Care Home: Southlands Nursing Home

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What the care home does well What has improved since the last inspection? What the care home could do better: CARE HOMES FOR OLDER PEOPLE Southlands Nursing Home 13 Wetherby Road Roundhay Leeds Yorkshire LS8 2JU Lead Inspector Catherine Paling Key Unannounced Inspection 2nd March 2009 09:45a 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 Southlands Nursing Home DS0000072596.V374365.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. Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlands Nursing Home Address 13 Wetherby Road Roundhay Leeds Yorkshire LS8 2JU 0113 2655876 01132329199 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) Westward Care (Yorkshire) Limited Kate Louise Brown Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N, To service users of the following gender: Either, Whose primary care needs on admission to the home are with the following categories: 2. Old age, not falling within any other category - Code OP. The maximum number of service users who can be accommodated is: 36 New service Date of last inspection Brief Description of the Service: Southlands Nursing Home is a converted Victorian house with an adjoining wing. The home is set in well-maintained grounds, which are accessible to people living at the home. It is on a bus route conveniently situated close to local shops and amenities. The home is a short walk away from Roundhay Park. There are 36 registered places and personal care with nursing is provided for men and women over the age of 65 years. The home has been registered as a nursing home for many years. The new providers, Westward Care limited were registered as providers of the service in August 2008. Information about the service is provided in a Statement of Purpose and Service User Guide. The current fees range from £600 to £675. There are additional charges for chiropody, hairdressing, toiletries and newspapers. This information was provided at the March 2009 inspection. The home should be contacted directly for up to date information about charges. Southlands Nursing Home DS0000072596.V374365.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 3 star. This means the people who use this service experience excellent quality outcomes. This was an unannounced visit by one inspector who was at the home from 09:45 until 16:30 on 2nd March 2009. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people who live at the home as well as with the manager and the staff. An Annual Quality Assurance Assessment (AQAA) had been completed by the home before the visit to provide additional information. This is a selfassessment of the service provided. Survey forms were sent out to the home before the inspection providing the opportunity for people at the home, visitors and healthcare professionals who visit to comment, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A number of surveys were returned by the time of this visit. Comments received appear in the body of the report. What the service does well: The manager wrote in the AQAA – “Since the takeover by Westward Care Ltd, Southlands will continue to carry out the following: Service user and relative meetings are held and have a dual function, firstly as a social evening and secondly as a formal meeting. Quality Assurance questionnaires sent out twice yearly so that all service users and their representatives have the opportunity to comment on the services provided. Regular daily contact with management is important to encourage an open culture where service users can express their views and concerns. Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 6 Care plan review meetings with service user and/or their relatives /representatives are held twice yearly or more frequently if required. Suggestion boxes are located in the main building and conservatory wing. Staff have good relationships with service users which allows people to feel comfortable in expressing their views.” The registered manger is highly skilled and uses her skills to the benefit of the people at the home. She has established an effective working relationship with the visiting general practitioners. Healthcare professionals said – “Nurse in charge is probably the best nurse in terms of assessment and communication in all the homes we serve.” The home provides a high standard of clinical care to people with complex needs. People said that they felt the care is “superb”. The training programme for staff makes sure that they have the skills so that they know how to look after people properly. Relatives are also very well supported by the manager and her staff and are welcome at any time. What has improved since the last inspection? This was the first inspection since the service provider changed. However, this is an established service and the manager has continued to strive to improve the service provided to people. The manager wrote in the AQAA – “At a resident/representative forum it was suggested that service users would benefit from the installation of improved outside lighting and an internal ramp. Both of these have now been installed and very positive feedback has been received. From the visitor satisfaction survey of June 2008, it was brought to our attention that we could improve our range of activities available. This has been discussed with the appropriate staff and a more extensive (programme) is now being compiled.” The new provider has already made some improvements to the environment to make sure that people continue to live in a safe and comfortable environment. Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 7 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. Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 8 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 Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 9 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): 1 and 3 (Standard 6 does not apply) People who use the service experience excellent quality outcomes in this area. People have enough information to help them make up their mind about moving into the home. Thorough pre admission assessments are carried out before anyone is admitted to the home. People admitted to the home can be confident that their needs will be met. