Inspection on 02/11/05 for Southfield

This inspection was carried out on 2nd November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Southfield 17/07/07

Southfield 23/05/06

Southfield 21/04/05

Southfield 20/12/04

Southfield 05/07/04

Southfield 12/02/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Poldhu

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

CARE HOMES FOR OLDER PEOPLE Southfield Victoria Road Devizes Wiltshire SN10 1EY Lead Inspector Roy Gregory Unannounced Inspection 09:15 2 & 18 November 2005 nd th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Southfield DS0000028318.V262954.R01.S.doc Version 5.0 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. Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Southfield Address Victoria Road Devizes Wiltshire SN10 1EY 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) 01380 723583 01380 728647 The Orders Of St John Care Trust Valerie Weston Care Home 42 Category(ies) of Dementia - over 65 years of age (12), Learning registration, with number disability over 65 years of age (1), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (8), Old age, not falling within any other category (42), Physical disability over 65 years of age (2) Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st April 2005 Brief Description of the Service: Southfield is a purpose-built residential home for 42 older people, some of whom may have dementia or be experiencing mental health difficulties. The home was formerly owned and run by the local authority, but has for some years been provided by the Orders of St John Care Trust, one of a number of homes provided by them in Wiltshire and elsewhere. Accommodation is all in single rooms, located on two floors, with a passenger lift to the first floor. All bedrooms have wash hand basins, but none have en-suite facilities. Toilets and bathrooms are located conveniently. There are sitting rooms on each floor, whilst behind the home are extremely attractive and secure gardens, including a patio area. The dining room overlooks the gardens. The home is located in a residential area a short walk from Devizes town centre, where shopping and social facilities are available. There are good bus links to neighbouring towns, whilst the home has its own adjacent car park. Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Wednesday 2nd November 2005 between 9:15 a.m. and 4:30 p.m., when the regulation inspector, Roy Gregory, was accompanied by regulation manager, Ken Redman. As the registered manager, Val Weston, was away on leave at the time, Roy Gregory returned to the home on Friday 18th November, in order to discuss findings with Ms Weston and to be able to access recruitment information. Care plans were sampled at each visit, to compare observations of care with records. Other records examined included staff training and fire precautions documentation. A pre-inspection questionnaire had been received from the manager. Both inspectors toured the premises and Roy Gregory shared a lunch table with three residents. A number of other residents were spoken with during the inspection, as were members of staff: care leaders, carers, housekeepers and kitchen staff. At the first visit, opportunity was taken to ask a visiting district nurse about experience of working with the home. This inspection has considered 22 of the 38 National Minimum Standards for care homes for older people, of which 9 have been assessed as not meeting their intended outcomes. This was the second unannounced inspection of Southfield in the current inspection year, and for information about standards not assessed on this occasion, reference should be made to the previous inspection report. What the service does well: What has improved since the last inspection? The home’s handyman has been making progress in bringing individual rooms up to more modern standards, both in terms of redecoration, and making wash basin surrounds more hygienic, as required at previous inspection. The provider Trust had agreed an additional handyman could be employed on a temporary basis to hasten these tasks along, and it is regrettable that a person recruited chose not to take up the appointment. Some new carpeting had been installed, and provision of new dining chairs was seen as a significant material Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 6 improvement, by both staff and residents. Standards of cleaning appeared improved on the previous inspection. 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. Southfield DS0000028318.V262954.R01.S.doc Version 5.0 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 Southfield DS0000028318.V262954.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4 Residents are admitted in line with the resources of the home to meet needs, and there are systems for maintaining a service in line with assessed and changing needs and preferences. EVIDENCE: The inspector spoke with a resident who had been recently admitted at the time of the previous inspection. This person considered the home to be meeting their needs in line with the original reasons for admission. They had chosen not to take up an offer of a place at an alternative home, nearer to their town of origin, due to satisfaction with how life was organised at Southfield. This resident considered the review system had helped them to give feedback and to remind staff of their preferences for how care is provided. These reviews were held six-monthly for all residents, as part of the Trust’s quality assurance mechanisms, with care managers invited to alternate review meetings. Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 Care plans cannot be relied upon to reflect current care needs of individuals, neither are they always reviewed accurately. Weight monitoring is inconsistent and, whilst health needs are recognised and responded to by way of effective liaison with health professionals, risk of pressure damage could be reduced by better assessment and planning for preventive measures. EVIDENCE: Care plans are based on a “long-term needs assessment” that is compiled as part of the initial assessment of a prospective resident, from which short-term (working) plans are devised to direct the provision of care in specific areas. There was inconsistency in how needs were identified for inclusion in the shortterm plans. For one resident, issues brought up by them in a six-monthly review, were in fact already contained in the long-term plan, but had not been carried into the working care plan. Daily care notes for this person included guidance on encouraging mobility, and use of a pressure-relieving