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Inspection on 03/12/07 for Southernhay Retirement Home

Also see our care home review for Southernhay Retirement Home for more information

This inspection was carried out on 3rd December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The registered provider and staff treat the people who use the service with affection and respect. The people who use the service are invited to participate in activities provided by the staff and by outside entertainers. These activities benefit the people who use the service by providing physical or mental stimulation. The people who use the service are encouraged to maintain contact with their families and friends and visitors are welcome at any time. The meals provided are good. In addition to having home cooked dinners with fresh vegetables, the people who use the service are also offered home made puddings and cakes. The complaints procedure is accessible to the people who use the service and their representatives. The home is kept clean by dedicated domestic staff and most of the rooms are well decorated and comfortably furnished.

What has improved since the last inspection?

Improvements have been made to the recording of daily events.Since the last inspection the registered provider has purchased a minibus with wheelchair access so that the people who use the service can be taken out more easily. There has been an increase in the number of staff who have achieved or are working gaining a National Vocational Qualification in Care at Levels 2 and 3. An induction training programme is now in place which meets the specifications of Skills for Care. The home is now notifying the Commission of deaths, accidents and significant events affecting the people living there. Improvements have been made to the recording of personal money held for safekeeping by the management.

What the care home could do better:

The people who use the service need to be given Service Users` Guides containing a contract and statement of terms and conditions. This is to enable them and their representatives to know what they should expect from the service providers. Care planning, including risk assessments and reviews need to be more detailed and the care staff should be made aware that these documents should be used to provide guidance on how to meet the needs of the people who use the service. The care staff need up to date training in Safeguarding/the Protection of Vulnerable Adults and encouragement to read the policies and procedures that relate to this. Although the premises are by and large satisfactory, there are some safety issues that need to be dealt with. Staff training, staff management and staff supervision are all areas that have been identified in this and previous reports are being areas in need of improvement. Although some improvements have been made, these issues continue to be of concern. The management and administration of this service is poor.

CARE HOMES FOR OLDER PEOPLE Southernhay Retirement Home Second Drive Landscore Road Teignmouth Devon TQ14 9JS Lead Inspector Judy Hill Unannounced Inspection 09:55 3 & 5 December 2007 rd 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.V354081.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.V354081.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.V354081.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th August 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 £372 to £400 a week. Extra is charged for professional hairdressing, chiropody and items of a personal nature. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out by one inspector over two days. The information contained in the report was gained from conversations with the registered provider and staff and from direct and indirect observations of the premises and the interaction between the staff and the people who use the service. Additional information was gained from an inspection of the records about the people who use the service, including the needs assessments, care plans, risk assessments and reviews and from staff training and recruitment records. Further information was taken from the report of the inspection carried out on 7th August 2007, the Service Users Guide and the Statement of Purpose. What the service does well: What has improved since the last inspection? Improvements have been made to the recording of daily events. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 6 Since the last inspection the registered provider has purchased a minibus with wheelchair access so that the people who use the service can be taken out more easily. There has been an increase in the number of staff who have achieved or are working gaining a National Vocational Qualification in Care at Levels 2 and 3. An induction training programme is now in place which meets the specifications of Skills for Care. The home is now notifying the Commission of deaths, accidents and significant events affecting the people living there. Improvements have been made to the recording of personal money held for safekeeping by the management. What they could do better: The people who use the service need to be given Service Users’ Guides containing a contract and statement of terms and conditions. This is to enable them and their representatives to know what they should expect from the service providers. Care planning, including risk assessments and reviews need to be more detailed and the care staff should be made aware that these documents should be used to provide guidance on how to meet the needs of the people who use the service. The care staff need up to date training in Safeguarding/the Protection of Vulnerable Adults and encouragement to read the policies and procedures that relate to this. Although the premises are by and large satisfactory, there are some safety issues that need to be dealt with. Staff training, staff management and staff supervision are all areas that have been identified in this and previous reports are being areas in need of improvement. Although some improvements have been made, these issues continue to be of concern. The management and administration of this service is poor. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 7 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.V354081.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Quality in this outcome area is adequate. The people who use the service and their representatives do not have the information they need to make an informed decision about whether the service will be able to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Copies of the homes Statement of Purpose and Service Users’ Guide were sent to the Commission and Mrs Crook (the registered service provider) confirmed that these were current. Mrs Crook said that the people who use the service had not been given a Service Users’ Guide and contracts, which should be included in the Service Users’ Guides, were not seen on in the individual files of the people who live at the home. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 10 On the first day of the inspection the needs assessment of the most recently admitted service user was requested but this was not at the home. On the second day of the inspection the assessment was seen. This needs assessment and that of another service user were seen to be basic but to contain the information needed as a basis for care planning. The provision of staff training in dementia care was discussed with Mrs Crook and with the staff on duty. Two of the staff spoken with said that they had received a half days training approximately two years ago. Mrs Crook said that she had obtained a DVD, CD and worksheets from the Alzheimer’s Society with a view to providing additional training. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. Care planning and areas of staff training need to be improved to ensure that the needs of the people who use the service are safe and well cared for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for two of the service users were seen, although one of these was requested but not available on the first day of the inspection. The information provided in the care plans was good, but further work is needed to ensure that all of the individual needs of the people who use the service are included. There was some evidence that individual risk assessments had been carried out and that consideration had been given to reducing risk. However, not all areas had been covered. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 12 Four care workers were interviewed during this inspection and it was apparent that the staff do not regularly refer to the care plans for guidance on how to meet the individual needs of the people living at the home and two of the staff interviewed did not appear to understand what a care plan was. All of the staff spoken with said that they read the daily records on a regular basis and shared information verbally during changes of shift. The people who use the service were observed to be clean and well dressed which indicates that they are receiving the help they need to maintain their personal hygiene. Evidence was seen to indicate that professional healthcare services are contacted in a timely manner as and when necessary. On the site visit the smell of urine could be detected in a small number of bedrooms. This could indicate that methods of continence control could be improved and it is therefore recommended that training is provided. One of the people using the service had developed a pressure sore and was being treated by a District Nurse. A member of staff said that this lady was being turned every three hours and the Mrs Crook said that she was planning to provide training for the staff on tissue viability. This should ensure that preventative measures could be used in the future. Several jars of cream were seen in the communal bathrooms. Most of these had not been prescribed for a named service user and Mrs Crook confirmed that she had bought them over the counter. The danger of cross infection from the communal use of creams and gels was discussed with Mrs Crook and the creams were removed during the inspection. Several of the beds had been fitted with cot sides. Although Mrs Crook demonstrated an awareness of the dangers of using cot sides and had carried out her own risk assessments, this had not been done as part of a multidisciplinary risk assessment with the district nursing service and care managers. None of the people using the service are able to administer their own medication. The staff administering medication had received training to do so. The home does not use a pharmacy controlled system to order, administer and dispose of medicines and it is suggested that consideration is given to changing to such a system as it would enable Mrs crook to carry out regular safety checks to ensure that medication was being given appropriately. The storage of medicines was found to be satisfactory and separate storage facilities are provided for controlled drugs. No information was seen with the medication administration record sheets to identify what each item of medication is prescribed for and/or possible side effects that the staff need to be aware of. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 13 It was observed that Mrs Crook and the staff treat the people who use the service with dignity and respect. Examples of this observed during the site visit include the practice of knocking on bedroom doors before entering bedrooms and talking kindly and gently to the people who use the service. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 14 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: Outside entertainers are used to work with the people who use the service and regulars include a group of belly dancers and Tranquil Moments. Mrs Crook and the staff interviewed said that they provide activities most afternoons and on the second day of the inspection the registered provider and staff were observed dancing with the people who use the service. The people who use the service were seen to be enjoying this group activity and even some of Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 15 those who could not get up and dance were tapping their feet in time to the music. Since the last inspection Mrs Crook has brought a mini bus and she and the staff said that the people who use the service are regularly taken out for short drives. The staff said that they also take the people who use the service out for short walks occasionally. The people who use the service continue to exercise choice in many aspects of their lives and can get up, go to bed and use their bedrooms as and when they choose. The Statement of Purpose states that visitors are welcome at any time but the Service Users’ Guide states that restrictions are imposed. This was discussed with the registered provider who said that the information in the Service Users’ Guide was incorrect and that it would be amended. The need to improve record keeping to provide evidence that the social, occupational and recreational needs of the people who use the service is considered as part of their individual needs assessment and care planning was discussed with the registered provider, as was the need to record daily activities and choices. The quality of the meals seen being prepared was very good. The cook said that she enjoys baking and home made chicken pie, freshly prepared vegetables, cakes and puddings looked excellent. There is currently a vacancy for a cook for two days of the week, but temporary cover has been provided. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. 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 displayed in the hall of the home and included in both the Statement of Purpose and Service Users’ Guide. Three members of staff were asked if they would know what to do if they received a complaint from a person using the service or a visitor to the home and all of them said that they would report the matter to their manager if they could not put matters right themselves. The home has a log book to record complaints in but this had no entries in it. The Mrs Crook said that she had not received any complaints and it was suggested that she re-evaluate her understanding of a complaint and include any concerns raised by the people who use the service and their representatives. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 17 The Annual Quality Assurance Assessment completed by Mrs Crook for the key inspection of August 2007 identified that the home had policies and procedures in place to safeguard the people using the service. Three members of staff were asked it they had read these procedures and said that they had not done so. Four members of staff were asked if they had received training on the Protection of Vulnerable Adults. All of them said that they had. The registered provider said that some of the staff had not received this training and that she had purchased a DVD and worksheets from the Alzheimer Society enabling updated training to be provided. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 18 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 & 26 Quality in this outcome area is adequate. Overall the premises are well presented and provide the people who live at Southernhay with a comfortable home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home was carried out as part of the site visit. The communal rooms consist of two lounges and a dining room, which are linked by open accesses to make them easily accessible to the people who live at the home. These rooms were seen to be pleasantly decorated and furnished and homely and informal in appearance. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 19 Some of the bedrooms seen were very well presented, while others would benefit from refurbishment. Most of the bedrooms have en-suite facilities and those that do not have communal toilets close to them. It was noted that a small number of bedrooms smelt of urine, this does need to be dealt with, if necessary by the replacement of carpets and treatment of floorboards. The bathrooms were seen to be adequate for the needs of the home and to be provided with hoists to enable them to be used safely by the people who use the service and to protect the staff assisting them. There is a shower room on the first floor. This provides a valuable facility for the home but consideration should be given to replacing the folding door with a proper door that can be locked from the inside for privacy. It was observed that some of the call bells in the bedrooms were not accessible from the beds. The registered provider said that not all of the people who use the service are able to use a call bell. Where this is an issue individual risk assessments should be carried out to assess what other systems could be used to enable the person to access help when necessary. Bedrooms are arranged on the ground floor, a mezzanine level that is accessible by stair lift and on the first floor that is accessible from the mezzanine level by a small flight of stairs. Individual risk assessments need to be carried out to ensure that the people occupying rooms on the mezzanine level and first floor can manage the stair lift and stairs safely. The gardens are accessible from the communal rooms, however the exit from the dining room was blocked. The safety of a decking area immediately next to the home was discussed as this can become very slippery when wet. The registered provider said that she was considering replacing the decking with non-slip tiles. The laundry facilities were seen to be adequate for the needs of the home. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. The provision of training is insufficient and staff are not deployed or supervised in a way that meets the needs of people who live at the home. Staff recruitment practices are not robust. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The recruitment records of three of the staff were inspected. Application forms were seen for all three staff, however one of them had not been filled in beyond the first page and so contained no information about the applicant’s employment history or qualifications. No records of interviews were seen. Criminal Record Bureau and POVA First checks had been received for all three applicants. Two of the staff files contained two references each while one contained only a single reference. Four members of staff were asked about their training and qualifications. One said that she was working towards gaining a National Vocational Qualification at Level 3 in Care. One said that she had achieved an NVQ in Care at Level 2 and two said that they were working towards gaining this qualification. The Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 21 registered provider said that most of the care staff had either achieved or were working towards gaining an NVQ. The registered provider has produced a form to record the staffs training needs and achievements but this had not yet been used. The staff who were interviewed identified the training that they had received and the provision varied considerably. There were gaps in the provision of health and safety related training, including Moving & Handling, Infection Control, Health & Safety and the Protection of Vulnerable Adults (Safeguarding). All of the service users have dementia but only two of the staff had received any training on dementia care. Feedback from the staff indicates that this training was provided over two years ago and was not sufficiently in depth for staff working in a home that caters exclusively for people with dementia. The home has a manual that provides worksheets for induction training. Some completed induction training records were seen but these were not kept in an organised manner and no evidence was seen to indicate that foundation training had followed. The staff rota did not identify any of the care staff as being senior staff. This was discussed with the registered provider who confirmed that she did not have any senior care workers and that when she is not on duty at the home no one is left in charge. The hours worked by the registered owner/manager are not included on the staff rota. Two domestic staff are employed and between them they provide between two are six hours a day cover. This was assessed as being adequate for the needs of the home. One cook is employed for seven to eight hours a day five days a week and a vacancy exists for a cook on the two remaining days. The registered provider said that she and her partner, who is also employed at the home to deal with maintenance, are currently covering the cooking duties on the two remaining days. The rotas show that care staffing levels vary from two on duty from 6pm to 8am and between three and four on duty at other times of the day. Some of the staff are working twelve hour day shifts and consideration should be given to reducing this as they could become over tired. All of the people who use the service have a high level of need and the registered provider does need to demonstrate that sufficient staff are on duty at all times to enable them to meet their needs. On the first morning of the site visit this was not considered to be the case. This was evidenced by the length of time it took the staff to answer the front door and by the lack of any supervision in the lounge for the people who were sitting in there. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is poor. The management and administration of the home is poor. Staff supervision and training is also poor. A quality assurance programme is not used to plan improvements. 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 said that she had recently finished her Registered Managers Award and was waiting for it to be signed off. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 23 The registered provider is clearly very caring and demonstrated this through her interaction with the people using the service and the staff. She did, however, acknowledge that she finds it difficult to cope with the administrative duties and this was evidenced by the poor quality of the care planning and other records seen at the home. Other areas of concern include a lack of regular formal (one to one) staff supervision, although the staff interviewed said that the manager was approachable and supportive on an informal basis. The absence of any senior staff means that the registered provider is leaving the home and the staff without any named person in charge when she is not there. The registered provider said that there is no quality monitoring or quality assurance system in place. The registered provider does hold some personal spending money for some of the 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. The Annual Quality Assurance Assessment that was completed by the registered provider for the last key inspection identifies that the home has the written policies and procedures needed. Conversations with two members of staff indicated that they did not know where these are kept and that they have not read or referred to them. The servicing of the boiler was found to be overdue by one month. Records showed that the fire alarms are being tested weekly and that fire safety training is being provided on a regular basis. Servicing of the hoists, stair lift and portable appliances was up to date. Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 24 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 1 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 1 X 2 Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 25 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 provide each of the people using the service with a Service Users’ Guide. The Service Users’ Guide must contain the terms and conditions in respect of accommodation to be provided including as to the amount and method of payment of fees and a standard form of contract for the provision of services and facilities by the registered provider for service users. Needs assessments for each of the people who use the service must be kept at the home at all times. The registered provider must ensure that the staff receive training in dementia care to ensure that they have the necessary skills to meet the needs of people with dementia. The residents care plans, daily DS0000038524.V354081.R01.S.doc Timescale for action 05/02/08 2. OP2 5(1) b & c 05/02/08 3. OP3 17(1) a 1 05/01/08 4. OP4 18(1) c 05/02/08 5. OP7 15(2) 05/02/08 Page 26 Southernhay Retirement Home Version 5.2 records and risk assessments must be reviewed and updated to accurately reflect the individuals current levels of need. Previous time scales: 10/10/05 30/08/06 16/02/07 15/08/07 6. OP7 12(1) a & b To promote and make proper provision for the health and welfare of the people who use the service, the registered provider must ensure that the staff use the care plans. To provide and make proper provision for the health and welfare of the people who use the service, the registered provider should: (a) Arrange for the staff to receive training on tissue viability. (b) Arrange for the staff to receive training on continence control. (c) Carry out risk assessments with the District Nursing Service and Care Managers regarding the use of cot sides. Although this issue was dealt with during the inspection, the registered provider must ensure that the staff are aware that the communal use of creams and gels seriously increases the risk of the spread of infection. The registered provider must provide up to date training on Safeguarding Adults and ensure that the staff have read and DS0000038524.V354081.R01.S.doc 05/01/08 7. OP8 12(1) a & b 05/02/08 8. OP9 13(3) 05/01/08 9. OP18 13(6) 05/03/08 Southernhay Retirement Home Version 5.2 Page 27 understand the policies and procedures relating to Adult Protection. 10. OP19 13(4) a The registered provider should ensure that the wood decking in the garden is treated so that it is not slippery when wet. The registered provider should carry out individual risk assessments to provide evidence that consideration is given to the safety of the people allocated bedrooms above ground floor level. 11. OP27 18(1) a Staffing must be maintained at the agreed level, in particular at weekends. Previous timescales 30/08/06 16/02/07 15/08/07 The registered person must ensure that the staff are appropriately supervised at all times by ensuring that there is always a named member of staff in charge when she is not at the home. The registered person must obtain two written references before employing new staff. All staff must be up to date with First Aid and Moving and Handling training. Previous timescales 31/10/06 16/02/07 31/10/07 05/02/08 05/02/08 12. OP27 18(2) 05/02/08 13. OP29 18(1) 05/01/08 14. OP30 13(5) 05/02/08 15. OP30 18(1) All staff must receive recognised 05/02/08 and certificated training in meeting the needs of people with DS0000038524.V354081.R01.S.doc Version 5.2 Page 28 Southernhay Retirement Home dementia. Previous time scales 31/12/06 16/02/07 31/10/07 16. OP33 24 A quality monitoring system must be developed. Previous time scales 31/12/06 16/02/07 31/10/07 All care staff must receive individual supervision sessions at least six times per year. Previous time scales 31/12/06 16/02/07 31/08/07 The registered provider must arrange for the boiler to be serviced annually. The registered provider must ensure that all of the staff know where the homes policies and procedures are kept and read those that relate directly to the safety of the service users and safe working practices. 05/02/08 17. OP36 18(2) 05/02/08 18. OP38 23(2) p 05/01/08 19. OP38 12, 13 & 18 05/02/08 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 OP9 Good Practice Recommendations Consider using a Pharmacy controlled system to order, administer and dispose of medication as this would ensure that regular checks can be made to ensure that the DS0000038524.V354081.R01.S.doc Version 5.2 Page 29 Southernhay Retirement Home medication is being administered safely. It is recommended that a list of what each item of medication is used for and possible side effects that the staff need to look out for is kept with the medication administration record sheets. 2. OP13 The information on visiting in the Statement of Purpose should be amended as it implies that restrictions are imposed when they are not. A record should be kept of minor concerns, and any action taken in response. The door to the shower room can be locked from the inside and that action is taken to remove the smell of urine in some of the bedrooms by cleaning or replacing existing carpets and treating or replacing floor boards if necessary. New staff should be required to complete an application form fully as this provides evidence of their employment history and qualifications. Records should be kept of staff interviews. A clear record should be kept of the collective and individual training needs and achievements of the staff. 3. 4. OP16 OP19 5. OP29 6. OP30 Southernhay Retirement Home DS0000038524.V354081.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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.V354081.R01.S.doc Version 5.2 Page 31 - 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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