Inspection on 12/04/05 for Southernwood

This inspection was carried out on 12th April 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Southernwood 13/03/09

Southernwood 20/02/08

Southernwood 04/12/06

Southernwood 20/06/05

Southernwood 30/09/04

Southernwood 20/04/04

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Hillview Farm

Dalewood Respite Care

Orchard,The

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Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Southernwood 148 Plantation Road Amersham Bucks HP6 6JG Lead Inspector Chris Schwarz Unannounced 12 April 2005 7:30 a.m. th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Southernwood Address 148 Plantation Road, Amersham, Bucks, HP6 6JG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01494 721607 Royal Mencap Society Mr David Stringer Care Home 6 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1 6 residents with learning disabilities, physical disabilities Date of last inspection 30 September 2004 Brief Description of the Service: Southernwood is a purpose built home, registered to provide accommodation for up to six adults with physical and learning disabilities. Everyone living at the home has high dependency needs. The home is staffed by Mencap. The home is within a mile or so of local shops and the towns of Amersham and High Wycombe are a few miles away. The home is not on a direct bus route. The home provides single room accommodation with rooms of a good size, personalised and decorated to individual tastes and interests. There are lounge and conservatory areas and a kitchen/dining room. The home has two bathrooms and has the adaptations and lifting equipment necessary to meet service users needs. There is an enclosed garden which can be accessed through patio doors leading off the conservatory. All of the service users facilities are on the ground floor with just the office and staff bathroom on the first floor. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a week day morning from 7.30 am to 10.45 am. It consisted of observation of the morning routine at the home, speaking with staff and service users, a tour of accommodation and examination of some required records. What the service does well: What has improved since the last inspection? What they could do better: Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 6 • • • • The provider should produce more detailed reports to demonstrate effective monitoring of the service. Staff need to ensure that they use the drug sheets to show when a tablet has been dispensed ahead of time from the blister packs. All serious occurrences such as admissions to hospital or treatment at A&E need to be consistently notified to the Commission. Staff need to add dates and signatures to all records to show when these were produced and by whom. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 3 Service users and their representatives have the information they need prior to admission to help them make a decision about moving into the home. The assessed needs of service users are well met, promoting healthy and safe living. EVIDENCE: A service users’ guide and statement of purpose are in place at Southernwood and contain all necessary information. There had not been any new admissions since the last inspection of the home. Care plans and supporting documentation showed that staff meet the complex care needs of the service user group, involving specialist outside agencies as necessary. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 and 10 Service users’ needs are assessed and reviewed to ensure they receive the care they need. Service users are consulted and are able to make everyday choices, giving them variety and a say in their care. EVIDENCE: Care plans are in place for service users and there was evidence of reviewing in the sample of files looked at. One person’s review contained realistic and achievable goals and aspirations. Observation of the morning routine provided opportunity to see service users consulted about choices such as what they would like for breakfast, whether they wanted the radio on and choice of radio station through listening to what a range of stations sounded like. Care plan folders, staff files and any sensitive information was kept secure and was not accessible to unauthorised persons. Care plan files contained risk assessments for a range of activities and tasks. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 and 17 Service users take part in fulfilling activities, have opportunities for varied leisure options and are part of the local community. This ensures that they have variation and stimulation in their lives. Meals are well managed and varied and incorporate choices for service users. Contact with families is encouraged to maintain family links for service users. EVIDENCE: Two service users were away on holiday in Cornwall, both of who have family links in that area. Other holidays have taken place and more are planned. There was evidence from documents that contact with families is supported by staff. Breakfast was well managed and individual preferences were catered for. Assistance was provided in an unrushed and gentle manner in order that service users could enjoy their meal. One service user signed to confirm that he had enjoyed breakfast and had enough to eat and drink. Staff responded appropriately when a service user used his hand to push a drink away. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 11 The kitchen contained a variety of foodstuffs and meal supplements were available for those service users who are unable to take food orally. Staff assisted service users to get up in an unrushed manner and they were assisted to the lounge individually. Staff spoke with service users as they were providing assistance and offered encouragement to eat, where needed. Three of the four service users went off to day services after breakfast, collected by buses. Documentation showed that service users had undertaken a range of activities and outings recently, both locally and further afield. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21 Service users’ health needs are met to ensure their wellbeing. Further work is needed to ensure that medication is administered in accordance with good practices, to keep service users healthy. Illness and accidents are appropriately managed to ensure that service users remain healthy. EVIDENCE: Medication was locked away safely and administered individually by the senior on duty. Drug records were generally of a good standard although there were three instances where a tablet had been pushed from the blister packs ahead of time, with no explanation evident on drug charts. The member of staff administering drugs said it was likely that service users had spat out or staff had dropped the original tablets and used the final ones as replacements. This is acceptable but staff must ensure that they use the reverse of the drug records to explain why tablets have been used in this manner. A requirement is set regarding this to ensure that medication can be properly accounted for at the home. Care plan files contained details of personal care needs to ensure consistency and there was evidence of involvement from health care professionals, such as physiotherapists, speech and language therapists and the consultant in Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 13 learning disabilities. Medical appointments were well recorded by staff so that it was clear to see what advice or treatment had been given. Records also showed that accidents had been appropriately handled with ambulances called where necessary. Care during illnesses had also been noted and showed that staff had provided appropriate care and liaised with health workers where necessary. There had not been any deaths at the home. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 The home had adult protection procedures in place, which ensure that service users are protected from abuse. EVIDENCE: Prior to this inspection, information had been sent to the Commission from the home demonstrating that staff are being proactive and involving outside agencies where there were concerns. There were no current concerns regarding these instances. Care plans contain behaviour management guidelines, where appropriate. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30 The environment at Southernwood is sufficient to ensure that service users have an attractive and homely place to live in. EVIDENCE: The building was clean and in good order at a busy time of day. Bedrooms were personalised and individually decorated with moving and handling equipment where necessary. There is a choice of lounge spaces to use and the kitchen has been refurbished since the last inspection. Bathrooms and toilets were appropriately stocked and clean. There were no unpleasant odours in the building and laundry was under control. The rear garden looked neat with evidence of a donation of plants from a relative, ready to incorporate into flowerbeds. There were also pots of flowering plants close to the patio doors, where service users would easily be able to see them. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35 and 36 Southernwood has an effective team of staff and in sufficient numbers to meet care needs; this ensures service users’ health, safety and wellbeing are promoted and that they have continuity of care. EVIDENCE: Staff on duty were able to explain care needs and answer questions regarding changes to service users’ needs. Interaction between them was quiet and demonstrated effective communication and this was also true of their interaction with service users. Three staff were on duty to four service users and rotas showed that there are generally three covering the morning shifts and four in the afternoons. Staff said that these were overall sufficient numbers but there were times where more staff are needed, depending on what was going on and health needs. A new member of staff confirmed that she was undergoing a structured induction and had received fire safety training and the other staff said they are about to start National Vocational Qualification level 3. There had been input for the staff team on communication, which was said to have been helpful. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 17 A chart on the office wall demonstrated that staff are offered supervision sessions. The senior on duty said the home was fully staffed now therefore no agency staff are required to cover shifts. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 41 The home benefits from overall effective management, which ensures that service users are kept safe and have continuity of care. Further work is needed to improve monitoring systems and inform the Commission of serious incidents, to ensure that service users receive appropriate levels of care. EVIDENCE: The home has a manager who has successfully become registered since the last inspection. Records look in better shape and are generally in more detail although dates and signatures of authors were not always evident. A recommendation is made regarding this. The provider carries out monitoring of the home and staff said that an internal service audit was due at the end of this month. Monitoring reports are brief and do not show that thorough assessment of care provision is being undertaken and a recommendation is Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 19 made to add more detail to these. The provider may wish to use the suggested template available on the CSCI website. Records showed occasions where serious occurrences have taken place, such as service users needing to be admitted to hospital. There were three occasions this year that ought to have been notified to the Commission and a requirement is made to ensure that this is done on future occasions. SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 N/A 3 x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 Southernwood Score 3 3 x 3 Standard No 24 25 26 27 28 29 30 Score 3 3 3 3 3 3 3 Version 1.20 Page 20 H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc 10 LIFESTYLES 3 Score STAFFING Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 2 x 3 x 3 3 x Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 21 n/a Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 20 Regulation 13(2) Requirement Staff must explain on drug sheets why medication has been removed from blister packs ahead of time. The staff team must consistently report all notifiable incidents to the Commission within 24 hours and follow up in writing within 3 working days. Timescale for action from 12 April 2005 from 12 April 2005 2. 37 37 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. Refer to Standard 39 41 Good Practice Recommendations Reports prepared by the provider should be in greater detail to demonstrate effective monitoring is taking place. Records should consistently be dated and signed by staff to show when produced and by whom. Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 22 Commission for Social Care Inspection Cambridge House, 8 Bell Business Park, Smeaton Close Aylesbury Bucks, HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Southernwood H53_H02_S23022_Southernwood_V220875_120405_Stage 4.doc Version 1.20 Page 23 - 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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