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “A pre admission assessment of need is carried out for each Service User. This assessment is done by a senior experienced member of staff; information is Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 10 gathered from a range of sources and from the individual concerned. Following assessment, in order to achieve positive outcomes for the individual, the assessment is discussed and a decision is made by the nursing team as to whether or not we are able to meet their needs. If any specialised training or research is needed this is then organised. The results of the outcome of the assessment are conveyed to the prospective resident in letter form. The home offers a three month settling in period.” “Our Statement of Purpose and Service User guide has been reviewed and updated since the takeover by Westward Care Ltd.” We saw detailed pre-admission assessments that included information about care needs, family support and the type of specialist equipment needed to allow the home to look after someone properly. Information was collected from a variety of sources. It was clear from the records we saw that the full and detailed information collected at this stage allowed a clear decision to be made about whether care needs could be met at the home. People said – “I visited many care homes before deciding Southlands was the right one for my husband” “….very confident that they would be able to take good care of my husband” “ We were given the induction talk and were shown around the building, we decided that this was the best one” Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience excellent quality outcomes in this area. The care plans provide clear and detailed instructions for staff to follow making sure that health and personal needs are met. The people at the home are treated with respect and dignity. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “Care plans are produced to cover all activities of daily living and specialised healthcare needs. These plans identify both strengths and needs and are reviewed regularly. Service users are positively encouraged to have input into Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 12 the development and review of their care plans. With agreement of the service user, families are also encouraged to be involved in the care planning and review process. Trained nurses are allotted supernumerary time to enable them to carry out thorough reviews and evaluations. Acute care plans are introduced if a service user becomes acutely ill. These continue until the problem is resolved, they enable staff to easily identify a service users changing needs. Risk assessments are in place to identify the following risks and action to be taken to reduce those risks:Risk of developing pressure sores. Nutritional risk Risk of falling Moving and handling Service Users are registered with a local General Practitioner of their choice and have access to chiropody, optical and physiotherapy services. The home has policies for the ordering, receipt, storage, handling, administration and disposal of medication. The Manager oversees these arrangements and carries out regular audits. End of life care plans are used and formal decisions regarding end of life care with advance directives are used to record wishes and feelings. Staffs are well trained to deliver a high standard of health, personal and social care. We are able to offer services to people with complex nursing needs and staff receive training which is specialised to meet the requirements of these clients.” We saw detailed care plans in place for people. The input and support needed from staff and equipment needed was detailed. Where wounds were being dressed there were clear records that showed that the condition of the wound was closely monitored and re-assessed. Staff had clear instructions on the type of dressing to use. Advanced care plans are in use and we saw clear information about end of life care and evidence of the people involved in making end of life decisions for people who were no longer able to make their own decisions. There was a whole range of detailed risk assessments in place for people. All were regularly reviewed and updated and include information about any specific equipment needed. There were clear records of the input from other healthcare professionals. Healthcare professionals said – “Exemplary” (What the care service does well) “Most things – especially attention to detail, sensitivity, nursing skill” Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 13 “This home is one of the best I have come across.” (What does the care service do well) “Communication, resident care, family liaison, nursing care” We saw some very good evaluation of care plans that was an informative and detailed review of the effectiveness of the care plan for the previous month. Some other evaluation was not quite so detailed, for example, “remains dependant” or did not really comment on issues identified in the care plan. We spoke to the families of some highly dependant people being cared for at the home and they were very satisfied with the care provided. One person said they felt the manager was “on the ball” and commented on the fact that when his wife had been admitted to the home she was underweight due to her illness but since admission there had been very good management of her nutritional needs and she is now a normal weight – “enough said!!” Another said that the care was “superb” and that the staff “give him the respect he deserves.” Southlands Nursing Home DS0000072596.V374365.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): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. People are supported to make choices about how they spend their time although some people said that they were bored. People are provided with a good and varied diet. