Inspection on 27/05/08 for Southernhay Retirement Home

This inspection was carried out on 27th May 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

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 13/04/05

Southernhay Retirement Home 14/10/04

Southernhay Retirement Home 08/06/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Southernhay Retirement Home Second Drive Landscore Road Teignmouth Devon TQ14 9JS Lead Inspector Judy Hill Unannounced Inspection 11:30 27 & 28th May 2008 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 Southernhay Retirement Home DS0000038524.V363734.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. Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southernhay Retirement Home Address Second Drive Landscore Road Teignmouth Devon TQ14 9JS 01626 773578 01626 772834 southernhay2002@yahoo.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs 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 DS0000038524.V363734.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd December 2007 Brief Description of the Service: Southernhay is registered to provide accommodation and care for a maximum of twenty people who are elderly and people who have dementia. The home is situated in a quiet residential area of Teignmouth and is less than a mile from the town centre, beach and railway station. Information about the service can be obtained from the service provider in a Statement of Purpose and a Service Users Guide. Copies of inspection reports are available on request from the home and/or can be found on the CSCI Website. The current fees range from £381 to £420 a week. Extra is charged for professional hairdressing, chiropody and items of a personal nature. Southernhay Retirement Home DS0000038524.V363734.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. The information contained in this report was gained in conversation with the owner/manager, staff and people who use the service during a visit to the home and from an inspection of the premises. Information was also gained from documents, including the homes Statement of Purpose, Service Users Guides, Annual Quality Assurance Assessment (AQAA) and records, including samples of the residents needs assessments and care plans, staff rotas and staff recruitment and training records. What the service does well: What has improved since the last inspection? The Service Users Guides have been revised to include individual terms and conditions/contracts and details of the fees and methods of payment and the rest are in the process of being amended. Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 6 By revising the assessment and care planning practices and involving the care staff in these processes through the introduction of a key worker system, considerable improvements have been made in identifying and recording the residents individual needs. The home has switched to a pharmacy controlled system to order, administer and record medication. Information about medicines used and possible side effects have been included in the medication records. All complaints are now being recorded. Staff supervision, the identification of the staffs training needs and the provision of staff training have all improved considerably since the last inspection, although there are still some gaps in training. A system has been put into place to ensure that the staff familiarise themselves with the policies, procedures and codes of practice of the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Quality in this outcome area is good. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Several of the residents Service Users Guides were seen to have been amended since the last inspection and now include their contracts, terms and conditions of residence, individual fees and methods of payment. When these have been given to the residents they will provide them with the information they need about the service provided. The owner/manager said that the homes Statement of Purpose was in the process of being updated and was reminded that she will need to send a new copy to the Commission following this amendment. Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 9 The assessments of the two most recently admitted residents were seen. Both need further work to fill in some gaps in the information collected, but the quality of the information gathered was seen to be sufficient to enable the owner/manager and staff to identify the residents individual needs and develop plans of care to meet their needs. Although there are still gaps in the care staffs training, records seen and conversation with the owner/manager and staff provided evidence that significant improvements have been made in both the identification of the staffs training needs and in meeting these needs (see ‘Staffing’). Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. The health and personal care that people receive is based on their individually assessed needs. Safe practices are used to administer medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual plans of care are kept in files in the office. The method of presenting information has improved considerably since the last inspection and this clarity enables the staff to access the information they need quickly and efficiently. The owner/manager has introduced a key worker system and conversations with the care staff demonstrated that they are enjoying the added responsibility of being directly involved in the care planning and reviewing the residents needs. Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 11 Although there are still gaps in the care staffs training, records seen and conversation with the owner/manager and staff provided evidence that significant improvements have been made in both the identification of the staffs training needs and in meeting these needs (see Staffing). The health care needs of the people who use the service are being monitored and evidence of this was seen in their care plans. Timely referrals are being made to professional health care services as and when necessary. Since the last inspection the home has switched to a pharmacy controlled system of ordering, administering and recording medication. The blister packs and records of administration were inspected and found to be accurate and up to date. Individual information sheets have been inserted into the record book, which identify what each item of medication is needed for and possible side effects. This is recognised as good practice as it enable the staff to identify any problems in use that could indicate that an individuals medication may need to be reviewed. The owner/manager and her staff were observed interacting well with the people who use the service. However, more could be done to ensure that the privacy of the people who use the service is respected by ensuring that they have safe access to and from their bedrooms during the day and that the bedrooms provide a safe and comfortable alternative to the communal sitting room if and when the residents want to spend time alone. One resident was seen using another persons bedroom and en-suite facilities, this is an invasion of the privacy of the people who room it is and should be discouraged. Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. Activities are provided to ensure that the people who use the service are able to participate in exercise and social activities if they choose to do so. The people who live at the home are provided with good quality home cooked meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home its own transport facilities with wheelchair access to enable the residents to be taken out individually or in groups. Conversations with the owner/manager and staff indicate that trips out to enable the residents to enjoy exercise and a change of scenery do take place but could be offered more frequently. The arrangements for residents to invite their visitors into their home are open and several visitors were seen during the site visit. The owner/manager said Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 13 that most of the residents have family members living locally and those who do not are helped to maintain contact by phone. Some indoor activities are lead by the care staff and these include communal singing, quizzes, craft workshops and softball. ‘Tranquil Moments’ visit fortnightly to lead music sessions and a group of belly dancers visit on the alternate weeks to provide exercise and activities for the residents. None of the residents attend church services but the owner/manager said that a curate calls at the home to provide services for the residents. Most of the residents have television sets in their bedrooms and there are also televisions and radios in the lounge. The home has a full time cook who prepares cooked dinners, home made puddings and home made cakes on the premises. The cook said that she had recently attended training courses on ‘Food for Special Needs’ and ‘Healthy Eating for the Aging’. The set menu for the day is displayed in the residents lounge and does not offer choices, although the cook said that alternatives to the set meal would be provided on request. The home is currently catering for three people who have diet controlled diabetes and the cook said that she was not experiencing any difficulties in meeting their dietary needs. Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. The people who use the service are able to express their complaints and concerns and, although some additional training is needed, policies and procedures are in place to protect people from the threat of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is included in the Service Users Guides and displayed in the entrance hall. A record of complaints was seen which demonstrated that complaints are listened to and taken seriously. Policies and procedures are in place to protect the residents from the threat of abuse and the staff are reading and recording that they have read them and understood their content. This is recognised as good practice. The provision of staff training has improved and although not all of the staff have received training in safeguarding/adult protection, arrangements are in place for this training to be provided (see Staffing). Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 & 26 Quality in this outcome area is adequate. A good standard of cleanliness is maintained throughout the home. The communal areas are comfortably furnished but some of the bedrooms need attention to bring them up to a satisfactory standard and to offer a safe and accessible alternative to the communal lounge. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A visual inspection was carried out of all of the rooms occupied or used by the residents and the standard of cleanliness maintained throughout the home was seen to be of a good standard. The inter-connecting communal rooms are attractively presented and comfortably furnished. Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 16 Most of the residents have single bedrooms with en-suite toilet facilities. There are three double bedrooms and screens are provided in these to provide some privacy for the residents. All of the bedroom doors are lockable and radiators had been fitted with covers to ensure that the residents could not scald themselves. It was observed that the presentation of some of the bedrooms is poor and that they do not provide a safe and comfortable alternative to the communal areas for the residents to use during the day. To meet this standard attention is needed to ensure that all of the bedrooms are comfortably furnished and that each resident has a bedside table, bedside or over bed light, a comfortable chair, a table to sit at, a call bell that is accessible from their bed and from their easy chair and a lockable storage facility. One resident was observed using another residents ground floor room because she could not access her own, which is on the first floor, independently. Although a stair lift is provided, risk assessments need to be carried out to ensure that residents with bedrooms on the first floor can access their rooms safely using either the stair lift or the stairs. For their personal safety, residents who cannot manage the stairs or stair lift independently and would be unable to call for assistance using their call bell should be offered ground floor bedrooms as and when they become available. The laundry facilities meet the needs of the home. Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. The staffing levels are maintained at a level that is high enough to meet the needs of the residents and most of the care staff have or are working towards gaining National Vocational Qualifications. There are still gaps in the provision of staff training but these are being filled. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff rota was seen and provided evidence that the staffing levels are high enough to meet the needs of the residents. There are usually three or four care workers on duty during the day and two care workers on duty at night. Two cooks and two housekeepers employed. The owner/manager works at the home on a fully time basis, as does her partner, who deals with the maintenance of the house and garden and assists with the computer work. The Annual Quality Assurance Assessment completed by the owner/manager states that safe practices are being used to recruit new staff to ensure that unsuitable staff are not employed to work with the residents. An inspection of the records for a person recently interviewed for the post of care worker Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 18 indicated that full checks and references were being taken up before she would be employed to work with the residents. Conversations with the owner/manager and staff identified that over half of the care staff had completed or were working towards completing their National Vocational Qualifications in Care at Levels 2 and/or 3. Previous inspections have highlighted shortfalls in the provision of staff training and although there are still some gaps in the training provision, conversations with the owner/manager and care staff and an inspection of records provided evidence that the owner/manager and staff have been working hard to make up this shortfall. Good progress is being made and the staff who were interviewed said that they were enjoying the training they were undertaking and felt that they had learned a lot from it. Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. The owner/manager has responded well to previous requirements and recommendations and made significantly improvements to the management and administration of this home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered service provider is also the manager of the home. She has completed an NVQ at Level 4 in Care and Registered Managers Award. Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 20 The owner/manager has taken on board most of the requirements, recommendations and comments made during previous inspection and in previous inspection reports and this has lead to significant improvements being made in the running of the home. This is most notable in the care planning, which is now shared by the owner/manager and the staff, in the provision of staff training and in the provision of one to one staff supervision, which is now being carried out monthly. Conversations with five of the care staff indicated that they are enjoying their additional responsibilities regarding care planning and their roles of key workers, which enables them to form a better understanding of the needs of the residents. The owner/manager said that two of her care staff had been identified as senior care workers to enable them to be in charge when she was not working at the home. There is still no quality assurance or quality monitoring system in place. The owner/manager hold some personal spending money for people who use the service. Very clear records were seen of this and money spent or used on behalf of people was double signed and regularly audited. There is, however, a need to ensure that receipts are obtained and kept for items purchased for the residents. The Annual Quality Assurance Assessment identified that there are some gaps in the homes policies and procedures and that some policies and procedures need updating. However, signed and dated records and conversations with the owner/manager and four of the care staff provided evidence that the staff are reading the homes policies and procedures and keeping records which identify when they have read them. One member of staff said that she had been surprised at the amount of information contained in these and felt that she had learned a lot from them. Records provide evidence that mobility equipment, fire detection and fighting equipment, the call bell system, heating systems and gas appliances are regularly serviced. Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 2 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 2 X X 2 Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 22 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 OP1 Regulation 5(2) Requirement The registered provider must give each of the people using the service their Service Users’ Guide. Previous timescales 5/02/08 & 13/04/08 not met. 2. OP1 4 The Statement of Purpose must be updated, made available to the residents and visitors to the home and sent to the Commission so that up to date information about what the home provide is easily available. The registered provider must respect the privacy of the residents by ensuring that they can safely access and use their own bedrooms during the day if they wish to do so. The registered provider must ensure that the bedrooms are adequately furnished and can be accessed safely by the residents at all times. 28/06/08 Timescale for action 28/06/08 3. OP10 12(4)a 28/07/08 4. OP24 12(4)a, 16(2)c, 23(2)f & 23(2) m. 28/07/08 Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 23 5. OP30 18(1) The registered provider must continue to arrange staff training to fill the gaps in training provision. A quality monitoring system must be developed. Previous time scales 31/12/06, 16/02/07, 31/10/07, 05/02/08, 13/04/08 Not met. 28/11/08 6. OP33 24 28/08/08 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. Refer to Standard OP1 Good Practice Recommendations To ensure that the Commission has up to date information about the home and the service provided a copy of the Homes Statement of Purpose should be sent to the Commission whenever this document is updated. A clear record should be kept of the collective and individual training needs and achievements of the staff. When purchasing items for residents from their personal money, receipts should be obtained and kept. The manager should continue to update the homes policies and procedures and provide policies and procedures where she has identified these as missing in the AQAA, unless they refer exclusively to nursing care. 2. 3. 4. OP30 OP35 OP38 Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 24 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 Southernhay Retirement Home DS0000038524.V363734.R01.S.doc Version 5.2 Page 25 - 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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