Inspection on 18/05/05 for Southcliffe House

This inspection was carried out on 18th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Southcliffe House 18/08/09

Southcliffe House 11/09/07

Southcliffe House 27/02/07

Southcliffe House 25/10/05

Southcliffe House 03/08/05

Southcliffe House 11/08/04

Southcliffe House 14/10/02

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

Care Home For Older People Southcliffe House 130 Ripon Road Stevenage Hertfordshire SG1 4ND Unannounced Inspection 11th February 2005 Commission for Social Care Inspection Launched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role. Inspection Methods & Findings SECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Southcliffe House Address 130 Ripon Road, Stevenage, Hertfordshire, SG1 4ND Email address Name of registered providers Mr K Sutcliffe Mrs Diane Sutcliffe Name of registered manager Mr K Sutcliffe/ Mrs D Sutcliffe Type of registration Care Home No. of places registered 3 Tel No: 01438 355 566 Fax No: Category of registration, (with number of places) Old age, not falling within any other category (3) Registration number I020000225 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply? Date of last inspection Date of latest registration certificate 30th July 2002 Yes No 11/08/04 If Yes refer to Part C Southcliffe House Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 3 11th February 2005 10:00 am Robert Kittle ID Code 117477 Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspection Not applicable Mr & Mrs Sutcliffe – owner/managers Southcliffe House Page 2 CONTENTS Introduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s Agreement Southcliffe House Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Southcliffe House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Provider’s response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates. Southcliffe House Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Southcliffe House is a semi-detached property located in a quiet residential area of North Stevenage. The adjoining property is the proprietors’ own dwelling and interconnecting doors have been introduced for ease of access. The ground floor of the home consists of a kitchen, dining room and toilet. There is also a lounge and conservatory which opens up onto the garden by means of French doors. The first floor comprises three single occupancy bedrooms, a bathroom and a toilet. This floor is also connected to the proprietors’ private dwelling. The service is designed for older people who are still able to enjoy some degree of independence and make choices for themselves. The proprietors are the main carers and are usually assisted by one care worker. No night staff are deployed and this is a consideration at the point of admission. Southcliffe House Page 5 PART A SUMMARY OF INSPECTION FINDINGS INSPECTOR’S SUMMARY (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Prior to the formal inspection taking place, the inspector, the Community Fire Safety Officer, the proprietors and their Fire Consultant met and examined the fire precautions in the home to confirm that they met current legislative requirements. The focus of this unannounced inspection was on discussions with the residents, staff and the proprietors as well as reviewing the findings of the previous report. The home met all the standards that were assessed. Where standards were not assessed on this occasion, details can be found in the inspection report dated 11 August 2004. This was a most positive inspection. To summarise the standards that were assessed on this occasion: Choice of Home (Standards 1 – 6) Two of these standards were assessed and both were met. The home does not offer intermediate care and standard 6 does not therefore apply. Health & Personal Care (Standards 7 – 11) This section was not fully assessed on this occasion. However, past inspection reports indicate that this aspect of care is appropriate. Daily Life and Social Activities (Standards 12 –15) Two of these standards were assessed and found to be satisfactory. Very positive comments were made about the food provided in the home. Complaints & Protection (Standards 16 – 18) One of these two standards was assessed and was found to be satisfactory. The home has an appropriate complaint procedure that is readily available. Environment (Standards 19 – 26) All the standards assessed in this section were found to be satisfactory. Since the last inspection took place, the proprietors have engaged the services of a consultant and have had work carried out to ensure that the home meets current fire safety requirements Staffing (Standards 27 – 30) Staffing arrangements were satisfactory although one of these standards was not met. A recommendation has not been made however, (please see text for details). Management & Administration (Standards 31 – 38) All the standards assessed in this section were met and residents, a visitor and the member of staff on duty confirmed that the home is conducted in a supportive and effective manner. Since the last inspection took place, Mr Sutcliffe has successfully completed a food hygiene course. Southcliffe House Page 6 Requirements from last Inspection visit fully actioned? If No please list below YES STATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for action Action is taken by the Commission for Social Care Inspection to ensure compliance in regard to requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). There are no additional conditions of registration Met (Yes / No) Southcliffe House Page 7 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office. STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action There were none. RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues, which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard * There were none. * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10. Southcliffe House Page 8 PART B INSPECTION METHODS & FINDINGS The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other (Specify) ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES NO NO NO NO YES YES NO YES YES NO NO YES YES NO YES 4 1 0 NO NO YES YES 1 1 11/2/05 1030 1.5 Southcliffe House Page 9 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls) 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable. Southcliffe House Page 10 Choice of Home The intended outcomes for the following set of standards are: • • • • • • 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. Standard 1 (1.1 – 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users’ guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the home’s service user’s guide. Range of fees charged From (£) 550 To (£) 550 Any charges for extras If yes, please state what the extra’s are: Yes Hairdressing, newspapers and chiropodist 0 Key findings/Evidence Standard met? Not assessed on this occasion, please see previous report for details. Southcliffe House Page 11 Standard 2 (2.1 – 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The home has a statement of terms and conditions that meets the requirements of the national minimum standards (NMS). The residents at Southcliffe House have been provided with a contract listing the terms and conditions governing their stay in the home. Standard 3 (3.1 – 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? There have been no new residents admitted to the home since the last inspection took place. Therefore, this standard was not assessed on this occasion. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? There have been no new residents admitted since the last inspection and this standard was therefore not assessed. Standard 5 (5.1 – 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Residents in the home confirmed that they were invited to see the home before admission as well as having an offer to take a meal with the existing residents and spend time in the home before making their minds up. After moving to the home, an informal meeting is held after four weeks for self-funding people and the care manager will call after six weeks and hold a formal review for funded residents. Southcliffe House Page 12 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Southcliffe House does not offer this service. Southcliffe House Page 13 Health and Personal Care The intended outcomes for the following set of standards are: • • • • • The service user’s health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. 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. Standard 7 (7.1 – 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 0 Key findings/Evidence Standard met? Not assessed on this occasion, please see previous report for details. Standard 8 (8.1 – 8.13) The registered person promotes and maintains service users’ health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 0 0 0 Key findings/Evidence Standard met? Not fully assessed on this occasion, please see previous report for details. Southcliffe House Page 14 Standard 9 (9.1 – 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 0 Key findings/Evidence Standard Met? Not assessed on this occasion, please see previous report for details. Standard 10 (10.1 – 10.7) The arrangements for health and personal care ensure that service users’ privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? Not assessed on this occasion, please see previous report for details. Standard 11 (11.1 – 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? The home would endeavour to provide a home for life for its residents, but is aware of the limitations of the service it can realistically offer. Since the last inspection took place, the proprietors have drawn up a brief policy/statement about the care of residents who are dying. Southcliffe House Page 15 Daily Life and Social Activities The intended outcomes for the following set of standards are: • • • • 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. Standard 12 (12.1 – 12.4) The routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. 3 Key findings/Evidence Standard met? At the time that this inspection took place, there were three residents in the home, (two long stay and one who enjoys periods of respite care) as well as a lady who uses the home’s day care service. All were either reading or entertaining whilst the inspector was in the home. However, each expressed their satisfaction with the services provided. It was noted that Mr Sutcliffe discussed the main meal of the day with each resident before he began to cook. One of the service users has a day activity outside the home. Standard 13 (13.1 – 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users’ preferences. 3 Key findings/Evidence Standard met? One resident user was entertaining a visitor in the lounge whilst this inspection was taking place. The lounge is set back from the conservatory (where residents tend to spend the day) and therefore the meeting was afforded the appropriate degree of privacy. Standard 14 (14.1 – 14.5) The registered person conducts the home so as to maximise service users’ capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? Not assessed on this occasion, please see previous report for details. Southcliffe House Page 16 Standard 15 (15.1 – 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Not fully assessed on this occasion. However, service users confirmed that breakfast is prepared at a time to suit individuals and that all meals are both attractively presented and appetising. Southcliffe House Page 17 Complaints and Protection The intended outcomes for the following set of standards are: • • • 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. Standard 16 (16.1 – 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure, which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X 0 X 3 Key findings/Evidence Standard met? The home has an appropriate complaint procedure that is readily available. In addition, the proprietors adopt a proactive approach in consulting with residents and their families or representatives. This approach ensures that issues are resolved before they escalate into complaints. Southcliffe House Page 18 Standard 17 (17.1 – 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? Not assessed on this occasion, please see previous report for details. Standard 18 (18.1 – 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Standard met? Not assessed on this occasion, please see previous report for details. Yes 0 0 Southcliffe House Page 19 Environment The intended outcomes for the following set of standards are: • • • • • • • • 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. Standard 19 (19.1 – 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users’ individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Since the last inspection took place, the proprietors have engaged the services of a consultant and have had work carried out to ensure that the home meets current fire safety requirements. The Community Fire Safety Officer confirmed this prior to the inspection taking place. The home continues to be maintained in good decorative order. Standard 20. (20.1 – 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users’ private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? The home provides ample recreational and dining space for the residents. During this inspection, residents also discussed the pleasure they derived from the garden, which was a focus of interest from the conservatory throughout the year. Southcliffe House Page 20 Standard 21 (21.1 – 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? There have been no changes since the last inspection took place. Standard 22 (22.1 – 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? Since the last inspection took place, the Environmental Health Officer has called and was satisfied with the standards maintained. The recommendation that refrigerator and freezer temperatures should be recorded has been followed. It is noted that, in order to comply with the Fire Safety requirements, it has been necessary to remove a section of handrail. This is regretted but it is felt that