Inspection on 20/09/05 for Southfield House

This inspection was carried out on 20th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 14/09/06

Southfield House 05/01/06

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 Southfield House Woolram Wygate Spalding Lincolnshire PE11 1PB Lead Inspector Julie Western Unannounced Inspection 20th September 2005 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 Southfield House DS0000002419.V251340.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. Southfield House DS0000002419.V251340.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Southfield 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 Southfield House DS0000002419.V251340.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2004 Brief Description of the Service: Southfield House is a purpose built care home catering for 32 people over 65 years, including two service users with a dementia, for personal care only. Accommodation is situated on the ground floor except for one room on the first floor. The Home has four lounges and a spacious dining room. Smoking is not allowed in these rooms, but there is a separate room designated for this purpose. The home is situated less than two miles from the centre of Spalding and is one of a group of homes managed by the Orders of St. John Trust. The Home is situated in a large garden laid to lawn and flower beds where seating in a patio garden is provided for service users to enjoy fresh air and sun. There is adequate parking at both the front and the back of the Home. Southfield House DS0000002419.V251340.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 4 hours. A partial tour of the building took place and care records were inspected. The main method of inspection used was called ‘case-tracking’; this involved selecting three residents and tracking the care they received through the checking of their records, discussions with residents and care staff and observation of practices. Some policies and procedures were examined and records concerning the safety of the home were also seen. Five of the 27 current residents, four of the 40 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 a new dining room carpet, curtains, tables and chairs, the complete refurbishment of four bedrooms, a new tumble drier, washing machine and dishwasher, the replacement of all door catches and windows, new courtyard doors and the replacement of all bedroom doors with fire resistant doors. Southfield House DS0000002419.V251340.R01.S.doc Version 5.0 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. Southfield House DS0000002419.V251340.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 Southfield House DS0000002419.V251340.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): The home clearly sets out what it intends to do for its residents and this information is freely available to residents. Prospective residents are encouraged to take time before making the decision to move into the home on a permanent basis. 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. Prospective residents were given an opportunity to experience life in a residential care home before making a final choice and some residents had spent a day or had coffee or meals in the home. Southfield House DS0000002419.V251340.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): 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 system for the main care plan which has been made more concise and contains 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 28/6/05, from which there were no requirements. Residents said they felt safe and well looked after; one resident commented ‘they’re extremely good – they respect your privacy and they’re friendly and caring’ and a visitor said ‘the staff are very good and any requests are usually met’. The staff team were observed carrying out their duties with kindness and sensitivity towards the residents, especially when attending to their personal needs. Southfield House DS0000002419.V251340.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): A variety of activities is available and residents are usually informed about the programme of events, although currently there is no activities co-ordinator. The residents exercise choice about which activities, if any, they wish to participate in and what meals they want to eat. EVIDENCE: Residents spoken with said that there were a number of activities at the home, including bingo, entertainers and music and movements; these were usually advertised in the ‘Southfield House Newsletter’, but the Newsletter for this month had not been printed. One resident said ‘I would love to go for a walk but the carer who used to do this has left’ and staff members said that they did not have a lot of time to devote to activities such as this. The Manager confirmed that this was because the post of activities co-ordinator was currently vacant and, although it had been advertised, there had been as yet no applicants. The Manager said that this was probably because the post was advertised for only 10 hours weekly and that next year the post would be increased to 20 hours weekly, which she felt would attract more applicants. The midday meal was balanced, nutritious and easy for older people to eat; one resident said ‘I can’t complain about the food at all’. There was a menu board displaying the day’s meals including the alternative choice. The home no Southfield House DS0000002419.V251340.R01.S.doc Version 5.0 Page 11 longer provides meals on wheels and the WRVS volunteers who used to deliver these meals have now become Friends of Southfield House and are assisting with organising activities. Southfield House DS0000002419.V251340.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): 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. The home had received three formal complaints in the last twelve months, all of which had been satisfactorily addressed within the time scales. 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. Southfield House DS0000002419.V251340.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): The residents live in a very comfortable and pleasant environment with both private and communal space, which is suitable for their needs. EVIDENCE: The home has a rolling maintenance programme and recent improvements to the home have included a new dining room carpet, curtains, tables and chairs, the complete refurbishment of four bedrooms, a new tumble drier, washing machine and dishwasher, the replacement of all door catches and windows, new courtyard doors and the replacement of all bedroom doors with fire resistant doors. A ground floor bathroom was in need of renovation and there was an old porcelain foot-bath in one corner. Another bathroom with a corner bath, which was unsuitable for residents, was unused and full of equipment. Risk assessments are carried out on the premises to ensure that residents are safe from any potential hazards. One resident said ‘I like my room it’s very comfortable’. Southfield House DS0000002419.V251340.R01.S.doc Version 5.0 Page 14 Overall the standard of decoration internally was good and afforded residents a great degree of comfort. The grounds were attractive and well tended. Southfield House DS0000002419.V251340.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): Staff numbers are in sufficient quantity for them to be able to care for the residents. Staff members are suitably trained, qualified and competent; they undergo an induction programme before commencing their duties. EVIDENCE: The residents were very positive about the care they received from the staff and a visitor said ‘they’re extremely good’. The most recent staff member to be appointed confirmed that she had given two references, which were followed up, a CRB check and undertaken an induction programme before commencing work. Training was given by either the in-house trainer, who was based at headquarters, or external trainers. The home had an at-a-glance training plan which showed that staff had received statutory training was completed with future recent specialist training being Moving and Handling, Bereavement and Health and Safety. Three staff members had achieved the National Vocational Qualification at Level 2 with four working towards it and one staff member had achieved NVQ Level 3 with two working towards it. The staff rota showed that there were enough staff numbers according to the staffing matrix and shifts were staggered to accommodate the needs of residents. Southfield House DS0000002419.V251340.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): 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 four years A resident compared the Manager favourably to the previous two Managers and a staff member who had worked at another home said ‘This is brilliant, especially the Manager’. The quality assurance manual demonstrated a positive approach to seeking the views of residents; residents’ meetings were regularly held and residents spoken with said they were constantly asked for their views on matters concerning the running of the home. The Manager said that quality Southfield House DS0000002419.V251340.R01.S.doc Version 5.0 Page 17 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 by the central office. Southfield House DS0000002419.V251340.R01.S.doc Version 5.0 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 4 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 X 3 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 X X X 3 3 Southfield House DS0000002419.V251340.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? None 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 OP12 Regulation 12, 16 Requirement The registered person must, so far as is practicable, ascertain and take into account the wishes of residents regarding activities. The registered person must forward plans for renovating and updating the ground floor bathroom containing the foot bath and the bathroom containing a corner bath. Timescale for action 16/11/05 2 OP21 23 16/11/05 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 Southfield House DS0000002419.V251340.R01.S.doc Version 5.0 Page 20 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. Extracts may not be used or reproduced without the express permission of CSCI Southfield House DS0000002419.V251340.R01.S.doc Version 5.0 Page 21 - 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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