Inspection on 21/06/07 for South View

This inspection was carried out on 21st June 2007.

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

South View 06/07/06

South View 21/11/05

South View 14/06/05

South View 20/09/04

South View 26/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE South View South View Sandford Avenue Church Stretton Shropshire SY6 7AB Lead Inspector Pat Scott Key Unannounced Inspection 21st June 2007 09:30 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 View DS0000020648.V336427.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 View DS0000020648.V336427.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South View Address South View Sandford Avenue Church Stretton Shropshire SY6 7AB 01694 723525 01588 672664 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) Mrs Catherine Elizabeth Vine Grace Mary Atkinson Care Home 15 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (15) of places South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may admit 1 named service user with Learning Disabilities under the age of 65 years - as named on attached Schedule A. 6th July 2006 Date of last inspection Brief Description of the Service: South View is a privately owned Care Home registered with the Commission for Social Care Inspection to provide a service for fifteen older people. It is a well-established home set in its own grounds and blending in with the local residences. South View is situated on the edge of Church Stretton. The home has been operating for over sixteen years and has become an integral part of the local community. The building has been extended and improved with the emphasis always being to avoid an institutional environment. There is an established staff group providing residents with consistency in a warm comfortable atmosphere. Southview makes its services known to prospective service users in: The Statement of Purpose and Service Users Guide. The inspection report is available for reading in the foyer of the home. The care home rates are reviewed annually on 1st April each year and service users are notified in advance. The only additional charges to service users are for extra hairdressing, chiropody and newspapers. Fees for Southview as of 1st April 2007 are: £390-410. South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider in the annual quality assurance assessment, staff records kept in the home, medication records, discussion with people who use the service, discussions with the staff team, discussion with the manager, tour of the premises, previous inspection reports, quality assurance processes, Fire Authority reports, Environmental Health Office reports, observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? What they could do better: The service needs to improve its care plan record keeping taking into account good practice guidance. Care plans are a tool of professional practice and one South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 6 that should help the care process and promote high quality health and personal care. Radiators in service users bedrooms should be guarded to prevent injury in the event of a service user falling against one. Carpet in the toilets and bathrooms should be replaced with washable flooring to improve hygiene. The gardens should be improved to make them more accessible and a pleasant area for service users to enjoy. The manager wants to improve and develop the running of the home in some areas. The owner should develop a process of supervision for the registered manager which would fit the service’s statement of purpose and maintain and improve standards of care for service users. Frequencies of supervision should be agreed so that the supervision of the manager can incorporate reviews of her role and responsibilities and progress to meet the business plan of the service. 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. South View DS0000020648.V336427.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 View DS0000020648.V336427.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Key Standard 3 (6 is not applicable to this service) This judgement has been made using available evidence including a visit to this service. Written records for the admission of new people to the service demonstrate that the process is personalised and that consideration has been given to all aspects of care. EVIDENCE: The admission records of two recently admitted service users were seen. These documents show the service takes into account all the individual care needs of a service user including a risk element. The assessor makes the assessment personalised with consideration of the individual’s social history. The manager stated she consults the assessment information to see if the home can meet the prospective service user’s needs before they make the decision to accept the application for admission and offer a placement. The South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 9 care files looked at, contained copies of the assessment summary and care plans of those carried out through care management arrangements. A service user made the comment that she had been made very welcome at the home and felt that she had made the right decision to live at Southview. South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is good. Key Standards 7,8,9,10 This judgement has been made using available evidence including a visit to this service. Not all service users’ care needs are set out in individual plans of care which will not ensure that all care needs have been addressed and will be fully met. The manager understands the need to comply with safe medication systems and staff practice ensures that the home’s procedures are complied with and that service users health matters are always safely addressed. The actions of staff and their approach to care ensures that service users are treated with respect and their right to privacy is upheld. EVIDENCE: Daily records provide details about care events and monitor the progress of individuals. The manager has not separated care progress from care planned and so there is a missing link between assessment and daily progress i.e. the care planned to meet the service user’s needs. The records show that good South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 11 care is provided. Daily notes demonstrate contact with healthcare professionals such as district nurse or GP. There are no photographs of service users on their care plans. Service users spoken with stated that support is flexible as they spoke of the various bed/rising times which are accommodated and always delivered in a way that respects their privacy. A relative letter received at the inspection stated: “Above all, residents are treated with dignity and cheerful patience, something that cannot be measured or quantified.” The service accepts responsibility for administering medication to service users. The service has storage facilities including storage for controlled drugs in the office. Medication charts are up to date with no gaps in recording. South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. Key Standards 12,13,14,15 This judgement has been made using available evidence including a visit to this service. Service users are provided with social activity and can keep in contact with family and friends. Social, cultural and recreational activities meet service user’s expectations through assessment, consultation and choice. Residents receive a healthy diet according to their assessed requirement and preference. EVIDENCE: The assessment process demonstrates that social/leisure pursuits are addressed prior to admission in a personalised way for the individual. Once living at the