the appropriate priority has been afforded to the overall safety of the residents, visitors and staff by this decision. Southcliffe House Page 21 Standard 23 (23.1 – 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16sq.m Total number shared rooms less than 16sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Yes No No 3 X X X 3 2 1 X X X X Key findings/Evidence Standard met? There have been no changes since the last inspection took place. Southcliffe House Page 22 Standard 24 (24.1 – 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? Although this standard was not fully assessed on this occasion, previous reports have recorded that rooms are personalised giving an individual and homely impression. Residents confirmed that this was the case. Standard 25 (25.1 – 25 8) The heating, lighting, water supply and ventilation of service users’ accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? At the time that this inspection took place, the home was maintained to a degree of warmth that suited the residents. Residents prefer to spend the day in the conservatory where they can take advantage of the natural light as well as enjoy the view of the garden. Standard 26 (26.1 – 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The home was maintained to its usual high standards of cleanliness. Southcliffe House Page 23 Staffing The intended outcomes for the following set of standards are: • • • • 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. Standard 27 (27.1 – 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X 3 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X 1 1 4 3 Key findings/Evidence Standard met? The care needs are provided mainly by the proprietors. There are three part-time staff also available as well as a volunteer. Staffing arrangements continue to be satisfactory for the size of the home. Southcliffe House Page 24 Standard 28 (28.1 – 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 0 0 2 Key findings/Evidence Standard met? The staff group have been with this home for a considerable length of time and have stated that they have no interest in perusing a qualification. The proprietors have pointed out that, should a younger member of staff be appointed at some time in the future, they would be actively encouraged to undertake an NVQ level 2 training course and that Mrs Sutcliffe is an NVQ Assessor and would be able to provide positive support. Therefore, it is not possible for the home to meet this standard for the foreseeable future. Standard 29 (29.1 – 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? No new staff members have been recruited for a number of years. The proprietors are aware of the range of paperwork required should a new staff member ever be needed. All staff have received a satisfactory CRB Disclosure. Standard 30 (30.1 – 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not fully assessed on this occasion, although it was noted that the proprietors arrange for staff to attend fist aid and moving & handling refresher courses as needed. Southcliffe House Page 25 Management and Administration The intended outcomes for the following set of standards are: • • • • • • • • 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. Standard 31 (31.1 – 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? Since the last inspection took place, Mr Sutcliffe has successfully completed a food hygiene course. He holds a City & Guilds qualification in care in the Community and in Care Management. Mrs Sutcliffe is a first level nurse. Standard 32 (32.1 – 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Residents, the visitor in the home at the time of that this inspection took place and the member of staff on duty all confirmed that the home is conducted in a supportive and effective manner. The management are approachable and endeavour to comply with all requests made to them. Standard 33 (33.1 – 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? Not assessed on this occasion, please see previous report for details. Southcliffe House Page 26 Standard 34 (34.1 – 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Not assessed on this occasion, please see previous report for details. Standard 35 (35.1 – 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 0 0 0 3 Key findings/Evidence Standard met? Although the proprietors would offer advice if asked, they are not involved in the residents’ financial affairs and no cash is kept on the premises on their behalf. Standard 36 (36.1 – 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? Whilst formal supervision is not undertaken, the nature of the home and the size of the staff group means that there is daily contact between staff and management. Southcliffe House Page 27 Standard 37 (37.1 – 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? All records that were seen on this occasion were maintained in a satisfactory manner and were up to date. Standard 38 (38.1 – 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? All elements of this standard that were assessed on this occasion were found to be satisfactory. They included water being delivered at a safe temperature, staff using appropriate protective clothing and appropriate fire precautions for a home of this nature. Southcliffe House Page 28 PART C (where applicable) COMPLIANCE WITH CONDITIONS Condition Old Age, not falling within any other category Compliance YES Comments There were three service users living at the home at the time that this inspection took place. Condition Comments Compliance Lead Inspector Second Inspector Robert Kittle Signature Signature Signature Regulation Manager Helen Pettengell Date 25th February 2005 Public reports It should be noted that all CSCI inspection reports are public documents. Southcliffe House Page 29 PART D D.1 PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTS Registered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection. We would welcome comments on the content of this report relating to the Inspection conducted on 11 February 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Southcliffe House Page 30 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YES Comments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 17th March 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required NO Action plan was received at the point of publication Action plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan Other: enter details here Southcliffe House Page 31 D.3 PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies. D.3.1 We, K & D Sutcliffe of Southcliffe House confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Proprietors 19th February 2005 K & D Sutcliffe Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable. Southcliffe House Page 32 Southcliffe House / 11th February 2005 Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.uk S0000019530.V207655.R01 © This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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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