being addressed. Processes must be put in place to ensure that this does not happen in future. A requirement was issued regarding this under standard 38. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 18 In order to help to protect residents from those who have been judged as being unsuitable to work with vulnerable people, no new members of staff are employed without appropriate clearance from the Criminal Records Bureau. All staff have received training in the recognition of adult abuse within the last year. One requirement relating to recruitment, and the completion of all of the necessary pre-employment checks was made under standard 29, which has affected this outcome group. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 19 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): Standards 19,26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who use this service consider that they live in a home, which suits their needs and expectations, and an ongoing refurbishment programme has been started so that it is a pleasant place for them to live in. EVIDENCE: Since the last inspection an ongoing redecoration and refurbishment plan has been implemented. Much of the home has been redecorated; pretty quilt covers and curtains have been put in the bedrooms, bathrooms have been upgraded, and new garden furniture has been purchased. The furniture in the communal areas has been rearranged to give more space for people to move around and a new television has been bought for the sitting room. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 20 The overall feel of the home is much cleaner, fresher and brighter than it was previously. New hoists, bedside tables and wheelchairs have been purchased and plate guards and double handled soup cups are now in use to help residents at mealtimes. It is to be hoped that this improvement programme will be continued and it will be monitored at future visits. The expert by experience joined the tour of the home. She considered that “there was a calm and friendly atmosphere in this home which is experiencing an ongoing programme of redecoration and some renovations, all of which seem very suitable, attractive and practical”. She noted, “there are 2 sitting rooms, one with a TV which was on continuously during our visit. Both rooms were arranged with chairs round the sides of the room but residents seemed to have developed friendships with those they sat with regularly and are not happy, we were told, if attempts are made to re-arrange the room. Bedrooms seemed a good size (though 5 are shared) and some residents and their families had made them very homely with pictures, photographs etc. Others could do with some nicer furniture and additional trimmings to make them more hospitable”. We were told that some of the furniture actually belonged to residents who had bought it from their homes. When we arrived the home was slightly malodorous however, once everyone was up, washed and dressed and all the beds were made, this disappeared. Laundry facilities are adequate and there are policies and procedures in place for dealing with foul linen including the provision of colour-coded bags. Protective gloves and aprons are supplied for staff as required. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 21 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): Standards 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. People who use this service are cared for by sufficient staff to meet their healthcare needs. Recruitment procedures generally ensure that they are protected from those who have been judged as being unsuitable to be working with vulnerable people. Training is in place to help staff to fulfil the aims of the home and meet the needs of the residents. EVIDENCE: On the day of the inspection there were sufficient numbers of staff on duty to care for the twenty residents currently living there. Off duty records confirmed this to always be the case. The majority of the care staff have completed an NVQ level 2 qualification and most of them have undertaken limited training in dementia awareness. The home intends to admit more people with dementia in the future so training in the problems experienced by these people will have to have to be increased. Mandatory training has all been completed and other sessions are planned for the forthcoming year. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 22 New personnel files are in use and these contain the details of each staff member along with evidence of their training and of their supervision sessions. Only one new member of staff had been employed since the last inspection. There was evidence of clearance from the Criminal Records Bureau however there was only one written reference available. A verbal reference had apparently been obtained and the member of staff had worked in the home before. The Registered Manager was reminded of her responsibilities in ensuring that all of the required checks are completed prior to the appointment of any new member of staff. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 23 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): Standard31,33,35,36,38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who use this service are protected by policies and procedures that are in place to promote their health and safety. There is now a registered manager in post and processes are being developed so that they can influence what happens in the home. EVIDENCE: The owner of the home, Mrs Wijayarathna, has now been registered as the manager and a new staffing structure is in place to support her. Currently this appears to be working well. The roles are well defined and there are regular meetings so that all staff are aware of the latest developments in the home. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 24 A quality assurance system is being developed within the home to gain the views of residents and their relatives in order to influence the way that services are delivered. There are quarterly meetings held and a newsletter is distributed following the meeting, discussing the topics that were spoken about. It was considered that this was a very positive step towards allowing residents and their families to comment on the home and the care being provided although, it is acknowledged that many of the residents may find it difficult to contribute their ideas. Social events also give relatives the opportunity to visit the home and speak with the management team and the recent party held to celebrate Christmas was apparently very successful. No money is currently held on behalf of any residents; a relative or representative deals with their financial affairs. Formal supervision of staff has now been developed to monitor their performance and identify any future training needs. Certificates providing evidence of maintenance and safety checks were all in place and a fire risk assessment has been completed. Kitchen premises were recently inspected and any issues that were raised have now been complied with. One concern was raised regarding the reporting of incidents that could have had potentially serious consequences for residents. The incident was managed appropriately however; the manager was reminded of her role in informing other outside agencies including the placing authorities and The Commission for Social Care Inspection. Further discussions will be held to make sure that proper systems are in place to manage the way that reporting is managed within the home. Southdown Nursing Home DS0000019123.V356562.R01.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 3 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Southdown Nursing Home DS0000019123.V356562.R01.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 OP29 Regulation Schedule 2 Requirement All necessary pre-employment checks must be completed prior to any new member of staff beginning to work in the home, in order to ensure the protection of those who live there. There must be a process in place to ensure that any incidents that affect the health or safety of residents are reported to the appropriate authorities. Timescale for action 31/01/08 2 OP38 37(1)(g) 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations It is recommended that any information intended for residents and their families, including The Service User Guide should be produced in a format that is easier for them to read. Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Southdown Nursing Home DS0000019123.V356562.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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