Inspection on 26/10/05 for Soothill Manor

This inspection was carried out on 26th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Soothill Manor 25/09/07

Soothill Manor 03/02/06

Soothill Manor 26/10/04

Soothill Manor 30/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Soothill Manor Soothill Manor Soothill Lane Batley West Yorkshire WF17 6EU Lead Inspector Tracey South Unannounced Inspection 26th October 2005 10:15 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 Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 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. Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Soothill Manor Address Soothill Manor Soothill Lane Batley West Yorkshire WF17 6EU 01924 284201 01924 471297 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) Tri-Care Limited Mrs Gwyneth Dawn O`Donnell Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2004 Brief Description of the Service: Soothill Manor is a care home providing personal care and accommodation for up to 36 older people. This is a traditional style house with extensions, which are in keeping with the older part of the building. The lounge and dining areas are very comfortable and pleasant for service users to sit talking together or entertaining their visitors. There are 22 single rooms and 7 double rooms, the majority benefit from ensuite facilities. There are two stair lifts. The home is set within pleasant gardens with far reaching views of the surrounding countryside. Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over 4 hours. The home is registered for up to 36 people. There were twenty-eight residents living at the home. One person was staying at the home for a short stay, leaving 7 vacant beds. Four residents, 3 staff and 1 relative were spoken to during the inspection. Their comments have been used as evidence and referred to within this report. Not all of the core standards were assessed during this inspection. The main focus for this inspection was health and safety practices and the environment. The remaining core standards will be assessed during the next inspection, which will take place before the end of March 2006. Documentation such as, training data, staff personnel files, accident books, service certificates, complaints log and residents’ personal monies were examined. A tour of the building was also undertaken. What the service does well: The home provides a homely environment for residents. The home is generally well maintained both internally and externally. Residents looked well cared for. Those residents spoken to said that they felt safe and that the staff are kind and supportive. One resident, who had not been living at the home very long, said she had settled in well and that she had no complaints whatsoever. Relatives felt that the home is a very nice place and the staff are very good. Residents are able enjoy their meals in a congenial setting. Dining tables are nicely laid out with all the appropriate condiments in place. Residents are offered a well balanced diet. Those residents spoken to said they enjoyed their meals. Regular activities take place and residents are encouraged to join in. Relatives are made to feel welcome when visiting the home. Families are always invited to functions throughout the year, for example, the annual garden party, bonfire night and the Christmas party. Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 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. Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 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 Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 Service users have the opportunity to participate in organised activities. Service users are able to maintain contact with relatives and friends. Service users receive a well balanced diet. EVIDENCE: Residents explained how they are able to choose how they spend their day. One resident said she prefers to stay in her own room during the morning then after lunch she likes to sit in one of the communal lounges. Residents were seen in various parts of the home. Some prefer the privacy of their own room whilst others were seen sitting in the company of others. There are no restrictions put on residents regarding what time they rise and retire to bed. Posters are displayed throughout the home of forthcoming events. Such events included arts and crafts, entertainers and movement to music. A number of residents were seen taking part in a general knowledge quiz. Relatives are made to feel welcome at the home and are able to visit at any reasonable time. The visitor’s book is a good indication that the home receives Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 11 a number of visitors on a regular basis. Residents explained how they are able to meet with their visitors either in the communal lounges or in the privacy of their own room. Relatives are invited to functions that take place at the home. The majority of residents prefer to eat their meals in the dining areas. A small number of residents take their meals in their own room where they are provided with an over bed table, and their meal is served to them on a tray. Dining tables were set appropriately and condiments were noted in place. The home operates a four weekly menu. The cook explained that she receives feedback from both residents and staff of people’s likes and dislikes. Specialist diets are catered for. Those residents spoken to said they were not aware of the meal on offer that day. The manager explained that menus are displayed and the staff let residents know what meal they can expect. Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 There is a complaints policy and procedure in place. Residents are potentially at risk from abuse as none of the staff have undertaken adult protection training. EVIDENCE: The home has not received any complaints since the last inspection in October 2004. The complaints procedure is displayed in various parts of the home. Residents confirmed that they would report any concerns they had to a senior member of staff. Although none of the residents spoken to said they had any complaints about the home. A recommendation was made in the last report that staff should receive adult protection training. This has not taken place. To ensure residents are protected from abuse, all staff must receive adult protection training within the next 6 months. All new staff are checked against the Protection of Vulnerable Adults list prior to them starting work. Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, 26 Service users live in a safe, well-maintained environment. The home offers comfortable facilities for service users. Service users are able to bring their personal belongings with them when the move into the home. No progress has been made with improving the laundry facilities. EVIDENCE: The home is generally well maintained both internally and externally. It provides a homely and comfortable atmosphere for residents. The home is clean and tidy and there were no unpleasant odours noted during the inspection. The grounds of the home are well maintained. Residents are able to sit in the garden areas during warmer weather. The manager confirmed that there are only minor works outstanding from the fire safety officer’s report dated 11.2.05. Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 14 There are a number of communal areas available to residents. The main lounge on the ground floor is spacious with plenty of comfortable easy chairs in place. The lounge areas are very homely with ornaments and fresh flowers in observed in place. There is a large dining area on the ground floor where the majority of residents eat their meals. The first floor accommodation is similar in that there is a lounge and dining area. There is no passenger lift at the home. However there are 2 stair lifts. The manager explained that these are in need of up grading to ensure they are more accessible to all residents. Quotes for a new stair lift have been requested and the manager is hopeful that a new one will be purchased and installed in the short term. The home benefits from having grab rails and handrails in place to assist residents throughout the home. There are 3 assisted baths. Call systems are accessible throughout the home. A small number of bedrooms were inspected during a tour of the home. Bedrooms were found to be clean and tidy. Residents’ personal possessions were seen in place giving a homely feel to their rooms. Recommendations have been made in past reports about the laundry facilities at Soothill Manor. The main issues are that domestic, not industrial type washing machines and dryers are used. Domestic washing machines do not have a specified programme to meet disinfection standards and only small amounts of laundry can be washed at any one time. In addition to this there is no designated laundry person and the care staff are expected to carry out these duties as part of their shift. Time spent in the laundry is time spent away from residents. The registered provider should make every effort to try and resolve these issues. Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 There are sufficient staff on duty to meet the needs of residents. Service users are not always protected against the risk of abuse. Recruitment procedures are not always followed in accordance with the organisation’s policies and procedures. EVIDENCE: The morning shift consists of 6/7 staff, including domestic staff. There are five staff on the afternoon shift, with 3 wakeful night staff on duty from 10pm until 8am. Care staff are supported by domestic and kitchen staff. There are 25 care staff employed at the home, 48 of which are qualified to NVQ level 2. A further 8 staff are working towards their NVQ level 2. An issue was raised regarding recruitment practices at the home. A separate letter has been sent to the Area Manager in order that such issues are addressed. Relevant training is provided to staff. Examples of recent training include, movement and handling, food hygiene, basic first aid and fire training. Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35, 38 Service users financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: Small amounts of monies are kept on behalf of residents. Records of all transactions are recorded. Receipts are kept in respect of any purchases made. Three residents’ monies were checked, all of which were found to be correct. Health and safety systems are in place to promote the health and safety of service users and staff. A sample of service certification was satisfactory. The bedroom door seen propped open, should have a “Dorguard” fitted to maximise the independence of the resident. Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 3 X 3 X 3 X 2 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 18 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 2 Standard OP18 OP29 Regulation 13 19 Requirement All staff must receive adult protection training within the next six months. Robust recruitment procedures must be carried out to protect service users from abuse. Timescale for action 30/05/06 26/10/05 Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP19 OP26 Good Practice Recommendations The minor works in accordance with the fire safety officer’s report should be completed. The laundry floor finishes should be impermeable and these and wall finishes are readily cleanable. Washing machines should have the specified programming ability to meet disinfection standards. The organisation should consider employing a laundry assistant to relieve care staff from this responsibility. 3 4 OP28 OP38 The home should continue working towards achieving 50 of the workforce being qualified to NVQ level 2 or equivalent by 31.12.05 A “Dorguard” should be fitted to the bedroom door identified during the inspection. Soothill Manor DS0000026290.V254525.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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