cushion, to relieve an identified soft sacral area; but no care plan had been drawn up as a result. The person’s GP had asked for attention to fluid supply, which had been added to the long-term needs assessment but again, not carried into the actual plan of care. There was evidence elsewhere in the person’s care records, but Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 10 not in the care plan, of district nurse guidance on pressure area care, including advice to apply cream to the sacral area. A visiting district nurse said she treated a number of pressure sores at Southfield. Whilst satisfied that staff were attentive to recognising danger signs early and reporting them for attention, before major problems occurred, she felt there was scope for more preventive planning, especially identifying residents at most risk and planning for mobilising, nutritional monitoring or skin care as necessary, thereby avoiding residents’ needs for nurse attention in the first place. During her visit, it was necessary for the district nurse to point out a resident who should have been sitting on a pressure-relieving cushion. The inspector is aware that the provider Trust had withdrawn the former pressure area risk assessment from its care planning documentation, whilst awaiting external professional guidance on a replacement. But this home has had a succession of requirements about pressure area assessment and care planning, and it remains the case that risks must be identified and reflected in short-term care plans. This approach will protect residents and demonstrate that care has been given in a consistent and planned way, based on best practice. Another aspect of health-related monitoring is the weighing of residents, with related record-keeping. Examples were seen of weighing plans not being kept up. One resident had a care plan for monthly weighing, but weights were recorded for only six months out of twelve. If the “missing” months were due to refusals or agreements not to weigh, this needed recording. Another resident was also care-planned for monthly weighing, but no weights were recorded between May and November 2005. On the latter occasion, when other ill health indicators were also noted, a significant fall in weight became apparent, prompting referral to the GP. Compliance with the plan, therefore, might have enabled an earlier recognition of declining health. A third resident had asked through review to be weighed weekly, but there was no evidence that this was done. The requirement from previous inspection about weighing plans was therefore not met. The inspector suggests that care plans may have become too unwieldy, and would benefit from being simplified to concentrate on core needs, as well as updated at each resident’s next review. There was good evidence that staff have been very alert to possible ill health indicators, leading to referrals to GPs and district nurses as appropriate, but if ensuing directions for care are contained only in daily care records designed mainly for handovers between staff shifts, rather than in a plan of care as required by regulations, then shortcomings or progress become equally difficult to track. It is also possible to lose sight of “the bigger picture.” For one resident there were repeated notes of staff concerns about and responses to behaviours such as wandering, but the care plan gave no indication of the extent of the person’s dementia, and thus no coherent plan for addressing their primary needs. Another resident was subject of some restrictions in connection with addictive behaviours, to Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 11 which they had signed agreement; some elements of the arrangements had changed, as all staff and the resident appeared to be aware, but the care plan had not been amended to take account of the changes, leaving a danger of dispute about detail. Southfield DS0000028318.V262954.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 & 15 Within existing resources, there is support to residents’ needs for activities and stimulation, but this is held back by a current lack of dedicated staffing to actively plan for and encourage engagement with individuals and groups. Residents are assisted to make some daily choices about everyday matters such as going out, but staff are limited in time available to offer motivation to those needing most encouragement. Meals are of high quality and served to meet individual needs. EVIDENCE: It is regrettable that as yet the home has been unable to recruit an activities co-ordinator, as many residents spend considerable time sitting without activities available to occupy them. There is in fact an attached day centre, which residents are welcome to attend to share in various activities. One resident used this facility regularly and could not understand why many others did not, but care leaders recognised that encouragement and motivation were necessary factors, and considered this was where shortage of staff had the greatest impact. The activities co-ordinator post provides for hours dedicated to this aspect of residents’ needs, and may be expected to make a considerable difference when filled. That said, a programme of events had been sustained, with two or three special events per month, including usually at least one concert. Residents expressed appreciation of these kinds of events. Recently there had been a successful cinema evening, including Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 13 popcorn and ices, and this was to be repeated, whilst there had also been a summer barbecue and skittles. A care leader said there would always be an attempt to put on some activity, such as bingo, on Saturday afternoons, but it would depend on staff availability. Some more active residents maintained activities and interests outside the home, and care plans indicated assistance to be given to these. For example, one care plan, together with a risk assessment, stated the need to assist with making taxi arrangements to enable trips into town, and this was seen being put into effect. The resident concerned said how important this was to them. Some residents spoke of a regular prayer meeting that had been recently started. The inspector joined residents for the midday meal. This was a relaxed, sociable occasion. The day’s menu was displayed in the main hallway, with choice of main course and sweet being exercised at table. Residents said they were very happy with meals served in the home. A vegetarian and a diabetic were each satisfied with the choices available to them. Examples of sensitive care were seen in respect of residents needing a little assistance with meals, and both kitchen and care staff displayed awareness of personal likes and dislikes, including the size of meal preferred by some. Southfield DS0000028318.V262954.