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “Service users are actively encouraged to be involved in all areas of daily living in the home and routines are kept as flexible as possible. They receive a monthly newsletter which informs them of the activities programme for the month ahead and includes quizzes, poetry and items of interest.” “Individual use of leisure plans are produced for each service user, therapies such as massage and aromatherapy are given on a one to one basis and other Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 15 activities are planned for groups and one to one. Religious observance and need are identified pre admission and reviewed regularly to ensure wishes are being met.” “We have open visiting arrangements, visitors are encouraged to stay as long as they wish are able to have meals with their relatives/friends if they so wish. Service users are able to choose whom they see and do not see.” The nursing home offers 3 meals per day, snacks and drinks are available throughout the day and night. All special diets are catered for and we pride ourselves in particular on the presentation of meals that are required to be liquidised. Service users can choose what time they have their meals, where they wish to eat them and they have a varied menu to choose from. Assistance with eating and drinking is available at all times.” There is a monthly Newsletter that includes poems and quizzes as well as the activities programme and celebration of peoples’ birthdays. There is also a weekly programme of activities. The activities person divides her time between spending 1:1 time with the very dependant people who live at the home and organising group activities. Leisure plans for very dependant people referred to aromatherapy and massage. More able people at the home did not seem to have a great deal to occupy them during the day and some said that they were bored. When asked what they did all day one person said “nowt” and that they were bored. The television was on but few people seemed to be showing any interest in it, others were reading the newspaper. From information provided by the manager before the visit in the AQAA it seems that there is an acknowledgement that more can be done for leisure and day to day stimulation and activities for people. This is what the manager felt the home could do better “Focus more in our pre admission assessment as to what a prospective service user’s hopes and aspirations are for their daily life and social activities. Improve our recreational facilities” This was how the manager said she would improve social activities over the next 12 months – “To continue to look at ways we can improve daily life and social activities for our dependent service users. To assist in setting up ’ The Friends of Southlands‘ with relatives.” The lunchtime meal looked and smelt appetising. Portions were generous and support was given as necessary. People said the food was good. Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. People feel listened to and that any concerns are taken seriously. People are protected by staff awareness of safeguarding procedures. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “We have an effective complaints procedure a copy of which is given to every prospective service user and it is displayed within the home. This can also be made available in other formats if required. All concerns and complaints made and the action taken are logged and dealt with within the required timescales. Service Users are kept informed about the progress of any investigation. The nature of all complaints and concerns received is reviewed in order that we may learn from these and use them as an aid to improve the quality of our service. The home has robust policies and procedures in place on adult protection. Staffs are well trained in safeguarding adults and know how to respond to any concerns. They are taught to understand the importance of listening to their services users and to take seriously any concerns raised to them. When Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 17 required, incidents are referred to the Local Authority and to the Commission for Social Care inspection and every assistance is given to these bodies in order to aid any investigation. All staff are subject to a Criminal Record Bureau check and check of entry on the Register for the Protection of Vulnerable Adults.” There is a clear complaints procedure that is included in information given to people when they move into the home. Information from our surveys showed that people knew how to raise concerns and who to talk to about any issues. A clear log is kept of any concerns raised and the records showed that issues are taken seriously and acted upon. Staff have training in adult safeguarding procedures and training is also arranged for staff about the Mental Capacity Act 2005 and Deprivation of Liberties. So that they will be clear on how to protect people’s rights better. Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience adequate quality outcomes in this area. Overall, people live in a safe, comfortable and well maintained environment. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “We have a range of specialised equipment to aid the comfort and safety of all service users. Where it is necessary to source large items of specialised furniture every effort is made to keep the environment as homely as possible. Improvements have been made to the garden area allowing better access for Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 19 service users enabling them to use the outdoor space. The nursing home is kept clean and odour free. We have rigorous procedures in place to reduce risk of spread of infection. All staff are given training in the control of infection. All senior staff are aware of when and how to contact outside agencies and are trained in the management of an outbreak of infectious disease.” “It is intended to carry out a major re-design of the Conservatory wing which will provide substantial improvements for the service users who live in that area. Access to the building is being improved by the addition of a new external access ramp. Ongoing programme of equipment upgrading. Improvement to bathing and laundry facilities.” We visited all areas of the home used by the people who live there and all areas were clean and fresh smelling. The new providers of the service have already made some improvements to the environment for example, replacing some internal steps with a ramp. Further work is planned to upgrade and improve the facilities. Some carpets were due to be replaced in the very near future. There were some maintenance issue we raised during the inspection, for example some window restrictors needed replacement and some bedroom doors were not closing properly. People said – (What could the service do better) “The garden could be put to better use in the summer. Seats and tables to provide nice seating areas” The new providers are committed to upgrading and improving the service facilities and have also applied for planning permission to further develop the site. Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. People are cared for by trained and competent staff. There are enough staff to look after people properly. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “The staffing numbers and skill mix are appropriate to meet the assessed needs of the service users. Staffing levels and skill mix are constantly reviewed and adjustments made as required to ensure the changing needs of the service users are met.” “We operate robust recruitment procedures to ensure we select the right person for the job. Staff come to us from many cultural backgrounds and are required to have a balance of skills and knowledge to meet the particular needs of our service users. Interview and selection are based on identified criteria for the particular post. The recruitment process is fully documented and required references and Criminal Record Bureau check and POVA checks are received before an employee starts work. All staff are given a copy of the Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 21 GSCC Code of conduct and the homes Aims and Objectives. We are committed to providing motivated, well trained staff to deliver care to our service users. There is an established training programme for all staff with a mixture of in house and external training.” There are good levels of staff and the nurses are well supported by a capable team of carers. There is an established ancillary staff team of domestic, laundry and kitchen staff. All the staff are knowledgeable about the people they look after and there is a training plan in place to make sure that they have the skills they need to look after people properly. Staff said – “Very good training” “We give love and understanding, I love my job” There are plans for more experienced carers to take on additional responsibilities as senior carers and interviews were to be held soon. Recruitment records demonstrated that all the required checks are complete before people start working at the home. Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. The home is well managed and is run in the best interests of the people who live there. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “Following the takeover by Westward Care Ltd, having worked closely for the past 7 years with the previous Manager, I am now in post as the General Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 23 Manager of Southlands. I am supported by an experienced team of professionals who now cover the functions of HR, Finance and Business Development. A Nursing Director is insitu to provide support and guidance when required. The home has a clear and accountable management structure. I am committed to running the home in the best interests of our service users and I review our services regularly to ensure that we meet our aims and objectives. Quality management systems are in place and twice yearly satisfaction surveys are sent to service users and their representatives. Information from these surveys is collated and action is taken to make any necessary improvements. Service Users and their representatives are informed of the results of the survey. Newsletters are sent to service users and visitors and social events are held for all to attend. These evenings give the opportunity for friends and relatives to meet other visitors to the home and the outcomes of the surveys, future plans and significant events are discussed. In addition we have a self assessment quality management system that is completed throughout the year. The views of other professionals involved with the home are sought and these continue to provide positive results. We have comprehensive written policies and procedures which are reviewed annually.” There has been a change of registered manager since the last visit and a change of ownership of the service. However, the manager has worked at the home for a number of years, as the clinical nurse manager, and this has provided stability and consistency for staff and the people living at the home during these changes. The manager has completed the Registered Manager’s Award (RMA) and was awaiting verification. She is an experienced nurse who provides knowledgeable and clear leadership for the staff. She is highly thought of by visiting healthcare professionals and is committed to providing high quality nursing care to people living at the home. People said – “Southlands is now under New Management and I hope it will continue to be run in the same efficient, warm manner.” Healthcare professionals said – “Nurse in charge is probably the best nurse in terms of assessment and communication in all the homes we serve.” (How can the service improve) “already a great service” Staff said – “Our manager is very helpful and very good at giving us the right advise” Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 24 The manager has the support of senior nursing staff from the new provider that will help her develop her new role as registered manager of the service. The provider carries out regular visit to the home, as required, as part of the ongoing monitoring of the service. There is also a system of audits of such things as accidents, medication practices and care plans. People living at the home, their relatives and visiting healthcare professionals are surveyed on a 6 monthly basis. The results of surveys are collated and action plans produced to address any identified shortfalls. The results are made available to people. Southlands Nursing Home DS0000072596.V374365.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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 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 Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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. 1 Refer to Standard OP12 Good Practice Recommendations The provision of activities, occupation and stimulation for people should be reviewed and developed further to make sure that people are not bored. Southlands Nursing Home DS0000072596.V374365.R01.S.doc Version 5.2 Page 27 Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 61 61 61 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.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 Southlands Nursing Home DS0000072596.V374365.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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