home, social activities are provided on a regular basis such as quizzes, readings, knitting projects, musical events and links with charities and youth work. Each week service users have the opportunity to have their hair done and nails are manicured by staff. There are occasional trips out which the manager aims to improve. Birthday parties are provided and one service user had just enjoyed his 90th. Newspapers, magazines and books were seen around the home with some people doing crosswords/quizzes or reading quietly. One service user goes to work during the week at a farm tea room. Service users stated that relatives and friends can visit at any time. South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 13 Service users spoken with said they liked the food and it is always nicely cooked. A relative’s letter stated that “their mother eulogises about the food and has never had a complaint about it”. A new cook is in post. Service users are asked what they would like each day from a variety of choice, although this is done verbally rather than from a written menu option. South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. Key Standards 16,18 This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure which is accessible so that people who use the service have information of how to make complaints about the home. Training is provided so that service users are protected from abuse and have their legal rights protected. EVIDENCE: Service users spoken to say that they would go to the manager, owner or one of the staff if they had a problem. All expressed confidence that issues would be dealt with. There is a high level of accessibility to the management at this home which ensures that concerns can be dealt with very quickly. Previous inspections have identified that staff receive full training on safeguarding adults. South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. Key Standards 19,26 This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home is safe and comfortable but improvements will enhance service user enjoyment of the facilities. EVIDENCE: The manager stated that there are parts of the premises which could improve which, while looking shabby and a bit worn, isn’t dirty or unsafe. There are plans to redecorate and re-carpet the lounge. The furniture arrangements will be changed so that service users can enjoy sitting privately or in small groups and so that visitors do not have to sit with everyone else. Generally areas seen around the home are clean and rooms personalised. Rooms for new service users had been decorated with new carpets laid. Call bell systems are working and are within reach of service users. However, the bathroom and toilets should have washable flooring rather than carpet. One toilet floor looked South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 16 heavily stained. Radiators in service users’ room were unguarded which is unsafe. The garden looks unkempt and is not safe or accessible for all service users. The laundry arrangements are appropriate for the service user group. Improvement has been made to dealing with foul linen and equipment has been mended. Environmental Health Officers have conducted an inspection of the kitchen facilities and matters arising are being addressed. South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is adequate. Key Standards 27,28,29,30 This judgement has been made using available evidence including a visit to this service. Staff in the home are being trained and are in sufficient numbers to fill the aims of the home and meet the changing needs of residents. The lack of thorough recruitment steps does not ensure the service secures suitability of candidates before working in the home and service users may not be in safe hands. EVIDENCE: Records seen show that the common inductions standards are being used for new starters. Supervision has commenced with documents on staff files detailing areas discussed. Training recently carried out includes dementia and medication with training on infection control planned. 50 of the staff team are trained at NVQ level. The service’s self assessment stated that all new staff have two references and POVA and CRB checks before employment. Three new recruit files were examined. The recruitment process was not robust. Two had started before two written references had been received. The manager stated that a verbal second reference had been obtained but had not recorded this on file. Two had started before the full criminal record check and one before the POVA 1st check South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 18 had been returned. The manager stated they had started due to staffing difficulties and had been supervised at all times. The management input has not and is not supernumerary to care staff numbers. South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. Key Standards 31,33,35,38 This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, with some quality assurance systems in place, so service users are assured that the overall conduct of the home is being well managed. EVIDENCE: Through discussion, the registered manager is aware of the need to plan the business activity of the home but does not hold responsibility to manage finances and resources to deliver any business plan. The manager does not receive formal supervision from the owner and therefore planning for improvement is sometimes difficult to achieve. The manager was open in her wishes and ideas for improvement to the service. She is fully aware of what South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 20 needs to be done to improve. The CSCI is confident the manager will eventually address issues in the long term. People who use the service stated that they trust the staff and feel safe in the home. The manager demonstrates a commitment to the equality and diversity of service users by addressing needs arising out of age and disability. One service user who has a learning disability is not segregated and care provision is inclusive of all living at the home. The manager trains and develops staff with consistency and equality so that they are competent and knowledgeable to care for people who use the service. Service users are pleased with the service and they and their families are asked if they have any concerns or ideas via residents’ meetings and questionnaires. The home has a system for recording personal monies with safe facilities. South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 21 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 22 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 OP29 Regulation 19(1) Requirement The manager must not confirm new employees in post before all recruitment checks have been completed. This ensures that service users are supported and protected by the home’s recruitment policy and practice. Timescale for action 22/06/07 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 3 4 Refer to Standard OP7 OP25 OP19 OP31 Good Practice Recommendations The recording of entries within care plans should improve demonstrating discussion with the service user. Radiators in service user’s rooms should be guarded. Grounds should be kept tidy, safe, attractive and accessible to service users. The registered provider should provide the manager with dedicated management hours in order to fulfil the aims and objectives of the home. The provider should provide supervision for the manager, at agreed frequencies. South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 23 5 OP37 A recent photograph should be on all care plans. South View DS0000020648.V336427.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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