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Complaints receive appropriate investigation and action, thus enhancing the service provided by the home. Staff in all roles are alert to the potential risks faced by residents, and the means by which to help ensure their protection. EVIDENCE: Since the previous inspection, the home had received four written compliments whilst ten matters had been addressed by way of the complaints procedure. These concerned issues such as noise, and laundry delivery. Where upheld, identified shortfalls were corrected by practical solutions, and reinforcement to staff of expected standards. For example, staff meeting minutes showed there had been discussion about how to improve handling of delicate items in the laundry, and distribution of clean laundry. In all cases an apology was extended to complainants for their experience of less than satisfactory service or care. The provider Trust’s procedures were followed and proved effective. In one instance, a matter of complaint had been referred to county office level. In recent months a need had not arisen for referral of any matters to interagency vulnerable adult procedures. Following recommendation at previous inspection, a total of 21 staff have attended abuse awareness training. Southfield DS0000028318.V262954.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26 The home has a run-down feel in many parts, the gradual improvements only slowly introducing more modern standards. Communal facilities, apart from the gardens and dining room, are uninviting. Residents have made themselves at home in bedrooms, with much use of personal possessions, but improvements to rooms have not significantly benefited existing residents. Bathrooms and toilets are sufficient, and hygiene standards were being maintained. EVIDENCE: There was little sign of use being made of communal sitting rooms, other than the large lounge downstairs, and the entrance hall area. There may be a preference among many residents to use television and radio in personal rooms, but in any case the recently redecorated bar/smoking room and small sitting room opposite were uninviting by virtue of burnt carpets, old furniture and lack of interest generally. Many bedrooms also had worn carpets and tired decorations. One bedroom occupied for some time by a male resident had “feminine” wallpaper that did not fit his personality. A female resident said she had ceased to ask about the possibility of redecoration and re-carpeting. Many rooms have been attractively redecorated as they have become vacant, and Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 16 one of these had been made available to an existing resident. Others were said to have not wished to move rooms, although a temporary move might enable a room to be worked on. The home was without a handyman for a substantial period, and the present post-holder is working hard on a programme of gradual improvement to rooms, including making good deteriorated wash hand basin surrounds, identified at previous inspection as posing a hygiene risk. The handyman demonstrated the multitude of tasks involved in each room improvement. The Trust had agreed the home could appoint an additional person for six months to hasten the programme of improvements to bedrooms and corridors, but as this has not come about, the manager was intending to make arrangements for contractors to attend. New carpeting was on order for downstairs corridors, and to replace carpet tiles in some bedrooms. Bathrooms and toilets mostly presented quite well and some previously identified hot pipes had been covered to make them safe from presenting risk of burn injury. The hairdresser’s room was mid-way through a facelift, although still in use. It was said that new equipment and furniture were to be provided. The dining room had been provided with new chairs, which found favour with both residents and staff. Standards of cleaning were improved on the previous inspection. A recently recruited housekeeper described receipt of some infection control training within her induction, which she appreciated. Southfield DS0000028318.V262954.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 Staff qualities and morale are undermined by low staffing levels that have reduced the quality of service and put residents at risk. A commitment to staff training has been upheld, and recruitment practice is very good. EVIDENCE: Maintaining staffing levels had been a problem for the home for some months. Shifts are arranged to provide at least five care staff in the morning and four on the later shift. These levels were achieved in the majority of cases, but rotas showed many shifts were programmed to be covered by agency staff, and there was no guarantee of agency staff being available to fill these gaps. Worse, was a problem of home staff giving late notice of unavailability, especially at weekends, when it was unlikely agency cover would be available at short notice. A care leader had left in response to questions about their competence, and three care workers were “acting up” at various times to the vacant care leader position. For the manager’s absence on leave, the Trust had arranged for a “Head of care” from another of its homes to lend support to the care leaders. Many staff were concerned about the effects of low staffing levels, one care leader saying “we are at the mercy of agency provision”. Some evening shifts had been covered by three care staff, including a care leader, and it was anticipated this level would be repeated on occasions. Sometimes some relief could be arranged by two hours additional care staff cover around teatime. Care staff identified that low staffing levels restricted “quality” time with residents, including support to making choices, and created risks of medication Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 18 errors or reduced vigilance. The visiting district nurse thought staffing levels were low. A care leader came into the home on their day off in order to catch up on administrative tasks, and the inspectors considered the standard of record keeping indicated too little time being available for this. It was evident that the task of recruitment was being tackled purposefully, but with no cutting corners in respect of safe recruitment. There were good records of all interviews, and of exploration of issues arising from application forms or from references. One potential appointee was on hold whilst further references were pursued. The Trust has good systems for obtaining CRB disclosures. With regard to staff training, it was easy to track “refresher” training for mandatory courses. For each staff member there was a record of training with copies of certificates obtained. In the current year, training provided had included fire training, infection control and stroke awareness, and also input from a district nurse on avoidance of needle sick injury, in response to a requirement from the previous inspection. Newer staff had given very positive written responses to their induction training provided by the Trust. Planned training included dementia awareness, which should improve the approach to care planning in this regard. Southfield DS0000028318.V262954.