Inspection on 20/02/08 for Southernwood

This inspection was carried out on 20th February 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southernwood 13/03/09

Southernwood 04/12/06

Southernwood 20/06/05

Southernwood 12/04/05

Southernwood 30/09/04

Southernwood 20/04/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

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 Jane Handscombe Unannounced Inspection 20 February and 3 March 2008 11:55 th rd Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 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 Southernwood DS0000023022.V352132.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 Adults 18-65. 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. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southernwood Address 148 Plantation Road Amersham Bucks HP6 6JG 01494 721607 01494 721607 h3m069stringer@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Mr David Stringer Care Home 6 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 6 residents with learning disabilities, physical disabilities Date of last inspection 4th December 2006 Brief Description of the Service: Southernwood is a purpose built home, registered to provide accommodation for up to six adults with learning and physical disabilities. Each person living at the home has considerable care needs. The home is staffed by Mencap and 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 directly accessible by public transport. The home provides single bedroom 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 with all necessary adaptations and lifting equipment. There is an enclosed garden that can be accessed through patio doors leading from the conservatory. All of the service users facilities are on the ground floor with just the office and staff bathroom on the first floor. There is parking at the side of the building. The fees for this service range from £966.00 to £2136.50 per week. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This was an unannounced inspection, which took place over two day on 20th February 2008 and a further visit on the morning of 3rd March 2008 lasting 2 hours, to view staff personnel files which were not able to be viewed on the first day as the staff available did not have access to this information. The purpose of the visit was to see how the home is meeting the National Minimum Standards. The home currently provides support to 6 service users. All of these users were sent questionnaires in order to ascertain their views upon the support they receive, responses were received from all 6. Likewise questionnaires were sent to health professionals 2 of who responded and to staff members, 8 of who responded. Two family members requested to speak to the inspector one of whom we attempted to contact by telephone on a few occasions to no avail and a further who we were able to contact and gain feedback. Contact with service users, health professionals, family members and staff inform the inspector of different aspects of the service and how it affects the daily lives of those using the service. Results of this inspection report are derived from feedback gained from the service users, from viewing client’s records, viewing policies and procedures, staff personnel files along with any information that CSCI has received about the service in order to gain an understanding of how the services provided by the agency meet the service users’ needs, and impact upon their lives. The inspector would like to thank all those who gave their time in responding to surveys and speaking to the inspector during the inspection process. What the service does well: The home deals with a number of diverse care needs and always ensures to offer a very personalised service to meet the needs of those using the service. There is a real commitment to ensure that users of the service, however diverse their needs, receive a person-centred package of care which meets their needs appropriately and according to their wishes. The home has a friendly, caring inclusive atmosphere in which the residents’ right to privacy and dignity is upheld at all times; this was clearly evidenced during the inspection. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Whilst the service generally provides good outcomes for service users, there are eight areas for which requirements and recommendations have been made within this report to address shortcomings in the health safety and welfare of those using the service which are as follows: Ensure that arrangements are in place and adhered to at all times for the safe storage, administration and recording of medications, at all times thereby promoting the health, safety and welfare of service users at all times. Further work needs to be undertaken on service user plans to ensure that all their health care needs are fully documented, kept up to date and met appropriately. Ensure that the domestic cleaning arrangements of the home meet with the service users needs appropriately and the allocation of this time does not impact on the health and welfare of the service users. Ensure that paper towel dispensers are provided in the laundry room, enabling staff to wash and dry their hands appropriately so as to avoid cross infection and the compromising of the service users’ health and safety Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 7 Ensure that service users monies are stored safely and securely at all times. Implement a nationally validated nutritional screening tool that is completed shortly after admission and reviewed at appropriate intervals thereafter. It is good practice to ensure that when undertaking an audit of service users’ personal monies they be checked and countersigned by a second member of staff for added protection. It is good practice to renew CRB checks every three years. 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. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 Quality in this outcome area is good. Prospective users of the service are provided with comprehensive information and an assessment of their needs to enable them to make an informed choice about where to live and be assured that their needs can be met appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection undertaken in December 2006, there have been no new admissions to the home, so direct evidence of the management of new admissions was not available for scrutiny. However, we were informed that the manager of the service ensures to visit all prospective users of the service and undertake an assessment of their needs to ensure that their needs can be met at Southernwood appropriately. Information is provided to all prospective and current service users in the form of a service users guide and statement of purpose in a format suitable to their needs. In addition to the provision of information, people looking to consider Southernwood are invited to visit the home on a number of occasions to include taking meals, day, overnight, weekend and weekly visits enabling them to spend time meeting with staff and fellow users to gain an all round picture Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 10 of the home and the people they will be living with prior to making their final decision. This is a two way process, which takes into account the views of those people currently living at the home. The service deals with a number of diverse care needs and always ensures to offer a personalised service to meet all the needs of their clients. There is a very real commitment to ensure that all clients, however diverse their needs may be, receive a person-centred package of care and support, which meets their needs appropriately. From the evidence seen by the inspector and comments received, the inspector considers that this service is able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. All those using the service have an individualised plan of care and support which details their assessed needs and personal goals and documents how these needs and goals are to be met, however these are not always updated appropriately This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user has an individualised plan of care detailing their individual needs, preferences and goals and how these needs are to be met. Service users records viewed during the inspection indicated evidence that their views, preferences and needs are taken into account when providing care and support. Service users have the necessary disability equipment they require to enable them to maintain their independence and robust risk assessments are in place Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 12 detailing how the care is to be delivered in a safe manner whilst maintaining and promoting their independence. Of those service users being case tracked during the inspection it was evident that the carers were aware of the users’ individual needs and had a good understanding of how to address their needs whilst promoting their independence. During the inspection the inspector viewed a sample of care plans and found them to be individualised, contain detailed information on the users individual health, social and personal care needs and preferences and how these needs are to be addressed, although care needs to be taken to ensure that these are updated where necessary. Whilst we were informed that reviews are undertaken and care plans updated accordingly, there was some information held within files that was clearly out of date. One service users file informed us that he/she has hydrotherapy once a week although upon discussion it was ascertained that the service user had not attended this year since the hydrotherapy pool has been closed and no alternative venue had been sought. The same service users health action plan was incomplete with the section headed general health not completed and no start dates evident. Likewise documentation entitled ‘this is me’ contained no dates to evidence if it had been reviewed or when it was drawn up. The home works well to meet the diverse needs of the resident group. Support around their disabilities and their differing personal situations and aspirations were well understood by staff and appropriately met. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. Opportunities and support is provided for people to access the local community and develop their life skills. Service users are enabled to keep in contact with family and friends, to maintain important social contacts. Meal times are well managed with different food options available, to provide service users with a varied and wholesome diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Users of the service live full and varied lifestyles according to their wishes and preferences. Details within the care plans, daily notes and feedback from service users and/or their representatives and staff evidenced that all are actively involved within the local community attending day service placements, Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 14 and local clubs within the local area. On the first day of this visit, five users of the service were out attending a local day service whilst one service user chose to remain within the home. Consultations are undertaken to gain ideas as to where service users would like to go on their trips, individual and group holiday choices and the choice of carers who they would like to accompany them. Arrangements for service users to meet with friends and family members are flexible and support is given to maintain personal relationships where required. A varied menu is provided and special dietary needs are catered for those who require. Service users are actively involved in aspects of the planning and choice of the daily menus and can take their meals with fellow users of the service around the communal dining table or privately if preferred. During the visit, staff were observed to assist those who required help in an unhurried sensitive manner. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Poor practices around the safe storage, administration and recording of medication put people who use the service at risk. Further work on service users care plans is needed to ensure that all their health care needs are fully met and documented appropriately. People are supported to access health care services both within the home and in the local community. This judgement has been made using available evidence including a visit to this service. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 16 EVIDENCE: In the main, service users are very dependent and staff attempt, through body language and other forms of non verbal communication to determine when service users would like to go to bed, bath, have their meals and take part in other activities. This is recorded in individual care plans. This extends to supporting service users to choose the clothes they wish to wear, hairstyles, make up and general appearance. The care plans set out in detail the service users preferred routines, their likes and dislikes and partnerships with families, friends and relevant professionals outside of the home. Essential information needed by staff to be able to provide personal and health care support was included in residents’ files although there was evidence of some gaps in information although staff were able to give a verbal update. Documentation within service users files is not always dated to evidence that regular reviews have been undertaken and the recording of incidences is not always documented appropriately. The Commission were notified, as is required, of an incident involving one of the service users, however whilst viewing the accidents and incidents book and the care plan of the particular service user there was no documented