Inspection on 04/01/06 for Southfield

This inspection was carried out on 4th January 2006.

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 01/10/08

Southfield 03/10/06

Southfield 25/07/05

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

St George`s

5 Seafield Road

Credence House

Poldhu

Queensmount

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

CARE HOMES FOR OLDER PEOPLE Southfield Park Road Stroud Glos GL5 2JQ Lead Inspector Mrs Ruth Wilcox Announced Inspection 4th January 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 Southfield DS0000064615.V275599.R01.S.doc Version 5.1 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 DS0000064615.V275599.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Southfield Address Park Road Stroud Glos GL5 2JQ 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) 01453 764892 01453 759642 The Orders of St John Care Trust Mrs Celia Denise Kidd Care Home 36 Category(ies) of Learning disability over 65 years of age (1), Old registration, with number age, not falling within any other category (35) of places Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2005 Brief Description of the Service: Southfield is a purpose built care home, providing long term personal care for thirty six older people, with one room designated to provide short term respite care. The home is also accommodating one named person over the age of 65 years with a learning disability. The home is managed by The Orders of St John Care Trust, and is situated in a residential area of Stroud. Medical and nursing services are accessed for residents if needed, from community resources. The home is built on three floors with a shaft lift and chair lift accessing all areas. Residents private accommodation is situated on the two upper floors, and is provided by 32 single rooms and 2 double rooms. There are a number of assisted bathrooms, shower rooms and toilets situated in convenient locations around the home. On the ground floor there are two homely lounges, an activities room, and a very spacious dining room. There is a small shop situated in the corner of the dining area for residents convenience. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this announced inspection over five hours on one day in January 2006. The home manager was present throughout the inspection providing assistance and information where required. The home appeared very organised, was warm and welcoming, relaxed and homely. The availability of information about the home to assist prospective residents and their families in making their choice was looked at, as were the contractual arrangements once admitted. Care records, medication management, the standard and choice of meals, and the opportunities for residents to engage socially were inspected. The care of three residents was closely looked at in particular, and there was direct contact with at least ten residents; their views regarding the standards of services and care at the home were sought wherever practicable. The provision of staff and the way in which they are recruited and trained was inspected. The management arrangements for the home were looked at, as were the policies for dealing with any complaints or concerns should they arise. A tour of the premises took place, and the arrangements for ensuring the health and safety of all living and working at the home was inspected. Staff were observed going about their duties whilst interacting with the residents. There was direct contact with eight other staff, all of whom were most welcoming and helpful, and were open to the inspection process. What the service does well: Southfield is a safely maintained, very clean and comfortable home for the residents living there. The home has a light, airy and pleasant atmosphere. Prospective residents and their families have access to information about the home, including the necessary contractual information, ahead of their Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 6 admission, in order that they can make an informed choice about moving there. Residents, without exception spoke very highly of the attentive and kind staff group, confirming that they feel well cared for. The staff group was very helpful and welcoming, and were clearly committed to the interests of the residents in their care. The team works under the guidance and leadership of an experienced and long serving registered manager. The home provides a variety of social opportunities for the residents, and endeavours to consult with the residents about their preferences. There is a good standard and choice of food available, and all residents spoken to said that the quality and quantity of food was consistently very good. There is a robust system for dealing with complaints and concerns when they arise, with evidence that there is confidence in the manager and staff to be receptive, to listen and be committed to addressing any issues. What has improved since the last inspection? What they could do better: The Orders of St John Care Trust have not yet produced updated and current versions of the home’s Statement of Purpose and Service User Guide, despite taking over the management of the home eight months ago. Work is reported to be ongoing at this time, and they are required to submit the new documents upon their completion to the CSCI. The standard of care plan documentation and medication management has greatly improved, and is generally very good, but there were isolated instances where improvements could still be made. These included the need for greater detail in care plans in respect of certain needs relating to mental health and Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 7 pressure area care, and regarding directions for some medication usage, for which instructions could be much clearer. Staff do have access to the NVQ training programme, though the home is not currently meeting the standard of having at least 50 of its staff qualified to NVQ level 2; the home continues to try to address this by encouraging and supporting staff to train. Recruitment of staff is generally in accordance with requirements; just one omission was identified on this occasion, and although was judged to be an oversight, could have posed a risk to residents. It remains that those responsible for recruitment must ensure that they adhere to the requirements regarding pre-employment checks at all times. 