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 The registered manager has been seen to begin addressing matters such as staffing levels and poor environment, that impact upon residents’ lives. Residents’ opinions about the quality of care they receive are effectively sought on an individual level, whilst there remains scope for improving group feedback and communication within the home. Health & safety monitoring is good, but lack of attention to fire precautions puts residents at risk. There are safe systems for protection of residents’ monies. Staff supervision has continued to be arranged. EVIDENCE: Val Weston was registered as manager of Southfield in June 2005. Staff at all levels were appreciative of the lead she has given, and her efforts to recruit new staff, whilst residents find her approachable. There had been meetings of care staff, night staff and housekeepers, with overlapping agendas, and there were senior staff meetings in May and July 2005, suggesting another was timely. Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 20 In addition to the shortfalls in care staff numbers and difficulties recruiting to handyman and activities co-ordinator posts, the home was also without an administrator for several weeks. A new administrator had just been appointed at the time of inspection. There were satisfactory arrangements for safe keeping of residents’ monies, where they or their families had requested this. Some care records showed how a resident wished for support with money issues. The manager said attempts were being made to establish bank accounts for some residents without such a facility at present. Two residents spoke of their awareness of how to access personal monies in safe keeping, and it was seen that immediate response was made to requests for access, with appropriate safeguarding systems in place. There was a displayed plan for staff supervision. This had shown some tail-off through the summer months, but it could be seen that supervision sessions were programmed into the staff rota and staff spoke of receipt of supervision. Inductions were well followed up by manager appraisals. One carer had received training in newsletter production, and this needed to be progressed. There had been a start on arranging “cluster group” meetings of residents, but this also needed more impetus, which was unlikely to be achieved until staff numbers are more dependable on the ground. On an individual level, residents received six-monthly reviews. These were well recorded and showed residents and supporters could have a say about the overall care they received, and specific preferences, which in the ones seen were often about food. In one example, the written record confirmed the resident’s recall of review, and showed delegation of identified matters for action, such as referral to an occupational therapist. For some residents less able to advocate for themselves, issues identified at review had not always been addressed, for example by incorporation into a care plan, from one review to the next. Whilst Trust and home procedures make good provision for ongoing attention to health and safety matters, the fire precautions documentation was in poor order, and following the resignation of a care leader, nobody had been delegated the task of appointed fire person. Weekly system tests had been maintained, but there was no recent record of routine checks on means of escape, and the record of identified defects did not show whether these had been rectified. In many homes, these tasks are delegated to the handyman. There was no evidence of a fire drill having taken place in the period July to September 2005, and the record of fire instructions to staff was incomplete. Southfield DS0000028318.V262954.R01.S.doc Version 5.0 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 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 3 X X 2 X 3 STAFFING Standard No Score 27 1 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 2 Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7OP8 Regulation 12 (1)(a) Requirement Pressure area risk assessments must be completed soon after admission, including for respite service users, and identified risks must be reflected in short-term care plans. (Requirement with original timescale of 31st May 2005) There must be a planned frequency of weighing for each service user, and weights must be recorded in a consistent manner. (Requirement with original timescale of 31st May 2005) All communal areas must be provided with sufficient and adequate seating and other furnishings. The number of care staff on duty, other than on night shifts, must not be allowed to fall below four; the Commission must be notified of any occasion when circumstances cause this requirement not to be met. There must be a designated person responsible for DS0000028318.V262954.R01.S.doc Timescale for action 31/12/05 2. OP7OP8 12 (1)(a) 31/12/05 3. OP20 16 (2)(c) 31/01/06 4. OP27 18 (1)(a) 37 (1)(e) 01/12/05 5. OP38 23 (4)(c)(v) 01/12/05 Southfield Version 5.0 Page 23 6. 7. OP38 OP38 23 (4)(d,e) 23 (4)(c)(v) organisation of fire precautions monitoring. All staff must receive routine fire instructions and experience of fire drills. Checks of all fire precautions must be carried out at least at recognised intervals. 31/12/05 01/12/05 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 OP7OP8 OP33 Good Practice Recommendations Individual reviews should be used as an opportunity to simplify care plans, whilst ensuring their accuracy. Continue to develop and record residents’ cluster meetings, and seek to commence production of a regular newsletter. Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Southfield DS0000028318.V262954.R01.S.doc Version 5.0 Page 25 - 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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