evidence of the incident taking place. A requirement has been made within this report to ensure care plans are reviewed to ensure that correct up to date information is recorded in them. Staff help residents to look after their own medication and see they get to see their local GP and other community healthcare services when needed. Comments received from health professionals who visit the service users in the home include: “ they seem to be aware of the residents’ needs…..professional approach, individually tailored…” “advice given is followed up and feedback given at subsequent appointments” The nutritional needs of service users are identified however there is no evidence held in their files of how these needs have been identified and assessed. Documentation within the service users files informs that their weight is to be monitored monthly, however their weight is not monitored and recorded appropriately. One service users file informed us that his/her food and drink intake was to be monitored and monthly weight be recorded due to his/her low weight, however it was noted that his/her monthly weights were not being undertaken on a regular monthly basis, that over the course of seven months only two months had been recorded and therefore clearly not meeting his/her health needs appropriately. Of the further three files viewed, Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 17 all had similar shortcomings around the recording of weight, these were not being undertaken on a monthly basis as noted in their files. Whilst the nutritional needs of service users are identified, current good practice recommends that care homes have a procedure for dietary assessment and nutritional screening using a nationally validated screening tool, such as MUST (Malnutrition Universal Screening Tool). This should be undertaken on admission and at appropriate intervals thereafter, with a record of nutrition, weight gain or loss and appropriate action taken. A recommendation has been made within this report to implement a procedure for dietary assessment and nutritional screening using a nationally validated nutritional screening tool, such as the MUST (malnutrition universal screening tool). Whilst the home has robust medication policies and procedures to ensure the health, safety and well being of those who use the service and whilst staff have received medication training to equip them with the necessary skills and knowledge, poor practices were seen to be evident on the day of inspection. None of the service users in the home are able to self-administer their own medication and rely upon staff to undertake this. Whilst touring the home the inspector found individually prescribed creams being stored insecurely in residents’ bedrooms and one communal bathroom with no provision of lockable facilities for their safe storage . Whilst viewing the service users’ medication records it was noted that medication administration record charts were signed when medicines were given to people, however when doses were not given there was no record made of the reason why, either on the MAR chart or in the care plans or daily care records. Medication was found to contain incorrect dates of opening; one such medication had been dispensed on 31st January 2008 yet the date of opening the medication was recorded as 7th December 2007. Within the medication cabinet was two sachets of a medication unaccounted for on any of the medication records within the home. We were informed that the medication folder is audited and reviewed every three months, however the last date entered was April 2007. When service users attend local day centres, visit family members or go on holidays and their medication leaves the premises in order that it can be administered whilst absent from the home, there is no evidence that a risk assessment has been put in place. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 18 A requirement has been made within this report to ensure that arrangements are in place and adhered to at all times for the safe storage, administration and recording of medications, at all times thereby promoting the health, safety and welfare of service users at all times. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Complaints and concerns are taken seriously and are looked upon as an opportunity to improve and provide a better service. Peoples records of financial transactions are well documented, although more care is needed to ensure that peoples money is stored and safeguarded appropriately This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure accessible to service users and visitors to the home. This is provided in pictorial form for service users, all of who are provided with an individual copy, which is posted in their bedrooms. A summary of the complaints procedure is included in the Statement of Purpose and Service Users Guide. This includes information on how to refer a complaint to the Commission. Information provided to the Commission prior to the inspection and during the visit informs us that no complaints have been received by the service during the last 12 months, likewise, the Commission for Social Care Inspection has not received any correspondence from the general public in relation to concerns, complaints or allegations since the last inspection. During the inspection process, it was acknowledged that any complaints, compliments and concerns are logged in a folder. It was recommended that whilst the service Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 20 has not received any formal complaints, any concerns or ‘niggles’ informally voiced should be treated in the same manner and logged. It is recommended that the folder contain a sheet detailing each complaint/concern received, the actions taken and the resultant outcome to allow for an easy form of auditing. The inspector discussed the protection of service users monies held within the home and viewed the financial documentation of the three service users who were case tracked during the inspection. People’s monies were found to be stored separately in individual locked petty cash tins although the tins were stored unsafely in an unlocked filing cabinet in the office; the office was not locked on either of the two days visited and therefore could be accessed by visitors to the home. This was discussed with the manager of the home who assured us that steps would be taken to ensure that the office would be kept locked when not in use, as would the filing cabinets. A requirement has been made within this report to ensure that service users monies are stored safely and securely at all times. During the inspection three peoples records of financial transactions viewed were well documented, with clear evidence of transactions undertaken, receipts kept and all were found to be accurate. It was noted that a senior member of staff regularly undertakes an audit of service users personal monies and it was recommended that it would be good practice to ensure they are checked and countersigned by a second member of staff for added protection. The home has systems in place to protect service users from abuse, and works to the local written protocol for safeguarding vulnerable adults. The safeguarding of vulnerable adults is taken seriously, any allegations are dealt with appropriately and staff members receive training at induction and regularly thereafter. The Commission for Social Care Inspection has not received any complaints about the home nor has it been notified of any allegations of abuse since the last inspection undertaken in December 2006. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 29 and 30 Quality in this outcome area is good. The physical design and layout of the home enables people to live in a safe environment. Bedrooms are decorated and personalised to service users choices and are provided with appropriate specialist equipment to meet their needs and maximise independence. More attention is needed to the domestic cleaning arrangements to ensure that it is kept clean and tidy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Southernwood is a purpose built bungalow set on a large plot in a pleasant road in Amersham with local shops and amenities a short distance walk from the home. The home is specifically for adults with learning and physical disabilities. There are 6 bedrooms, all of which have wheelchair access and each have their own washbasins. All bedrooms at Southernwood are single occupancy and have been decorated and personalised to suit the service users Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 22 different tastes. It was noted that the call alarm systems in the service users bedrooms did not have pull cords attached to call for assistance. One users’ bedroom did contain a listening device/alarm in order that staff were alerted if any problems should arise. Upon discussion with the manager it was acknowledged that a pull cord was unsuitable for the people living in the home and that staff regularly check and monitor residents when they are in their bedrooms, however there was no evidence of any monitoring documented within the care plans. The registered manager acknowledged the shortcoming and assured us that documentation would be put into place. There is a large conservatory for service users and their visitors to enjoy, which overlooks the garden, a lounge, large kitchen area, two bathrooms one of which contains an assisted bath, two toilets and further rooms for storage. The homes office is located upstairs in the loft area, which is also used for overnight staff sleep-ins. Whilst touring the home, it was noted that whilst it provides for a safe, comfortable environment and provides necessary equipment and aids, the general cleanliness of the home could be improved upon. Some service users rooms appeared dusty in places, cobwebs were apparent and games were observed to be scattered under the sofa in the conservatory area. Feedback gained from relatives and service users via surveys and telephone conversations also evidenced the cleanliness of the home as an area of concern. Comments included: “kitchens and bathrooms are generally kept clean but other areas are rarely cleaned thoroughly. My biggest complaint is that furniture needs to be moved, paintwork washed and furniture dusted and polished on a regular basis…”“Rooms sometimes need cleaning and dusting (public areas) and my bedroom” “My mother X (named relative) is pleased that I live at southernwood she feels on the whole that I am looked after; would like the home to be a lot cleaner….” The comments regarding the cleanliness of the home and the observation during this visit were discussed with the manager of the home who informed us that until recently, the home did not employ domestic staff and the care and support staff undertook this role as part of their day to day routines. He explained that a member of staff has agreed to take on this role, separate to his/her role as a carer, which should allow for a robust cleaning of the home once a week and care and support staff will continue to undertake the lighter cleaning duties as part of their everyday role. A requirement has been made within this report to ensure that the domestic cleaning arrangements of the home meet with the service users needs appropriately and the allocation of this time does not impact on the health and welfare of the service users. The laundry facilities for the home are sited so that soiled washing does not come into contact with the kitchen. It was noted that whilst there are hand washing facilities sited in the laundry and provision of liquid soap, there were no hand towels for staff to dry their hands appropriately. The lack of appropriate facilities could in fact deter staff from washing their hands Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 23 appropriately and thereby potentially placing service users at risk of cross infection. The manager agreed to ensure that staff are provided with appropriate hand washing facilities. A requirement has been made within this report to address the shortcoming. It was brought to the Commissions attention that there have been problems with the central heating, resulting in one half of the home without heating which had been an ongoing issue from November last year. Heaters were provided in bedrooms and communal areas that were affected and risk assessments put in place. Discussions with the registered manager ascertained that the problem has recently been rectified and a service users family member confirmed this during the visit. The commission was not notified of the problem and the registered manager is reminded that the Commission is to be notified under regulation 26 of any event that adversely affects the service users safety and welfare. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 24 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 24, 25 and 36 Quality in this outcome area is good. There are effective recruitment procedures in place to ensure service users are protected from harm. Staff are provided with training and support to ensure that they have the skills and knowledge to undertake their roles competently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The contents of staff personnel files evidenced that there is a robust recruitment and selection procedure, which acts to ensure the service users health, well-being and security. Application forms are completed, references are collected and a face-to-face interview is undertaken. Relevant POVA (protection of vulnerable adults) and CRB (criminal records bureau) checks are undertaken prior to appointment to ensure the persons suitability with working with vulnerable people. It is a good practice recommendation to renew CRB disclosures every three years. Feedback received from carers provided evidence that they felt their recruitment was done fairly and thoroughly. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 25 All newly recruited members of staff receive a structured induction training including shadowing more experienced carers until both parties feel confident and comfortable. Staff are provided with mandatory training in core subject areas which is updated accordingly, and undertake ongoing development in order that they are appropriately trained and equipped with the skills to meet the varying personal care needs of the service users, thereby protecting the service users health, well being and safety. Of the eight surveys sent out to care staff and responded to 100 informed us that they are provided with training that is relevant to their role and helps them to understand and meet the individual needs of those using the service. All who responded felt that the training they are provided with keeps them up to date with new ways of working. Staff training is recorded in individual staff files and those viewed demonstrated the home’s commitment to staff development and training. All staff are encouraged to undertake the National Vocational Qualification (NVQ) at level 2 or above in care. Presently, five of the eleven care workers hold NVQ’s in care at level 2 or above with a further four carers working towards the qualification. Feedback from staff was very positive. Every staff member who provided feedback from questionnaires provided by the commission said that the manager gave them enough support and meets with them regularly to discuss how they are working, evidence of which was found within those staff personnel files viewed during this visit. During the visit it was apparent that the staff have a clear understanding of their roles and responsibilities and demonstrated a good sense of team work. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 26 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42 Quality in this outcome area is adequate. Whilst the manager is qualified and has the experience to run the home competently evidence of poor procedures taking place namely around medication, poor recording procedures, and the cleanliness of the home do not serve the service users best interests and could compromise the health safety and welfare of those using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager has the required qualifications and experience to run the home and meet its stated aims and objectives. He is widely experienced and is a Registered Nurse for people with learning disabilities and works hard to continuously improve the service. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 27 The administration in the home is shared between the manager and 2 deputy managers who work together well as a team. The Annual Quality Assurance Assessment (AQAA) sent out prior to the inspection was returned within the appropriate timescale and contained detailed information. The AQAA informed us of changes they have made and where they still feel they need to make improvements and detailed how they are going to do this. The data section was accurately and fully completed. The service has policies and procedures in place although the manager needs to ensure that staff follow the homes policies and procedures at all times and translate policy into practice to ensure that they are working in the service users best interests and promoting their health, safety and welfare at all times. Whilst the manager is qualified and has the experience to run the home competently evidence of poor procedures taking place namely around medication, poor recording procedures, and the cleanliness of the home do not serve the service users best interests and could compromise the health safety and welfare of those using the service. Improvements are needed in record keeping for some of the key document tools such as care plans, risk assessments and medication practices to ensure the health, safety and welfare of those receiving a service. These issues have been identified elsewhere in this report. The manager obtains feedback from residents and visitors when talking to them in the home, and has an ‘open door’ policy that encourages people see him without the need to make an appointment. Examination of a number of health & safety records indicated that all necessary checks and servicing of equipment are routinely undertaken to safeguard the health and welfare of users. Service users and staff are protected by the insurance cover for the business, professional and public liabilities. Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 28 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. 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 3 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 x 28 x 29 3 30 2 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 2 x 3 2 x 2 x Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 29 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 YA23 Regulation 16(2)(l) Requirement Ensure that service users monies are stored safely and securely at all times. Ensure that arrangements are in place and adhered to at all times for the safe storage, administration and recording of medications, at all times thereby promoting the health, safety and welfare of service users at all times. Further work must be undertaken on service users care plans to ensure that all their health care needs are fully documented • Ensure care plans are reviewed to ensure that correct up to date information is recorded in them. All documentation must be dated to show when it was produced. Timescale for action 04/04/08 2 YA20 13(2) 04/04/08 3 YA6 15 04/04/08 • Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 30 4 YA30 23(2)d 5 YA30 13(3) Ensure that the domestic cleaning arrangements of the home meet with the service users needs appropriately and the allocation of this time does not impact on the health and welfare of the service users Ensure that paper towels are provided in the laundry room, enabling staff to wash and dry their hands appropriately so as to avoid cross infection and the compromising of the service users’ health and safety 04/04/08 04/04/08 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 YA23 Good Practice Recommendations It is good practice to ensure that when undertaking an audit of service users’ personal monies they be checked and countersigned by a second member of staff for added protection. It is good practice to renew CRB checks every three years. Implement a nationally validated nutritional screening tool that is completed shortly after admission and reviewed at appropriate intervals thereafter 2 3 YA34 YA17 Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Southernwood DS0000023022.V352132.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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