Inspection on 08/11/06 for Southernwood House

This inspection was carried out on 8th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

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Bramble Lodge

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

CARE HOMES FOR OLDER PEOPLE Southernwood House Southernwood House 20 Matmore Gate Spalding Lincs. PE11 2PN Lead Inspector Julie Western Unannounced Inspection 8th November 2006 09:00 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 Southernwood House DS0000066569.V318095.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. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southernwood House Address Southernwood House 20 Matmore Gate Spalding Lincs. PE11 2PN 0121 308 8861 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) Wellbeing Residential Ltd Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Not applicable Brief Description of the Service: Southernwood is a private home, providing personal care for a maximum of twenty-four older people. On the day of the inspection 20 residents were in residence. The home consists of a large detached property with the addition of a single storey extension and is situated in a residential area on the outskirts of Spalding. It is set in well-maintained gardens with a large patio area and a summerhouse. It is situated close to all amenities. Car parking is provided at the front of the home. The main aim of the home is to provide a quality care service in a homely environment. In August 2006 the ownership changed hands. At the same time a new Manager was appointed; she is at present unregistered. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a new service due to the change of owners and therefore a key unannounced inspection was carried out. The site inspection took over three hours and consisted of case tracking a sample of residents’ records and assessing their care. Some policies and procedures were examined and some records concerning the safety of the home were also seen. Three residents, two care and ancillary staff and one visitor were spoken with. The Manager of the home, who is presently unregistered, and the owners were present throughout. At the time of the inspection the home confirmed that the weekly fees ranged from £360 - £450, depending on the assessed needs of the resident. Additional charges are made for services such as chiropody and hairdressing. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report is available in the Manager’s office. What the service does well: What has improved since the last inspection? The new owners of the home have made many changes, including new IT documentation throughout. There is now a large manual containing policies and procedures, which have all been updated. There is also a new management and training system for staff, which currently involves twomonthly appraisals. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 6 The exterior of the building has been repainted and has a new sign. The driveway has been partly laid to gravel. The front door has a lock with a keypad to which relatives are given the code so that they may come and go freely without having to wait for a staff member to open it. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home sets out how it intends to meet the needs of its residents. There is currently no service user guide to give residents appropriate information about the home’s facilities. An intermediate care service is not provided EVIDENCE: Discussions with residents and staff confirmed that residents had visited the home for trial visits and had the information to make an informed decision about the home’s facilities. Care plans showed that residents’ needs were assessed and met. The Manager said that the service user guide was not yet ready to publish. In response to thematic enquiry questions none of the 3 residents spoken with had up to date copies of the service user guide. 2 of 3 residents were unclear about contracts but said their families managed these issues. All 3 had Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 9 information about costs and changes to these. All 3 residents said their needs were assessed and they were present for this. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s records give a clear picture of the needs of residents and enable staff to meet their needs with sensitivity and regard for their privacy and dignity. EVIDENCE: The three care plans looked at in depth contained clear assessments. They were reviewed regularly and signed where possible by the service user or relatives/advocates. They would benefit from having a social history for each resident. There was a clear medication policy and the pharmacist visited regularly; his last report contained no issues of concern. The proprietor confirmed that only trained senior staff members were able to administer medication. Residents said they felt safe and well looked after; one said ‘the staff are excellent, first class’. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 11 The staff team were observed carrying out their duties with kindness and sensitivity towards the residents, especially when attending to their personal needs. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Social activities create a variety of events and activities, which residents are informed about. The residents exercise choice about which activities, if any, they wish to participate in and what meals they want to eat EVIDENCE: The home has a programme of regular activities, which include entertainers, armchair exercises, church services, dominoes, manicures and massages, and outings to local garden centres. An activities co-ordinator was appointed two weeks ago; residents said this was a good thing, as in future they would be able to go out accompanied by staff. One resident spoken with said she did not wish to participate in any of the events but was quite happy to stay in one of the quiet rooms reading books and receiving visits from her relatives. Television and books were available and a ‘shop’ trolley visited the home weekly for residents to make various purchases. The home has two cats and a ‘pat-dog’ visits regularly. Residents said they had monthly meetings and were always consulted about matters concerning the running of the home. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 13 Residents spoken with enjoyed the meals served at the home and said they had a choice of food and were regularly consulted about the menus. One said ‘there’s plenty of it and it’s all good’. There was fresh fruit placed around the home and the mid-day meal contained fresh vegetables. The cook had achieved NVQ 2 in catering and had the basic food hygiene certificate. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure is clear and gives residents and their relatives the confidence that comments and concerns will be listened to. The current adult protection procedures are unclear and do not safeguard residents. EVIDENCE: Residents spoken with and the visitor all said they did not wish to complain but knew how to make a complaint. The home had a copy of the Local Authority Adult Protection procedures and its own policy and procedures for dealing with complaints. An element of the procedures described interview and investigation processes, which if followed by staff, could contaminate any future police evidence. The owners agreed to re-write these and forward a copy of the new procedures to the Commission. Three staff members spoken with had received training on adult protection and the Manager confirmed that all staff had received this training. In response to thematic enquiry questions all 3 residents spoken with had received written information about complaints and knew how to raise concerns about their care. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a comfortable, pleasant and safe environment with both private and communal space being on the whole suitable for their needs. EVIDENCE: Overall, the standard of decoration internally was high and afforded residents a great degree of comfort. The ongoing maintenance programme has resulted in two bedrooms being redecorated. The new owners have repainted the exterior of the building and laid parts of the drive to gravel. A visitor said that a recent improvement was an electronically coded front door lock to which regular visitors had the code; this meant they did not have to wait outside when carers were busy. Rooms were clean, comfortable and well personalised; residents had signed a document to say they whether or not they wished to have locks to bedroom doors. The gardens were well tended, with plenty of places for Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 16 residents to sit out in good weather and residents said how much they enjoyed the gardens. Cracks between the paving stones on the patio and uneven paths were still apparent. The owners said that an extension was being planned for next year and the paths would be lifted at that time. Meanwhile it was recommended that a risk assessment was conducted on residents when using the garden, to prevent accidents. The home was clean and hygienic throughout, with a use of fresh flowers in all communal rooms. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are in sufficient quantity for them to be able to care for the residents. Residents are confident that staff members are suitably trained, qualified and competent to give them the appropriate care. EVIDENCE: At the time of the inspection one senior care staff and two carers were on duty. Residents spoken with said they felt there were enough staff members to attend to their needs. The new owners have recruited an extra carer to work in the evenings and there are now four kitchen staff. The Manager was also present. The most recent staff member to be appointed confirmed that she had given two references, which were followed up and had a CRB check before commencing work. This is a stable staff group of many years’ experience. Two staff members said they had received an induction and they had the opportunity to attend regular training courses. The owners were installing an IT training package on the day of the inspection. The training record was not available for viewing but the Manager confirmed that both in-house and external courses were booked and attended and staff confirmed this. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 18 All of the senior care staff have the NVQ at level 2 and some at level 3. Records showed that formal supervision induction had commenced and the owners confirmed that they were responsible for all supervision and that currently staff members were receiving monthly appraisals. . Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed competently and the staff members are supported in carrying out their respective roles. The views of residents are listened to and they are involved in decisions affecting them. EVIDENCE: Since purchasing the home in August 2006 the owners have redeveloped the policies and procedures manual, which is comprehensive and clear. The Manager who was appointed at the same time, is not registered but has applied for registration. She operates an open-door policy, which allows residents and staff to talk to her throughout the day. Residents and the visitor were very positive in their comments about the staff one said ‘they’re such Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 20 good girls – you couldn’t wish for better’. The home received the Investors in People Award in February 2005. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 22 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 OP1 Regulation 5 Requirement The registered person must provide an up to date service user guide for current and prospective residents and forward a copy of this to the Commission. The registered person must ensure that the adult protection policy and procedures are linked to Local Authority safeguarding adults procedures. Risk assessments must be conducted for residents wishing to use the garden to prevent trips and slips on the uneven paths. Timescale for action 03/01/07 2 OP18 12[1] 13[6] 03/01/07 3 OP18 13[4] 03/01/07 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 Refer to Standard OP7 Good Practice Recommendations Care assessments would benefit from gathering social histories from those residents who wish to do this, and DS0000066569.V318095.R01.S.doc Version 5.2 Page 23 Southernwood House involving their families or friends. Southernwood House DS0000066569.V318095.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 House DS0000066569.V318095.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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