Inspection on 29/10/08 for Southbourne Residential Care Home

This inspection was carried out on 29th October 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Southbourne Residential Care Home 07/07/09

Southbourne Residential Care Home 21/08/07

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/01/2009.

CARE HOMES FOR OLDER PEOPLE Southbourne Residential Care Home Cary Avenue Babbacombe Torquay Devon TQ1 3QT Lead Inspector Michelle Finniear Unannounced Inspection 08:30 29 & 30 October 2008 th th 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 Southbourne Residential Care Home DS0000069861.V366262.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. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southbourne Residential Care Home Address Cary Avenue Babbacombe Torquay Devon TQ1 3QT 01803 323502 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) southbournecarehome@btconnect.com Rosepost Healthcare Limited Mrs Kay Lorraine Allen Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (21), of places Physical disability over 65 years of age (21) Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) - maximum 21 places Dementia, aged 65 and over (Code DE(E) - maximum 21 places Physical disability, aged 65 and over (Code PD(E) - maximum 21 places The maximum number of service users who can be accommodated is 21. 21st August 2007 2. Date of last inspection Brief Description of the Service: Southbourne Residential Care Home is a detached residence that stands in its own grounds, it provides 24-hour residential care for persons in the category of Old Age, not falling into any other category, Dementia over the age of 65 years and Physical disability over the age of 65 years. The home’s accommodation is set over two floors, there are 17 single bedrooms, and two for shared occupancy. All rooms have en-suite facilities. A large comfortable lounge is available, meals are taken in a separate dining room at small tables seating up to four persons. A stair lift is provided for people who have mobility issues. At the front of the building there is a large hard standing car park, which has the capacity to take several vehicles. There are gardens with a large lawn area to the rear and sides of the home. Southbourne is situated in the Babbacombe area of Torquay and is within level walking distance of local amenities and the Babbacombe downs. The weekly cost of care at Southbourne is between, lowest £325.00 and the highest £360.00. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience Adequate quality outcomes. This report reflects a summary of a cycle of Inspection activity at Southbourne since the last key Inspection in 2007. It also includes information from a shorter focussed inspection, called a random inspection in May 2008. To help us make decisions about the home the owners and manager gave us information in writing about how the home is run; documents and correspondence submitted since the last inspection were examined along with the records of what was found at the last inspection; Two site visits were carried out without telling the home when we were coming on the first occasion; discussions were held with the manager and staff on duty; various records were sampled, such as care plans and risk assessments; questionnaires were sent to staff who work at the home; a tour was made of the home; discussions were held with visitors and visiting professionals during the day; and time was spent with the people who live at the home both individually and in groups. In addition a sample group of people living at the home were selected and their experience of care was ‘tracked’ and followed through records and discussions with staff and management, looking at how well the home understands and meets their needs, and the opportunities and lifestyle they experience. This approach hopes to gather as much information about what the experience of living at the home is really like. What the service does well: The staff seen were competent, friendly and clear about their duties with the people living at the home. The handover seen between shifts showed staff communicate well about events and peoples care needs, and daily records are completed. Time was spent discussion with staff about the care they deliver to people, and this was reflected in the service users care plan seen. This helped to show staff work consistently to support people. The accommodation has been refreshed and communal areas redecorated so that people can live in comfortable surroundings. People living at the home said that they liked the meals provided and confirmed that choice was always available to them concerning what foods they would like to eat. Snacks are provided on request. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 6 People spoken to said that they were well looked after. One person said “Nothing is too much trouble. I only have to ring and they come “ and another said “The staff are really good, they look after me really well.” One person felt they had improved since being at the home, and said that their family and the district nurses were very pleased with their progress. What has improved since the last inspection? What they could do better: The registered person must carry out all the required checks on people before they start working unsupervised at the home. This includes criminal records bureau checks and references. These help to make sure that people are only looked after by people who are suitable to work with vulnerable people. This was a requirement at the last inspection but is still not being done, and it places people at risk. Prescription dressings no longer required by that person must be returned to the pharmacy and not used for other people. This is because prescriptions may not be suitable for other people and are the property of the person for whom they are prescribed. The broken call bell to room 19 must be repaired. This is so that people can summon help if needed. Risk assessments must be undertaken to ensure a safe environment and safe working practices at the home. These must include assessments for Infection control and first aid. Risk assessments help to identify areas of risk at the home and how they can be managed. The home must provide a system for reviewing and improving the quality of care at the care home. This helps to identify what is working well at the home and what needs to be improved. