CARE HOMES FOR OLDER PEOPLE
Southernhay Retirement Home Second Drive Landscore Road Teignmouth Devon TQ14 9JS Lead Inspector
Sharon Goldsworthy Unannounced Inspection 7th August 2007 09:25 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.V344553.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.V344553.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 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.V344553.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last key inspection 28th June 2006 Brief Description of the Service: Southernhay is a detached house in a quiet residential area, a little more than half a mile from Teignmouth town centre. It caters for people aged sixty-five and over, and the service is designed for people with a dementia. The home has two lounge areas, and a small conservatory adjoining the dining room. There are twelve single rooms, three double, and all but two have an en suite WC. There is a stair lift to the first floor. There is a pleasant enclosed garden to the rear, and a small patio and car parking area at the front. Fees are currently £363 per week. A copy of the last inspection report can be obtained from the owner/manager on request. Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Since the last key inspection in July 2006, two further random inspections have taken place in January 2007 and July 2007. This inspection took place over two days (7th and 10th August 2007) over a period of nine hours and covered all of the key standards. Time was spent with staff, people living in the home, the owner/manager; a tour of some of the premises was conducted; a sample of records were observed and a two hour detailed observation of four persons in the main lounge was conducted as part of this inspection visit. Surveys were received from three staff members and an Annual Quality Assurance Assessment completed by the owner/manager. What the service does well: What has improved since the last inspection?
The owners have continued to improve the décor of the building, with the ongoing decoration and refurbishment of the bedrooms, bathrooms and main communal rooms. They have completed a room which is now used for clean laundry drying and ironing, which keeps this separated from soiled laundry. Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 6 Two written references are now obtained for any prospective employee before they start work in the home. The owner/manager has now obtained the Alzheimer’s Disease Society Guidelines and Standards for Older People in care homes, which she intends to share with the staff team as a means of improving care practice and as an inhouse training opportunity. What they could do better:
Care plans and daily records are not as detailed as required in order that they inform the care giver of the exact level of assistance or support required at any one time. Daily records had lines left between each entry which creates the opportunity of records being added to at a later date and therefore leaves the home open to legal challenges should the need for such records be required in a court of law for example. The level of interaction between staff and people living in the home needs to be monitored and improved upon. In a two hour observation, the level of interaction was observed to be minimal and was only in relation to care related tasks. The layout of the communal rooms does not allow for staff to give discreet attention to those people requiring assistance with beverages, unless they are moved to another room. A member of staff was observed leaning over an individual giving assistance with a cup of tea, where if room had been allowed, they would have been able to sit discreetly next to the person. The level of activity offered to individuals and to the groups of people sitting in the lounges, could be improved upon. During the two hour observation, no level of activity or social stimulation took place, with the exception of care related tasks. Activity records record what the group activity was and who attended, but does not record the outcome for the participants and cannot therefore be used for evaluation purposes. The complaints book was blank. There is no record of any informal complaints, suggestions or comments brought to the attention of the manager. As such the owner is unable to demonstrate or evidence that all complaints are taken seriously and dealt with appropriately. The owner was unsure as to whether they have a copy of the new adult protection national policy and guidelines and therefore it can be assumed that this document is not currently available to all staff. It is important that all staff are aware of this policy and know where to find it in the event of an allegation of abuse being made known to them and that all staff receive training in this topic.
Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 7 The staff rota indicated that staffing levels remain low, in particular at weekends when only two care staff are on duty. The manager herself was covering for the cook, whilst on planned leave, and indeed carries out all kitchen duties every weekend. This level of staffing has led to the owner/manager not carrying out and concentrating on management tasks and can lead to people living in the home not receiving an appropriate and safe level of care, in particular at weekends. Two staff have NVQ training, whilst another three have enrolled on NVQ training. This is a low percentage of staff with NVQ qualifications and needs to be improved upon. Whilst new staff have received the basic induction training, the manager has not completed the foundation skills for care as part of their extended induction training. Only two staff have completed manual handling training, first aid training is out of date and staff have only received very basic dementia care training. This means that staff do not currently have the appropriate level of skills or competencies in meeting the needs of people living in this home. Some staff have received supervision with the owner/manager, but for some this was some months ago, and is not an ongoing programme. This therefore does not give the staff the opportunity to discuss personal training needs or objectives and does not formally give the owner/manager an opportunity to discuss any issues or development needs with them either. Although a quality assurance auditing system has been purchased and updates have been obtained in recent weeks, it has not been implemented as yet. This means that there is currently no formal process in place by which people living in the home, staff, relatives and other stakeholders are consulted about their views of the home. Records are in place for monies held on behalf of people living in the home. However, the manager is the only person signing for all transactions. This is not safe practice for either the manager or for the full protection of the individuals’ whose monies it is. A wheelchair was observed to be in use without footrests fitted first thing in the morning of this inspection. This was placing the individual using this chair at risk of injury. Staff practices in relation to manual handling were unsafe for both themselves and for the persons they were lifting. This evidenced that all staff present on the day of this inspection were in need of certificated manual handling training. Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 8 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.V344553.R01.S.doc Version 5.2 Page 9 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.V344553.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is adequate. Appropriate assessments are carried out prior to prospective persons being offered a place in the home. However, staff are not sufficiently trained to meet the needs of the current resident group. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of four records were observed as part of this inspection visit. There is evidence of the manager carrying out appropriate assessments with prospective persons wishing to move into the home. These visits have been carried out at the person’s previous address. There is evidence of the placing authority’s care plan/assessment of need also on file, which forms part of the manager’s assessment process. The staff team have all attended a two hour information session in relation to dementia care. However, none have attended any formal or certificated training in this area. From observations and discussions with staff at this inspection visit, it is evident that all staff require this level of formal training if they are to sufficiently care and offer a higher level of service to the current and any future persons moving into the home.
Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 11 The manager has very recently purchased the Alzheimer’s Disease Society good practice guidance for care homes and hopes to introduce this to the staff with an aim to improve the level of service offered to this particular client group. Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is adequate. Individuals health and personal care needs are met and individuals are treated with dignity and respect. Records pertaining to individuals’ needs have continued to lapse over the last year. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of four care records were observed at this inspection visit. An additional five were observed at an inspection on the 9th July 2007. The care plan system in use is clear and easy to read and to this end should be an easy tool for staff to use. Whilst all persons living in this home had a care plan in place, not all gave an accurate picture of the individual’s current level of need. There are no signatures or dates at the bottom of the care plans and as such it is difficult to determine exactly when the care plans were written and by whom. There are good review records in place and in the main most have been reviewed on a monthly basis up until January or February 2007. The level of recording in care plans need to be more detailed in the description of the individual need. For example, the documents very often state “need helps with dressing, washing, toileting”. This does not give the care staff the sufficient level of information with which to give or support care.
Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 13 Daily records are very task orientated and do not reflect the level of care or support given or of the individuals state of mind or emotional well-being. There is insufficient detail following GP visits for example…with only a recording of “GP visited” – but not stating the outcome of this visit, or any monitoring or follow up in daily records on the days following this. These records were improved upon directly following the last inspection visit of the 7th July 2007, but within two weeks had reverted back to the previous level of recording, which is very task orientated and for many just states that the individual has had “a good day”. With four sets of records viewed there were gaps left between each entry, which creates the opportunity of records being added to at a later date and therefore leaves the home open to legal challenges should the need for such records be required in a court of law for example. People living in the home were observed to be in clean clothing, with hair neat and well groomed, nails clean and gentlemen cleanly shaven. A member of staff was observed offering to help one lady with make-up. One member of staff was observed taking a lady to the dining area and blow drying her hair after having it washed a little while earlier. Records indicate that access to health care professionals is obtained on a regular basis as required. District nurses visit some people on a regular basis and staff and the manager were very aware of the visit and outcome. There is obviously good communication between the two for the benefit of the individual’s. Staff were observed knocking on doors before entering and offered assistance with personal care needs with dignity and sensitivity. Medication was found to be stored, administered and recorded appropriately and safely. All staff responsible for the administration of medications has received training. The procedure was on display for staff to consult. No persons living in the home have been assessed as being capable of selfadminister their medication. There was a suitable safe system for administering Controlled Drugs, if needed. There was a lockable fridge for the storage of certain medications required to be at a refrigerated temperature. Southernhay Retirement Home DS0000038524.V344553.