Inspection on 14/09/06 for Southfield House

This inspection was carried out on 14th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Southfield House 05/01/06

Southfield House 20/09/05

Southfield House 27/07/04

Southfield House 29/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE South Field House Woolram Wygate Spalding Lincolnshire PE11 1PB Lead Inspector Julie Western Key Unannounced Inspection 14th September 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 South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Field House Address Woolram Wygate Spalding Lincolnshire PE11 1PB 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) 01775 724612 The Orders Of St John Care Trust Mrs Dawn Louth Care Home 32 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (30) of places South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care to service users whose primary needs fall within the following categories:Old age, not falling within any other category (OP) - 30 and Dementia (DE) - 2 The maximum number of service users to be accommodated is 32. 2. Date of last inspection 5th January 2006 Brief Description of the Service: Southfield House is a purpose built care home, formerly owned by the local Authority and now owned by the Orders of St. John Care Trust, who manage a group of 16 homes across the county. The home provides care and accommodation for up to 32 people over 65 years, including two service users with a dementia, for personal care only and on the day of the inspection 30 residents were being accommodated. Accommodation is situated on the ground floor except for one room on the first floor. There are four lounges and a spacious dining room, with a separate room designated for smoking. The home is situated in a quiet residential area a mile from the centre of Spalding, which has a good range of shops and facilities. It is situated in its own grounds and includes a large garden laid to lawn and flower-beds, with seating and a patio area for residents to sit out in good weather. There is parking to the front and the side of the Home. South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced, was carried out over 2 ¾ hours and took into account any previous information held by CSCI including the home’s previous inspection reports, its service history, pre-inspection questionnaires completed by the Manager and residents’ questionnaires sent to the home by the Commission prior to the inspection. The site inspection consisted of case tracking a sample of residents’ records and assessing their care. Some policies and procedures were examined and some records concerning the safety of the home were also seen. Five residents, three care and ancillary staff and two visitors were spoken with. The Manager was present throughout the inspection What the service does well: What has improved since the last inspection? Recent improvements to the home have included ongoing maintenance of the bedrooms, which are refurbished as they are vacated. The post of activities coordinator has been increased to 20 hours weekly and the activities programme has benefited from this. All requirements and recommendations from the previous inspection have been met. South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 6 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. South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to the service. The home’s records give a full picture of the needs of each resident to ensure that health and personal needs are met. The home does not provide intermediate care. EVIDENCE: The statement of purpose was very comprehensive; it took the form of a folder with inserts. The Manager said a copy was given to all residents on admission, together with a copy of the service user guide, which was called the Residents’ Handbook and a copy of the latest Orders of St. John Care Trust quarterly magazine. Assessments were made by the Manager or a Care Leader, using two dependency tools and the ‘Standex’ information cards. The home has a respite care bed and prospective residents are given an opportunity where possible, to experience life in a residential care home before making a final choice; a resident described how she had spent a day and had lunch at the home before admission. South Field House DS0000002419.V311805.R01.S.doc Version 5.2 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): 7-10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The home’s records give a clear indication of the needs of residents and enable staff to meet their needs with sensitivity and regard for their privacy and dignity. EVIDENCE: The three care plans looked at in depth contained clear and comprehensive assessments, were reviewed regularly and were signed where possible by the service user or relatives/advocates. The home uses a ‘Standex’ information system for the main care plan, which has been adapted to contain only the most important information, additional information being kept in folders. There was a clear medication policy and the most recent visit from the pharmacist was July 2006, from which there were no ssues. Residents said they felt safe and well looked after; one resident said ‘I knew after two days Iwanted to live here’. The staff team were observed carrying out their duties with kindness and sensitivity towards the residents, especially when attending to their personal needs. South Field House DS0000002419.V311805.R01.S.doc Version 5.2 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): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. A variety of activities is available and residents are informed about the programme of events. The residents exercise choice about which activities, if any, they wish to participate in and what meals they want to eat. EVIDENCE: The designated activities co-ordinator now works 20 hours weekly; staff members spoken with said that the increase from 10 hours had meant that more personal and individual attention could be given. Residents spoken with said that there was a number of activities at the home, including bingo, puzzles, keep fit and dominoes. Recent events had included several entertainers and these were advertised in the ‘Southfield House Newsletter’. Two residents spoken with said they preferred not to take part in activities, although they were very happy to watch or to stay at home. The Manager said that there was to be a meeting next week to discuss how to recruit more volunteers to assist with trips out. The midday meal was balanced, nutritious and easy for older people to eat; one resident said ‘I always eat everything – it’s all good’. There was a menu board displaying the day’s meals including the South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 11 alternative choice and the cook said she visited each resident for their choice of meal for the following day South Field House DS0000002419.V311805.