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 DS0000064615.V275599.R01.S.doc Version 5.1 Page 8 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 DS0000064615.V275599.R01.S.doc Version 5.1 Page 9 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): 1 & 2. The pre-admission information and contractual arrangements ensure that residents have access to adequate information when making their choice about the home. EVIDENCE: Prospective residents are provided with an information brochure, which informs about the home and The Orders of St John Care Trust; the information is currently under review, with a revised and more up to date Service User Guide being produced. The home’s Statement of Purpose is contained in a large folder, which is easily accessible in the main hall for anyone choosing to read it. This is fully reflective of the requirements in the regulations, but is also under review by The Orders of St John Care Trust; some of the information contained in here will actually need to be included in the new Service User Guides, to ensure that they fully meet the requirements. Residents are supplied with contracts on admission to the home; a sample was seen. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 10 The home also issues a copy of the terms and conditions of the home for County Council funded residents, which accompanies their Individual Service Contract from Social Services. Intermediate care is not provided at Southfield. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 11 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 & 9. There is a care planning system in place, which can adequately provide staff with the information they need to satisfactorily meet residents’ health and personal needs; very isolated omissions in recording have not compromised this at this time, and improved recording in these cases would be more representative of how health needs are being met in practice. The systems for the administration of medications are generally good, with arrangements in place to ensure residents’ medication needs are met; some additional recording would ensure greater consistency in isolated cases. EVIDENCE: Each resident has an individual plan of care, which in the main is based on an assessment of their needs, including risk assessments. Three were selected as part of the case tracking exercise. Generally, staff have worked very hard to improve the standard of their care planning documentation, and plans are now mostly well written, are done so in consultation with the resident concerned, and are regularly reviewed. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 12 The majority of plans that formed the case tracking exercise contained clear instructions as to how each individual’s health needs are to be met, with visual evidence confirming that this is carried out. However, despite very good recording in most cases, there were some isolated gaps where more detailed planning for care should have been recorded. These instances were in respect of two residents who were under the care of the psychiatric services for mental health issues, one of whom could present with some behavioural difficulties; guidance for the management of this by staff was not documented. There was no documented plan of care for the other person regarding their mental health needs at all. This same person had also been identified as being at risk of developing a pressure sore; there was no plan of care to address this fact. Residents themselves spoke very positively about the care they receive from the staff, appearing keen to confirm that they receive very good care. Two people actually said that they had benefited enormously in terms of their health and happiness since coming into Southfield. The system for handling residents’ medications is generally safe, clean and well managed. All staff responsible for the management of medications have received accredited training. All medications are stored appropriately, with good stock rotation, and with clearly printed Medication Administration Records from the supplying pharmacist. These records are thoroughly recorded by the staff, and are well maintained. Some of the medication administration charts do not include the precise administration instructions regarding the use of prescribed external medications and ‘when needed’ (PRN) medications; neither are there care plans to demonstrate their appropriate usage. There were also isolated instances of ‘as directed’ instructions on charts. Residents are supported to self-medicate if they wish and are able to, and this is done on the basis of a documented risk assessment. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 13 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 & 15. An activities and entertainments programme is offered, in order that residents are provided with regular and varied opportunities for social activity. Dietary needs of residents are adequately catered for, with a good selection of food available that meets their tastes and choices. EVIDENCE: The home provides a range of social opportunities for residents, and is currently exploring options to enhance and increase this further; there is a designated activities coordinator to consult with the residents, and plan social events. Opportunities vary from social gatherings, to entertainments and observations of calendar festival dates, to small group activity and interest sessions, to something more individual. Physical exercise sessions are available, and religious services also. A knitting circle is being reinstated. There has recently been a good programme of seasonal activities and entertainments over the Christmas period. A novel, but much enjoyed display of ballroom dancing had been put on for the residents’ entertainment. Some of the residents themselves confirmed that they pursue their personal interests in terms of recreation, with some saying they regularly go out. Others Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 14 were reading their newspaper and books, listening to music, doing crosswords or just socialising. There is a good range of varied and nutritious meals available for residents, and from conversations