CARE HOMES FOR OLDER PEOPLE
Soothill Manor Soothill Lane Batley West Yorkshire WF17 6EU Lead Inspector
Tracey South Unannounced Inspection 3rd February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 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.V254513.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Soothill Manor Address Soothill Lane Batley West Yorkshire WF17 6EU 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) 01924 284201 01924 471297 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.V254513.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th October 2005 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.V254513.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out over 5 hours. The home is registered for up to 36 older people. There were 28 residents living at the home on the day of the inspection. The manager, 2 staff and 6 residents were spoken to and their comments have been used as evidence and feature within this report. A visiting activities co-ordinator also gave feedback about the home including the type of activities that take place. This information is detailed within the main body of the report. Documentation examined during this inspection included, residents’ case files, medication records and training data. What the service does well:
All residents spoken to gave positive feedback about their life at Soothill Manor. Residents said the food was always good and there was always a good choice available. One resident said she had “praise for all” and spoke of how at one time she had been very dependent on staff due to ill health and how the staff had supported through this difficult time. A visiting activities co-ordinator at the home said “Soothill Manor is a nice home, one of my favourites”. She also said how much the residents benefit from taking part in activities especially on a one-to-one basis. The home is well maintained and makes a homely environment for residents. The atmosphere at the home is warm and friendly. Relatives are made to feel welcome in the home and the visitor’s book is a good indication that a number of people visit the home on a daily basis. Residents looked well cared for. Staff and residents were observed chatting with each other. Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 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.V254513.R01.S.doc Version 5.1 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.V254513.R01.S.doc Version 5.1 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): 3 Residents are assessed prior to them moving into the home although the documentation used when assessing people, is not being completed thoroughly enough. EVIDENCE: A senior member of the management team is responsible for visiting prospective residents prior to them being admitted to the home. The purpose of the visit is to ensure that the home is able to meet the needs of that person. As part of the visit, a pre-admission assessment is completed. The assessment must include details of the needs of that person as well as indicating the level of support they will require. The pre-admission assessments examined did not provide sufficient detail as to the person’s needs. Without such information in place it is difficult for staff at the home, to make an informed decision as to whether or not the home will be able to meet this person’s needs. The manager must ensure that thorough pre-admissions assessments take place and the information collated is recorded in sufficient detail. Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 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): 7, 8, 9, 10, 11 Good progress is being made with the new care planning documentation. Resident’s health care needs are being met. The home has good medication systems in place. Residents are treated with respect. EVIDENCE: Since the last inspection in October 2005 new care plans have been introduced. The staff have completed a number of care plans and were pleased to have the inspection at this point to validate their work so far. Two resident’s case files were examined in detail. Each case file is divided up into sections such as personal care and physical well-being, mobility and dexterity, continence and social interests. An assessment is completed under each section to ascertain the specific needs of the resident. Depending on the outcome of the assessment a care plan may be introduced. For example one resident who has limited mobility had a care plan in place which read “1 carer to assist while walking, would need bath hoist to get in and out of bath. Raised seat on toilet. Grab rails”. It was explained to both the manager and deputy manager that this information was
Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 Page 10 insufficient. The care plan must clearly state the needs of the resident and the level of support required, to ensure that those needs, will be met. The management staff agreed that further work is still required to ensure care plans are meaningful and provide staff with the necessary information they need when caring for residents. However, it is fair to say that good progress has been made so far and the CSCI acknowledge the amount of work staff have already undertaken in implementing this new system. The new files are currently being stored on the desk in the office. This needs to be addressed as all personal information must be stored in accordance with the Data Protection Act 1998, that is, all residents’ files must be kept securely. A number of health care assessments are completed including, nutrition, sight, hearing and communication. Again depending on the outcome of the assessment a care plan may be introduced. There was good evidence in place that residents have access to health care services. The deputy manager was observed arranging GP visits for those residents who were ill. Medication records were examined. Stocks of medication were found to balance with records kept. The medical records indicated that residents receive their medication at the correct time. Residents are treated with dignity and respect. Staff were observed knocking on doors before entering the private space of residents. Staff were seen attending to residents in a sensitive and caring manner. Care plans clearly state the resident’s preferred term of address. Medical visits take place in private. Information about the resident’s wishes following death is recorded within the case file. Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 Page 11 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): 12,14 Residents confirmed how they are able to make their own decisions about everyday matters. EVIDENCE: Those residents spoken to gave positive feedback about their life at Soothill Manor. Residents spoke of how they are able to choose when they get up and go to bed. Each day the staff inform residents of the choices available at meal time. Residents are able to choose where they take their meals, whether it be in the dining rooms or in their own rooms. Evidence that residents are able to choose how they spend their day is contained within the daily reports. Some residents are happy to spend their time in the communal lounges whilst others prefer the privacy of their own room. Residents are able to bring their own personal possessions with them when they move into the home. Evidence of this has been seen during previous visits to the home. An arts and crafts session took place during the afternoon of the inspection. A small number of residents had joined in. The activities co-ordinator explained
Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 Page 12 how she visits the home every fortnight to undertake different activity sessions with the residents. She spoke positively about the home and indicated how the atmosphere was always welcoming. She said she found the staff to be very caring and the residents appeared to be well looked after. Residents spoke of how they enjoyed the activity sessions and how it helps to break the day up. The residents also benefit from having regular outside entertainers visit the home. Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 Page 13 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): None of these standards were assessed on this occasion. EVIDENCE: Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 Page 14 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): None of these standards were assessed on this occasion. EVIDENCE: Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 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): None of these standards were assessed on this occasion. EVIDENCE: Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 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): 31, 33, The home is well managed. The home is run in the best interests of the residents. EVIDENCE: The manager at Soothill Manor has been employed at the home for over 19 years. She has a number of year’s experience of working with older people in a residential setting and has recently completed the NVQ level 4 in Management award. The management team consists of 2 deputy managers and senior care staff. The manager explained that recent quality assurance questionnaires have been sent out to both relatives and staff. A number of relatives’ questionnaires have been returned and have been forwarded to the organisation’s head office to be collated. Once collated a report will be produced and made available to
Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 Page 17 residents, staff and relatives. The manager was unable to locate the latest quality assurance report. The manager explained that relatives are becoming more involved in the care planning process. Relatives are now requested to contribute towards the completion of resident’s care plans. Evidence of this was seen whilst examining the case files. Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 Page 18 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 1 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X X Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Thorough pre-admission assessments must take place and the information collated must be recorded in sufficient detail. Further progress is required to ensure all care plans contain detailed information about the needs of the resident and the level of support they require. Care documentation must be kept securely in accordance with the Data Protection Act 1998. Timescale for action 30/03/06 2 OP7 15 30/03/06 3 OP37OP7 17 30/03/06 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 OP19 Good Practice Recommendations The minor works in accordance with the fire safety officer’s report should be completed. Brought forward from the last inspection report. The laundry floor finishes should be impermeable and
DS0000026290.V254513.R01.S.doc Version 5.1 Page 20 2. OP26 Soothill Manor 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. Brought forward from the last inspection report. 3. OP28 The home should continue working towards achieving 50 of the workforce being qualified to NVQ level 2 or equivalent by 31.12.05 Brought forward from the last inspection report. Quality Assurance reports should be readily available for the purpose of inspection. 4 OP33 Soothill Manor DS0000026290.V254513.R01.S.doc Version 5.1 Page 21 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
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