Inspection on 13/04/05 for Southernhay Retirement Home

This inspection was carried out on 13th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Southernhay Retirement Home 27/05/08

Southernhay Retirement Home 03/12/07

Southernhay Retirement Home 07/08/07

Southernhay Retirement Home 28/06/06

Southernhay Retirement Home 25/08/05

Southernhay Retirement Home 14/10/04

Southernhay Retirement Home 08/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Southernhay Retirement Home Second Drive Landscore Road Teignmouth TQ14 9JS Lead Inspector Stella Lindsay Announced 13 April 2005 th 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 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. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Southernhay Retirement Home Address Second Drive, Landscore Road, Teignmouth, Devon, TQ14 9JS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01626 773578 01626 870469 scary-mary49@yahoo.co.uk Mrs Mary Crook Mrs Mary Crook Care Home 20 Category(ies) of Dementia (20), Old age, not falling within any registration, with number other category (20) of places Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th October 2004 Brief Description of the Service: Southernhay is a detached house in a quiet residential area of Teignmouth, about half a mile from the town centre. It cares for up to 20 people over the age of 65, and the service is designed for people with dementia. The home has two lounges, and a small conservatory adjoining the dining room, which overlooks the garden. There are twelve single rooms and two double. All but two have an en-suite wc. There is a pleasant enclosed garden, and a small patio at the front of the house. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an Announced Inspection, and took place between 10am and 5pm on a Wednesday in April. It included a partial tour of the premises and examination of care records, staff files, health and safety records and the medication system. As well as discussion with the Home owner, the inspector spoke with 12 residents, two visitors, and five staff members, and thanks all for their time. In addition, two residents and two relatives returned questionnaires to the CSCI. What the service does well: What has improved since the last inspection? Work has continued to assure health and safety in the home, with refurbishment of the laundry and kitchen, and a survey carried out with regard to any risk from Legionella. Redecorating and re-carpeting is on-going, with hall, stairways, and some bedrooms completed since the last inspection, keeping the house pleasant. The small conservatory overlooking the garden has been brought into use since the last inspection, and is a sunny place for resident and their visitors to sit. An annual plan has been drawn up, prioritising future improvements. The Home owner has provided statements of terms and conditions for the staff, and has implemented supervision sessions, thus providing support and consideration to the staff. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 6 Training has been provided to assure the safety of residents, in particular in Fire Safety, Control of Infection, and Safe Handling of medicines. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 and 5 The Homeowner and staff are approachable and pleased to discuss their service with prospective residents and their families or representatives, and visitors are made welcome at all times. Information is therefore available to families although the Home’s written information needs up-dating. The Homeowner has admitted people to the Home appropriately, but has not recorded the reasons why she thinks their needs can be met at Southernhay. EVIDENCE: Southernhay has a Statement of Purpose which is clearly written and gives all the information recommended by the National Minimum Standards, but is due to be re-written as some of the information is out of date. Prospective residents are welcome to visit. This does not always happen, sometimes because the person is happy to trust their family to choose their home, but sometimes because some people concerned want to arrange a quick move, or there is no family to bring them. They should all be offered a chance to visit. The Homeowner has met people in hospital or in their home while assessing whether Southernhay is appropriate for them. In a recent admission, the Homeowner had received a full nursing referral from a hospital about a person’s many care needs, but had not recorded how these Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 9 needs could be met at Southernhay. In another instance, brief information had been sent by a previous care home, and the Homeowner had gathered information by phone, but this was not recorded. Staff said that they are given enough information when a new person arrives, either verbally or in the care plan. Care needs assessments were carried out after the people moved in. This work must be started before accommodation is offered, to be sure that the Home is prepared to meet the needs. The inspector met both new residents, and found that they were settling into their new home. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,9,10 The personal care of residents at Southernhay is very good, with staff being aware of individual requirements. The medication is well managed, promoting good health. EVIDENCE: All Service Users have had their care needs assessed and care plans completed. The ‘service provided’ is written, describing care tasks that are needed, and ‘objective’ is also included, which encourages staff to think about what it means to the resident. Summaries are written monthly. The inspector did not see any care plans that had been signed by a resident or their relative, showing that they had been consulted. During the inspection relatives said that they were confident with the care provided. The inspector saw staff treating people as individuals, and this was confirmed by residents - one resident said that Southernhay is a good place to live, because ‘they let you get on with your life’. There is a sound procedure for administering medication, and staff deal with it carefully. The proper guidelines and information are available for staff. All are working together on a training course for the Safe Handling of Medication. No residents at Southernhay are able to manage their own medication. One person keeps possession of their inhaler as they would be agitated without it. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14, and 15 Staff are successful in their efforts to make residents feel cared for in a way which suits them. The residents’ interest in daily life is maintained by activities and good food. EVIDENCE: One resident said that ‘you can go to bed when you want, and have a bath when you want.’ Another said there are always staff to help when they are wanted. Residents were pleased that their soiled clothes were taken to the laundry every day, and returned promptly. Staff lead social activities within the home, and entertainers visit. A relative said that they usually visit in the mornings, because there is nearly always something going on in the afternoons. On the morning of the inspection, residents snoozed quietly in the lounge, read the newspaper, or chatted while staff completed the housework. In the afternoon an entertainer gave a Gracie Fields tribute. Seven residents were on their feet dancing, with staff and with each other. All the residents who mentioned food said that they enjoy their meals. One said they did not remember being asked what they would like to eat, but staff know what they do not like, and always offer an alternative. A new cook has been appointed, who has experience of cooking for people with sensory disabilities. She has not yet talked to all the residents about their preferences. Suitable food is provided for people with diabetes, and people who need soft food. A record was kept of the soft food served, but a record of all alternatives Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 12 to the menu should be kept, as a nutritional record for individuals, and to help pinpoint the cause if there are any problems with digestion. On the day of the inspection, lunch was a very tasty stew and dumplings. Most residents sat to tables in the dining room, which is bright and overlooks the garden. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents are protected because they feel secure and able to tell staff if they are worried, and feel that if they have any concern they will be heard and the Home owner will deal with any problems. However, the Home’s procedures did not include the local arrangements for reporting any allegation of abuse. EVIDENCE: The Complaints policy is published in Southernhay’s Service User Guide. There are forms available, and a complaints log. No complaints have been received by the Homeowner or the CSCI. There is a good policy for Adult Protection, including whistle blowing, but it did not include the local arrangements for reporting allegations to the Social Services Adult Protection team. The Homeowner will bring the whistle blowing policy to staffs’ attention at the next staff meeting. Staff and residents said that they find the Homeowner to be very approachable, and that ‘if anything was wrong, she would put it right’. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20, 24 and 26 The residents have a bright, comfortable and safe home to live in. Cleaning is carried out every day in order to keep the house sweet-smelling and pleasant. EVIDENCE: Work on the fabric of the building has continued throughout the year. The laundry refurbishment has been completed, and the kitchen units have been fitted. Work on the garden has continued and it looks attractive and is much more safe and accessible. The patio at the front is largely for staff use, because of direct access to the road. The Home owner stated that she is considering how to make the front of the house more attractive. Some bedrooms have been redecorated and carpeted, and new carpets laid in the hallway and up the stairs. The little conservatory has been furnished and is now in use and very attractive. A call bell has been fitted at the top of the stairs, for residents to use if they need help with the stair lift. There are alarms fitted to external doors, and also available on bedroom doors, to alert night staff of a person on the move. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 15 All bedrooms have suitable locks which shut with large knobs on the inside, and can be opened by staff in an emergency. Most residents have a lockable drawer or cupboard. Electrical sockets have been fitted at easy-to-reach heights, and aerial sockets have been fitted for television shelves. Family photographs and the occupants’ craftwork were on display. All pipe work and radiators accessible to residents have been guarded, and baths are fitted with temperature regulation valves. The laundry has been refurbished, and has a washable plastic surface on the walls. A procedure for ensuring that no contamination occurs between clean and soiled laundry is in place, and staff have received training in Control of Infection. Care staff share cleaning duties, and a carpet cleaner is in daily use. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29, and 30 Southernhay has sufficient staff to care for the residents. There is a sound recruitment system, to ensure that people employed in the home are trustworthy and reliable, as well as having a caring attitude. Good effort is put into continuing training, with the result that staff are competent in safe methods of working, and are developing their skills in caring for people with many and varied needs. EVIDENCE: A rota is kept, which shows that there are four or five staff on every morning, and four for the rest of the day, with two waking night care staff. This can be seen to be sufficient in that residents say that they can get help when they need it, and in that their appearance was well cared for. Residents said that ‘there are always staff to help when you want them’. Questionnaires received also gave the opinion that sufficient staff are available. The only reservation is that there is a heavy burden of cleaning, due to personal and health problems of the residents, and no cleaner was employed at the time of the inspection. Care staff share the duties, which results in less attention for residents until the work is done. Staff regularly provide social activities during the afternoons, but were not available in the lounge during parts of the morning. The Home owner stated that she would raise this at the next staff meeting. Staff files contained application forms and CVs., CRB disclosures, written references and proof of identity. Induction training had not been to the standard of Skills for Care, and had been signed off by the Home owner, but not the staff member. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 17 Of the 12 care staff, two have achieved NVQ2 or 3, three are working towards NVQ3, another is working towards NVQ2, and four were due to embark on their NVQ2 a week after the inspection. This shows serious commitment to achieving a qualified workforce. Other training received has included fire safety, Moving and Handling, First Aid, Control of Infection, and all staff are working together on Safe Handling of Medicines. Two staff have attended a training day on Mental Health, which covered awareness of depression and dementia. As Sothernhay specialises in care of people with dementia, further specific training would be beneficial. The Home owner works in the home most days, and is available with her experience to support and advise staff. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,35,36, and 38 The residents benefit from a relaxed atmosphere in the Home, combined with close attention to their individual needs. The Home owner leads by example with kindness and consistent good care. Communication is good and staff feel supported in their work. All health and safety requirements have been acted upon promptly, providing a safe and comfortable home. EVIDENCE: The Home owner is in day to day control of the Home, and there is no separate Registered Manager. She is competent and experienced. She has achieved the NVQ Assessors’ Award, and has two further units to complete the Registered Managers’ Award. A resident with their visitor said ‘there could be nobody kinder or nicer’, and she is always available as well as being very approachable. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 19 Staff meetings are held, and staff have individual supervision sessions with the Home owner. Staff reported that their training needs are considered, and that communication within the team is good. All were positive about their work. There can be delays in up-dating documents, as the Home’s computer is currently based at the Home owner’s private address. She looks after small amounts of cash on behalf of 9 residents. This is properly accounted for, but she might accept help in keeping the records up to date. Staff have received training in safe working practices. Fire Safety training was delivered on 12/11/04, and an up-date covering use of extinguishers is booked for 17/05/05. The Home has a video for maintaining awareness of fire safety. Staff should be required to record when they have viewed it or received any other fire awareness up-date. The door to the newly refurbished laundry was wedged open, as was the door to the bedroom of one resident who stays in her room. These are both fire doors, which must be kept shut unless an approved hold-open device is fitted. Accidents are reported and recorded. Advice was given to record observation of unexplained bruises. A Water Hygiene Survey and Risk Assessment was carried out professionally in January 2005. The Home owner continues to work towards making and keeping the home safe and comfortable. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x 2 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 4 x x 2 3 x 2 Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement The Registered Manager must confirm in writing to a prospective resident or their representative, following assessment, that the Home is suitable for meeting their needs. Previous time scale 30/11/04. The Registered Manager must complete a full assessment before offering accomodation to a new resident, which would include mental health needs and behavioural problems. The Adult Protection policy must include the local reporting arrangements. Previous timescale 30/11/04. All fire doors must be kept shut, unless approved hold-open devices are fitted, following consultation with the Homes Fire Safety officer. There must be evidence that all staff are up to date with fire safety training (ie 3 monthly for night staff, 6 monthly for day staff). The Registered Manager must provide induction training which meets the specification of Skills for Care. D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Timescale for action 31/05/05 2. OP3 14 31/05/05 3. OP18 13 31/05/05 4. OP38 23 31/05/05 5. OP38 23 31/07/05 6. OP30 18 31/07/05 Southernhay Retirement Home Version 1.20 Page 22 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 OP15 OP30 OP38 OP5 Good Practice Recommendations A record should be kept of alternatives to the main meal, and who has eaten them. All staff should receive training in meeting the needs of people with dementia. Any unexplained bruises (or other injuries) should be recorded as soon as they are observed. All prospective residents should be offered a visit to the Home. Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 23 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Southernhay Retirement Home D54-D07 S38524 Southernhay V210528 130405 Stage 4.doc Version 1.20 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!