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): Quality in this outcome area is adequate. People living in the home can expect a basic level of social stimulation, but this is not at a level that meets everyone’s needs and is not tailored or specific to good dementia care practice. People living in the home can expect a good variety and choice of good meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home are supported in maintaining control over their lives with the options of getting up when they wish and retiring to bed when they wished, spending time in their rooms during the day if they wish or spending time with others in the main communal rooms. With staffing levels as they are the majority of the mornings are taken up with personal care and house keeping tasks. During a two hour observation in the communal room, there was little staff interaction with people, with the exception of assistance given with personal care tasks, and there was no social interaction or stimulation. Some people spent a considerable amount of time asleep, with no indication that they were tired from care records (having stated that they had a good night sleep the night previous) but due to lack of stimulation. The staff reported that they do tend to organise an activity during the afternoons, often with musical quizzes or dancing, ball games, discussions, crafts, manicures and hand massages, and some regular entertainment visiting. There are activity records in place with records of some activities with participants’ names, but
Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 15 this did not record the level of participation or enjoyment. A discussion was held with staff and the owner/manager about the need to extend the activities offered in line with good dementia care guidelines and more person centred and individualised according to need, interests and wishes. No trips have been arranged for this summer. The Manager stated that she is considering buying an accessible vehicle and is continuing to source one. The garden is accessible and was looking attractive. The owners plan to further extend the garden area with more accessibility and more level paving areas. Some people reported that they do go out into the garden during good weather. One person living in the home was particularly keen to state that the food is always really good here. The food is home cooked, using fresh ingredients. There is usually a cook who works Monday to Friday, but currently none at weekends. The owner/manager was cooking during the week of this inspection visit, covering for the cook’s leave and stated that she also does the cooking every weekend. The owner did state however, that the cook’s position for weekend working has now been advertised and it is hoped this position will be filled in the near future. It must be said that meals cooked by the owner on the first day of this inspection were of a good quality, home cooked using fresh ingredients and were seen to be enjoyed by the people living in the home. Staff were observed offering discreet assistance with meals where this was required and for some foods were cut up for some individuals before it was taken to the table. Some people were supported in remaining in the lounge area to eat if they wished and for some meals were taken on trays to their rooms. Southernhay Retirement Home DS0000038524.V344553.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): Quality in this outcome area is adequate. People living in the home feel comfortable with raising concerns. Policies and procedures in place ensure that people living in the home are protected from abuse, but not all staff have the necessary training or access to appropriate procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a clear and simple complaints procedure available to residents, which is displayed in the hall, and is also contained in the Resident’s Agreement. At an inspection in January 2007, people living in the home were not aware of the complaints procedure, but this is due to their confusional state. They did however state that felt able to talk to anybody at the home if they were unhappy about anything. A complaints log is in place, but this had nothing recorded in it. The home has a protection of vulnerable adults from abuse procedure and they have recently received (but not implemented) an updated version of this policy from a company that produces such documents for them. The owner/manager was aware that the local adult protection procedure has been replaced, but could not locate this at the time, and there was no evidence that this has been introduced or made available to the staff team. The owner stated that a Department of Health published DVD “No Secrets” is given to all staff to view as part of their induction. Some staff have completed formal training in relation the protection of vulnerable adults from abuse, but not all staff. Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home is comfortable, safe and well maintained, with ongoing and continual refurbishment and improvements being made. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owners have continued with their work to improve facilities in the home. The owner’s partner carries out all repairs, maintenance and improvements. The roof to the home is currently being repaired and retiled completely in places. The owners have further plans to extend the property, which will include the creation of a much larger lounge area, with better access to the garden area. Additional communal space was seen to be needed, to allow a better layout of chairs and tables and will help to allow space between chairs to allow for staff or visitors to sit next to an individual, which is currently not possible. The garden provides a safe enclosed and attractive space for people, with sturdy garden furniture, parasols, and well-maintained gardens. Some bedrooms have patio doors onto a balcony.
Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 18 Alarms are fitted to external doors, and also available on bedroom doors, to alert night staff of a person on the move. All communal rooms are bright, attractive and tastefully decorated and furnished. A new bath with a hoist, and a toilet, have been installed in the ground floor bathroom, and staff reported that this was a great benefit to themselves and the residents. All pipe work and radiators accessible to residents have been guarded, and baths are fitted with temperature regulation valves. The laundry walls have an excellent smooth finish, to make them cleanable. The owners have made room for an additional space to be used next to the laundry where all clean laundry is stored, dried if necessary and ironed. This keeps this completely separate from soiled laundry. Staff have received training in Control of Infection. The home was found to be clean and free from odour throughout on the two days of this inspection visit, and on a previous additional visit at the beginning of July. Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Staffing levels do not always meet an adequate and safe level to meet the needs of the people living in this home and staff training is not adequate or being maintained. The home’s recruitment practices are safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In June 2006, staffing levels were found to be adequate at times, but on occasions there were not sufficient staff present to adequately meet the needs of all people living in the home and often did not allow enough staff to be present to monitor or support all individuals, with people being left in the lounges for periods of time in the mornings when staff were dealing with personal care tasks for other people. The owner/manager at this time was including herself as part of the care staff hours. A requirement was set for staffing levels to be maintained at an agreed level, with a timescale of 30th August 2006. At an inspection in July 2007, the staff rota was viewed. At the time, Monday to Friday there were three care staff on duty all day and two waking night staff, and a chef and the owner/manager being present. A new domestic started work on the day of this inspection, which will mean there was a cleaner seven days a week. On Saturdays and Sundays there were only two care staff on duty, with no cook. The owner states she or her partner are present at weekends and that they do the cooking. Two waking night staff are employed for weekends as weekdays. The owner/manager was informed that two care
Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 20 staff was not sufficient to appropriately meet the needs of the persons living in this home and a requirement was made that staffing must be maintained at the agreed level, in particular at weekends, with a timescale for this as 15th August 2007. At this inspection the owner reported that a new member of staff was due to start work on the day of this inspection, but they had not turned up. She was able to ring a local newspaper and place a new advertisement for care staff on the same day. On the day of this inspection (7th August 2007), the staffing levels had not improved and it remained that there were only two staff on duty at weekends and often only three care staff on during the weekdays. The owner/manager at the time was carrying out cooking duties whilst the cook was on leave (for two weeks) and cooks every weekend, as the weekend cook post remains vacant. The owner/manager reported that they are finding it very difficult to recruit to care posts for various reasons, but at the time reported that they now intend to look into the recruitment of overseas staff. Evidence that an agency had been contacted and two CV’s had been sent for care workers from Poland. A further care staff was due to start work the week following this inspection visit. The owner/manager stated that it would be hoped that the staffing levels are raised and meet the needs of the people living in this home before the end of September. An immediate requirement was made following this inspection visit reiterating that staffing levels must be maintained at a level to ensure the safety of people living in the home, and that should this regulation continue to be breached, then regulatory enforcement action may be taken by the CSCI. At the inspection of July 2007 and again at this inspection visit, staff personnel records were viewed and found to be in order, with appropriate checks having been made before they took up employment and appropriate records held. Staff training records were viewed and discussed with the owner. Two care staff have an NVQ at level 2 and two are doing an NVQ at level 3. It is hoped that three additional care staff will soon commence on an NVQ level 2 programme in the near future. All staff require some updated First Aid training. Observations of manual handling practice on the day of this inspection led the inspector to raise concerns with the owner about current practice and the level of training in this area. Only two staff have completed Moving and Handling training. Some staff require training in relation to the Protection of Vulnerable Adults from Abuse. All care staff employed at the time completed a two-session workshop on dementia with a locally based CPN in November 2006. Whilst this training is recognised as giving staff a good basic knowledge of dementia care, a discussion was held with the owner about the need to ensure that all staff receive a more in depth and recognised and certificated training in this topic.
Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 21 There are a number of staff whose induction training was commenced, but this has not continued into the provision of the foundation standards for care training. Southernhay Retirement Home DS0000038524.V344553.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): Quality in this outcome area is poor. The level of management of the home, administration and staff supervision, training and support is currently poor. There is no quality assurance programme in place and some practices in relation to safety are not safe, particularly in relation to manual handling and adequate staffing levels. Individuals’ monies are kept safely, but practices are not entirely safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owner manager has many years of experience in the care of older people. She has achieved NVQ 4 in care and management, the Assessors’ Award, and has one further unit to complete the Registered Managers’ Award. With her partner, she has drawn up plans for the development of the service and improvement of facilities. However, she has acknowledged that staff training and supervision, administration and care records have lapsed and that this is her responsibility.
Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 23 She has attempted to keep on top of issues such as those mentioned and the ongoing staffing difficulties, but because staffing levels are low and she is spending a considerable amount of time on the floor with hands on care, she has neglected her management responsibilities. In some areas such as staffing levels and staff training, this is of a serious concern and can place people living and working in the home at risk. Attempts have been made to rectify the staffing levels and fill vacancies and it is hoped that this will allow the owner/manager to focus on and spend more time on her management tasks. The owner reported that although a quality assurance and audit system had now been put in place, and copies of recent updates to these systems were found to have been obtained, the system itself has not been implemented. Staff supervision and meetings have not happened at regularity as expected or required, and there is no system in place by which the views of people living in the home, their relatives and visitors and other visiting professionals can be obtained. An audit of monies held in the home on behalf of the people living in the home, was undertaken. Balances and actual monies held were checked and found to be accurate. Receipts and invoices were also found to accurately reflect the monies held and spent. For one person there was a substantial amount of monies being held and this was discussed with the owner/manager, who agreed to contact the family to agree a smaller amount being held in the home. The owner/manager has put in place a new format for the recording of monies held. This has space for two staff signatories or one staff member and the person themselves. However, on all occasions only the owner/manager has signed for monies being taken out or spent. The owner/manager and her partner are the only persons who have a key to access monies. The owner/manager stated in her Annual Quality Assurance Assessment that annual checks are carried out on electrical, gas and water appliances and storage. Additional checks in relation to water temperature regulation and fire safety systems are carried out as required. Fire safety records and accident records were observed at this inspection visit and found to be accurate and up to date. In July 2007, observations were made by the CSCI of two wheelchairs in use with no footplates fitted. The owner reported that for one of these, it had been felt safer for the person using the chair if the footplates were removed. However, this decision had been made without consultation with health care professionals. At this inspection one wheelchair was observed to be in use and on arrival at the home, this wheelchair did not have footplates. An hour later they had been put on and were seen to be in use for the duration of the inspection. Southernhay Retirement Home DS0000038524.V344553.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 X X 3 2 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 2 X 1 Southernhay Retirement Home DS0000038524.V344553.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 OP7 Regulation 15(2) Timescale for action Care plans, daily records and risk 30/09/07 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 The level of activity offered and planned needs to be individualised and appropriate to the needs of people with dementia. Obtain the new guidance in relation to adult protection and make this available to all staff. Staffing must be maintained at the agreed level, in particular at weekends. Previous timescales 30/08/06 16/02/07 15/08/07 Staff should be trained to a level where they are competent to
DS0000038524.V344553.R01.S.doc Requirement 2 OP12 16(2)(m) 30/10/07 3 OP18 13(6) 30/09/07 4. OP27 18(1)(a) 01/09/07 5. OP28 18(1) 31/03/08 Southernhay Retirement Home Version 5.2 Page 26 carry out their role. Previous time scales 31/10/06 16/02/07 31/03/08 6 OP30 18(1) The Registered Manager must provide induction training, which meets the specification of Skills for Care. Previous time scales 31/07/05. 30/08/06 16/02/07 30/09/07 All staff must be up to date with First Aid, Moving and Handling, Adult Protection and current certificated and recognised training in relation to dementia care. Previous timescales 31/10/06 16/02/07 31/10/07 A quality monitoring system must be developed. Previous time scales 31/12/06 16/02/07 31/10/07 Care staff must be appropriately supported through an individual supervision programme. Previous time scales 31/12/06 16/02/07 31/08/07 The registered person must notify the CSCI of all deaths, accidents and significant events affecting the persons living in this home. Previous timescale: 15/07/07
Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 27 30/09/07 7 OP30 13(5) 31/12/07 8. OP33 24 30/11/07 9. OP36 18(2) 30/09/07 10 OP38 37 10/08/07 11 OP38 13(4)&(5) Unless it is assessed as presenting a risk and clearly recorded in care plans, footplates on wheelchairs must be used at all times. 10/08/07 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 OP4 OP7 OP16 OP19 Good Practice Recommendations Make available and discuss with staff current good practice guidance in relation to dementia care. There must be no gaps left between entries in daily care records A record should be kept of minor concerns, and any action taken in response. Review the layout of lounges to ensure that all individuals requiring assistance or space to receive visitors can be accommodated discreetly and without implications for other persons in the room. Two signatories must be obtained for all transactions of monies held on behalf of people living in the home. 5 OP35 Southernhay Retirement Home DS0000038524.V344553.R01.S.doc Version 5.2 Page 28 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.V344553.R01.S.doc Version 5.2 Page 29 - 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!