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 7 Staff must be appropriately supervised. Supervision is a system comprising staff development and performance management and should help to ensure staff are working to their full potential and in a consistent fashion to support people living at the home. Staffing levels must ensure that peoples care needs can be met, and be commensurate with the number and dependency level of the people living at the home. This is so that people can have all their needs met. The owner feels this is the case. Staff should be provided with contracts of employment. This is so that people know what their duties and employment rights are. Care plans should be made more person centred. This is so that people can influence the way their care is delivered to ensure it is carried out in the way they wish as well as reflecting their chosen lifestyles and choices. More activities should be made available that are person centred and accessible for people who are frail. This is so that people can receive some opportunity for activity and stimulation whatever their level of disability or choice of lifestyle. 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. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 8 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 Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 9 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): 1, 2, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available about the home to help people make a choice about whether it is the right place for them. The home makes sure they can meet peoples needs before they agree to admit them. EVIDENCE: The home has a user guide available, which contains information about the home and the services it provides, for example the address of who to make a complaint to, as well as information about the terms and conditions of residency in the form of a contract. People spoken to or who completed questionnaires indicated they had received enough information about the home before they moved in, either through documentation, or through trial visits. People are encouraged to visit the home and see the accommodation available before making a decision about moving in., Sometimes this may be done by Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 10 relatives on their behalf for example if they are ill in hospital. Two people spoken to were at the home for respite or convalescence. Time was also spent looking at the pre-admission assessment provided for a person, due to move to the home for a trial period a few days after the inspection. The assessment indicated the person’s needs and the support that they required in their day-to-day life. The owner had also spoken to Social Services staff who had been responsible for their care and information had been supplied in writing about their needs, medication and interests. This helps to ensure the home can meet their needs. Each person living at the home was said to have a contract, a copy of which is given to people before they make a decision about whether the home is the right place for them. A blank copy was seen. This contract contains information about peoples rights and any conditions of residency, for example whether visitors are charged for meals they wish to take at the home and periods of notice required. Information is also available in the service users guide on pets, and how the home manages quality standards. The home does not cater for intermediate care. This means they do not provide specialist intensive rehabilitation services with an aim to return the person to their own home. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were being well cared for, however care plans would benefit from being more ‘person centred’ and more information being made available on the impact of health conditions on the individual. EVIDENCE: Six care plans were seen during the first visit. These were then referred to the people they concerned and one was discussed with staff to see that they were a reflection of the care actually being given. Care plans contain information on the support people need and how that support is to be given. They also contain information on risks and how they are managed. Care plans seen outlined people’s personal care and health needs and showed that these needs were reviewed and re-assessed regularly in consultation with the resident and/or their representative wherever possible. Those residents with failing health or life limiting illness are able to remain at the home if hospitalisation is not required and their Nursing needs can be managed by the Community district nursing service. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 12 Medication, including controlled drugs, is stored safely and administration practices protect residents from risk. The medication in use is given out only by senior staff who have received training from the supplying pharmacist. Controlled drugs – which are those that need special storage and control due to their strength or effects were being stored safely. The balance held is recorded after each administration and this was checked and found to be correct. The manager agreed to remove some prescription dressings from a general use cupboard. These were dressings that belonged to people no longer at the home. The home has equipment available for both the safe moving and handling of people with limited mobility and also specialist bathing facilities and mattresses to relieve pressure for people who spend considerable time in bed or immobile. Other aids such as raised toilet seats, specialist seating and grab rails are provided as the person needs. People spoken to said that they were well looked after. One person said “Nothing is too much trouble. I only have to ring and they come “ and another said “The staff are really good, they look after me really well.” One person felt they had improved since being at the home, and said that their family and the district nurses were very pleased with their progress. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14, 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home have opportunities to take part in organised activities if they choose, but the home plans to develop these further to take greater account of the needs of people with mental health problems. Contacts are maintained wherever possible with family and friends with visitors being encouraged. Meals are well balanced and offer choice. EVIDENCE: Time was spent with a number of people living at the home discussing how they chose to spend their day. Discussion was also held with the manager on the provision of more person centred activities for people who are more frail. A more person centred approach would be to identify, as the home has been trying to develop, what the person enjoys and is able to participate in despite their impairments and provide that rather than encouraging them to fit into what the home provides. The home have plans to increase the amount of time an activities organiser spends at the home. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 14 Since the last inspection some life histories have been provided for the people living there. This has been a really positive development for people at the home and the staff who care for them, opening up channels of communication and a deeper understanding of the lives people have lived and the experiences they have had. One person said they did not want people to have that information on them as they felt they wanted to be private and that has been respected. People were being respected and their privacy maintained. Staff knocked on peoples doors before entering their rooms and addressed them respectfully in accordance with their wishes. Interactions witnessed between staff and people living at the home demonstrated an understanding of their needs, including where communication was difficult. Discussion was held with the cook on duty concerning the diets and meal provision. The home currently provides for some special diets. On the day of the first site visit the main meal being served was Roast pork, roast potatoes, fresh broccoli and carrots, with fruit flan for dessert. It was also one person’s birthday and a celebration cake and tea was being provided. People at the home buy their own fruit and one person supplemented their meals with specific items of their choice. Evidence was also seen of people having supper in the evening if they wished with sandwiches available if people feel hungry. People spoken to generally said they enjoyed the food and that the home would always do something else for them if they wanted something different or were feeling poorly. As an example, one person who didn’t want pork for lunch was made a cheese omelette. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 15 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): 16, 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures for the management of complaints and concerns. Staff have received training in the protection of vulnerable adults, but the homes procedures for appointing staff could leave people at risk. EVIDENCE: The home has a complaints procedure, which is in the service user guide. This tells people how and to whom to make a complaint, as well as what will happen if they do. One formal complaint has been received since the last inspection, which concerned access to medical care, and services at the home. This was addressed via the provider’s complaints procedure. Staff have received training in safeguarding, but for most this has been delivered in House. External training provided by the care trust has been accessed for some senior staff, along with training on the Mental capacity Act. The home has information available on safeguarding and protecting vulnerable adults and it is recommended that this be displayed more openly in the home. There is also a whistle-blowing policy available. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 16 Discussion with the manager and examination of staff files indicated that staff start working unsupervised before a Criminal records bureau check is undertaken or a POVA First check, which is a check which helps to ensure people have not been barred from working with people who are vulnerable. This could put people at risk from being cared for by people who are unsuitable. Files seen showed evidence of recent checks having been made at other employment. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 17 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): 19, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained, and offers comfortable accommodation. EVIDENCE: Southbourne is a converted Victorian villa situated in the level area of Cary Park. There is a garden to the rear of the building and parking to the front. Local shops and facilities are close by, ad the home is opposite a church. During the first site visit a tour was made of most of the home. Not every bedroom was seen, but those that were looked homely and there was evidence that people have been able to bring personal belongings with them in to the home. Bedrooms were fitted out to meet individual needs with some rooms having adjustable beds, pressure relieving and moving and handling equipment and adaptations to promote independence. Those people spoken to about their Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 18 private environment who could express an opinion said they like the décor in their own rooms. Some rooms have older style furnishings, but have en-suite facilities. A call bell tested in a toilet was not working properly and another could not be turned off easily by staff. The manager said the home were to replace the system in the future but agreed to remedy the broken point without delay. The furniture, furnishings and equipment in communal rooms appeared to be in good order. A stair lift provides access for less mobile people to the mezzanine and first floors. All areas seen on the visit were clean and fresh smelling. Rooms are being refurbished as they become vacant, and since the last key inspection the premises have undergone considerable improvement to make them more comfortable and homely. There is a newly refitted laundry, and service areas were clean and free from obstruction. Secure storage is available for clinical waste. Equipment was available to support the control of infection, such as anti bacterial cleansers, gloves and aprons. The home does not have an infection control risk assessment but information was available in individual peoples files on any specific infection risks. An infection control risk assessment would identify infection risks in the overall home and how they should be addressed to prevent infection being spread from person to person. The laundry is said to be capable of achieving a sluicing cycle, which means that laundry can be disinfected properly. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 19 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): 27, 28, 29, 30. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Sufficient checks are still not being made on people employed by the home before they start to work. This puts people at risk. Staffing levels may not be sufficient to meet peoples care needs in safety. EVIDENCE: During the second visit time was spent looking at the numbers and skills of staff on duty, the training they receive and how the home recruits and selects their staff. Time was also spent with staff at a handover and observations made during the two visits on how they carry out their job. The staff seen were competent, friendly and clear about their duties with the people living at the home. The handover seen between shifts showed staff communicate well about events and peoples care needs, and daily records are completed. Time was spent discussion with staff about the care they deliver to people, and this was reflected in the service users care plan seen. This helped to show staff work consistently to support people. Staffing levels at the home were also discussed. It is understood that staffing levels were being reduced in the afternoon, and that this was planned to leave only 2 care staff on duty, with the manager for 17 people, many of whom have Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 20 dementia, and several of whom need two staff to support them with their care needs. This could potentially mean people could not be monitored properly and have their care needs met. The home has managed to achieve a settled staff group, after a turbulent year when 19 staff had left since the change of ownership. Several staff files were selected at random to look at the recruitment practices followed when they were employed. Staff files did not contain contracts of employment and staff spoken to confirmed they had not received any. The recruitment practices followed did not protect people from being cared for by staff who may be unsuitable and staff were starting work without full checks having been undertaken as to their suitability. This was also the case at the last Inspection when it was made a requirement. Some files did not include two references or information on peoples career history, although one looked at had been employed by the previous owners. Newer files did contain a training and development plan for each person with information on peoples training needs and when they attended specific courses. Some training is delivered internally, but evidence could be seen of other free courses being attended locally. On the day of the first visit 4 staff were attending a course on wound care, and the manager confirmed that this had been useful. Discussion was held on Induction practices at the home. A file for a recently appointed staff member was seen and this did contain an Induction document, although it was not fully completed despite the person having been at the home for five months. The manager confirmed much of the areas in the induction had been covered with the person but the paperwork had not been completed. A full induction programme helps to ensure that staff receive the appropriate training to care for people at the home. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 21 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): 31, 33, 35, 36 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Attention is required to health and safety risk assessments to ensure the home is a safe place to live and work in. The quality assurance system needs development to ensure it provides a full development plan of what is working well and what can be improved. Staff supervision is not being delivered to staff regularly. EVIDENCE: The manager of the home is Mrs Kay Allen. She has been a registered manager in previous homes and has extensive experience in care. She leads a team of four senior staff, care and domestic staff. The owner of the home, Rosepost Healthcare Ltd owns and operates another care home for Older people next door to Southbourne. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 22 The home is developing a system for quality assurance which has so far consisted of a series of questionnaires being sent to out to enable people to comment on the service, and the gathering of information from various internal and external audits. This will need to be gathered into an annual development plan, which will help the manager identify which systems are working well and which could be improved. It is important that the perspective of the people living at the home is taken into account as a part of this process. Staff supervision is not being delivered to staff regularly. Supervision is a system comprising staff development and performance management and should help to ensure staff are working to their full potential and in a consistent fashion to support people living at the home. Time was spent with the manage of the home looking at health and safety practices at the home and several maintenance contracts were seen for example for the servicing of hoists and maintenance of chair lifts. Staff receive basic training in Health and safety. Risk assessments were not available for many areas of the environment or safe working practices for staff. Risk assessments help to identify risks in the environment and how they can be managed to safeguard people. This could put people living or working at the home at risk if potential risks were not identified and minimised wherever possible. The home has implemented a system for the safe storage and management of food and the fire log book was completed appropriately. The home has a fire precautions workplace risk assessment but it was not clear how well this related to Southbourne or the other home owned by Rosepost Healthcare Ltd. Risk assessments are also needed for Infection control and First aid as discussed. The management of small amounts of people’s monies held in trust was seen. This showed individual balances are kept for each person and receipts obtained for any purchases of services made on their behalf. This includes hairdressing and chiropody appointments which are not covered in the fees. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 23 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 3 3 3 x 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x 2 x 2 Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 Requirement The registered person shall not employ a person to work in a care home unless - he has obtained in respect of that person the information and documents specified in - (i) paragraphs 1 to 7 of Schedule 2. Previous timescale of 30/09/08 not met. Prescription dressings no longer required by that person must be returned to the pharmacy and not used for other people. The broken call bell to room 19 must be repaired. Risk assessments must be undertaken to ensure a safe environment and safe working practices at the home. These must include assessments for Infection control and first aid. The home must provide a system for reviewing and improving the quality of care at the care home. Staff must be appropriately supervised. Staffing levels must ensure that DS0000069861.V366262.R01.S.doc Timescale for action 03/12/08 2. OP9 13 03/12/08 3. 4. OP19 OP26 OP38 23 13 03/12/08 03/02/09 5. OP33 24 03/02/09 6 7 OP36 OP27 18 18 03/02/09 Southbourne Residential Care Home Version 5.2 Page 25 peoples care needs can be met, and be commensurate with the number and dependency level of the people living at the home. 15/12/08 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. 2. Refer to Standard OP29 OP7 OP12 Good Practice Recommendations Staff should be provided with contracts of employment. Care plans should be made more person centred. More activities should be made available that are person centred and accessible for people who are frail. Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. Extracts may not be used or reproduced without the express permission of CSCI Southbourne Residential Care Home DS0000069861.V366262.R01.S.doc Version 5.2 Page 27 - 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. 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