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The home’s complaints procedure is clear and gives residents and their relatives the confidence that comments and concerns will be listened to; there is a robust adult protection procedure. EVIDENCE: Residents and visitors to the home all said they did not wish to complain but knew how to make a complaint. There was a clear adult protection procedure, which was linked to the Local Authority procedures. Staff members spoken with had received training on adult protection issues. South Field House DS0000002419.V311805.R01.S.doc Version 5.2 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, 26 Quality in this outcome area is excellent/good/adequate/poor. This judgement has been made using available evidence, including a visit to the service. The residents live in a very comfortable and pleasant environment, with both private and communal space, being generally suitable for their needs. EVIDENCE: The home has a rolling maintenance programme and on the day of the inspection a recently vacated bedroom was being completely refurbished. The ground floor bathroom had also been completely renovated and wash handbasins were gradually being replaced. All four lounges had been redecorated and a new call system had recently been installed. Risk assessments were carried out regularly on the premises to ensure that residents were safe from any potential hazards and the most recent risk assessment had identified the need for a new boundary fence where a deep dyke ran alongside, to prevent possible accidents. The Manager said that the five year maintenance plan included re-surfacing the driveway. South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 14 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): 27-30 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to the service. Sound procedures for the recruitment of staff are in place and the residents are cared for by a knowledgeable and well-trained group of staff. EVIDENCE: The staffing rota showed that there were sufficient staff on duty to care for the residents and both residents and staff said that there were enough staff members available to complete their tasks in the given time. The Orders of St. John Care Trust have their own training manager at headquarters and there is a full training programme. Training records showed that 53 of the staff had achieved the National Vocational Qualification at Level 2 or above and all Care Leaders had achieved or completed the NVQ at Level 3. All statutory training had been completed with each staff member having a skill matrix. All new staff had a ‘probationary period record’ and files showed that the home had undertaken all necessary recruitment checks. Future training included a course on dementia and all staff members are expected to have completed this course by the end of the year. South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 15 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, 35, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to the service. The home is managed competently and the staff are supported and supervised in carrying out their respective roles. The views of residents are listened to and they are involved in decisions affecting them. EVIDENCE: The registered Manager has been a nurse since 1989 and she also holds the Registered Manager’s Award. She has specialised in the care of the elderly since 1990 and has worked at the home for the last five years. The open-door policy allowed residents and staff to talk to her throughout the day. Visitors and staff were very positive in their comments about the staff and said they were very patient and caring. One resident said ‘they’re like angels’. Finances are audited regularly from the headquarters in Wellingore. The quality South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 16 assurance manual demonstrated that the home had a positive approach towards seeking the views of residents, with results being taken from service user questionnaires, which were sent to the quality assurance manager at headquarters for action. Residents described regularly held meetings and said they were constantly asked for their views on matters concerning the running of the home. The home has the ISO 9000 award and the Investors in People award. Regular audits included training, medication, meals and health and safety. The Manager said that quality surveys went out with invoices each month, for relatives/advocates to complete. There was a monthly record of meals with satisfaction, complaints and concerns logged and forwarded to headquarters. The home has the ‘International Standards Organisation 9000’ award and the ‘Investors in People’ award. In addition, the home is regularly audited from headquarters. Policies and procedures were very comprehensive. Two monies held on behalf of residents balanced and clear accounts were retained, including receipts. Staff members described how they had regular supervision sessions with the Manager. South Field House DS0000002419.V311805.R01.S.doc Version 5.2 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 4 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 4 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 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 4 South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations South Field House DS0000002419.V311805.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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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