and observation of the lunch it was clear that they are also offered choice with their meals. Residents are consulted regarding their choices from the menu, with a list of preferences sent to the kitchen for the cook’s reference, with special diets observed. The meal at lunchtime looked wholesome and appetising, and residents confirmed their enjoyment of it. The meal was nicely presented by the attentive staff in the spacious and comfortable dining room, with the use of serving dishes and gravy boats; napkins, condiments and drinks were provided. All residents spoke very positively about the quality and quantity of food provided for them, saying that the food was ‘really very, very good’. The kitchen has recently been inspected by the Environmental Health Inspector, so was not visited on this occasion. The home is to be commended for receiving an award from the Council on the basis of that inspection, for the high standards it has achieved in the kitchen. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 15 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 The home has a satisfactory complaints system, with evidence that residents feel that any concerns they may have are listened to and acted upon. EVIDENCE: A copy of the complaints procedure was clearly displayed for anyone wishing to read or use it. Residents confirmed that staff are attentive to them, with some saying that staff will do what they can to help them. Those spoken to had confidence in the staff and manager to respond quickly to any concerns raised, and to take any corrective actions necessary. The home maintains a record of complaints and concerns received. The record contained evidence of one complaint received since the last inspection, which had been appropriately addressed. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 16 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 & 26. The standard of the environment within this home is good, and provides residents with a comfortable and safe place to live. The home is clean, with appropriate and full observations regarding the control of infection. EVIDENCE: Southfield provides a safe, comfortable and well maintained environment for the residents living there. A maintenance person is employed, and a rolling programme of redecoration is carried out, with some bedrooms, lounge and corridors having been done since the last inspection; further decoration and repair work was being carried out during this visit to improve the appearance around the entrance hall and downstairs corridor. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 17 Records show a range of periodic and cyclical maintenance tasks that are carried out routinely. The home is cleaned to a good standard, and despite very occasional transient odours, was largely fresh and odour free throughout the visit. Laundry and clinical waste is safely managed, and gloves, aprons, liquid soap and paper towels are provided. There is due regard to infection control procedures by all grades of staff throughout the home. A new washing machine has been provided since the last inspection to improve the washing facilities in the laundry room. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 18 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, 28 & 29. Staffing provision is adequate to meet the needs of the residents currently living in the home. The home encourages care staff to undertake a care qualification, in order that they can fully understand their roles. Robust recruitment procedures ensure that suitable staff are employed for the protection of residents, however any failure to observe these consistently could pose some risks. EVIDENCE: Staff rotas are recorded, and these plan for five, four, and three carers to be on duty during the morning, afternoon and overnight respectively. In addition to this, the Registered Manager works in a supernumerary capacity on five days of the week. Since the last inspection a new Deputy Manager and Shift Leader have been appointed, and a recruitment day is planned for later this month to address a small number of existing staff vacancies. There is a well established designated ancillary team of administration, domestic, catering and maintenance staff to support the care team. Staff were observed whilst assisting and interacting with the residents, and were attentive, sensitive, and polite. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 19 The home appeared calm and organised, and residents without exception were very complimentary about the staff team as a whole. There are currently five care staff who are already qualified to NVQ level 2 standard. One carer is making progress with the level 3 award, and there are two others making good progress on the level 2 programme at present. The number of qualified carers does not meet the 50 target that should have been achieved by the end of 2005, due in part to some leavers, though the home will continue to make all efforts to work towards achieving it in the future. A random selection of staff files was chosen for inspection. Each record contained application forms, including a full employment history. Records of interviews were seen. Full and complete evidence of the required pre-employment checks was seen in the files. There was just one exception to this however. An error had been made when the home had mistakenly understood from The Orders of St John Care Trust county office that a POVA First clearance had been obtained for a care worker, and her employment was commenced under supervision. Upon close scrutiny it was noted that the POVA First clearance had not been received, merely requested, resulting in the worker starting work without a POVA clearance. Given the clearly robust procedures followed in all other cases, it is accepted that this was an unfortunate oversight in these circumstances, and is not likely to recur. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 20 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 & 38. There are good, effective management systems in place to ensure that the welfare, health and safety of the residents is safeguarded. EVIDENCE: The home manager is very experienced, and is a long serving member and leader of the staff team. She is registered with the CSCI, and has achieved the Registered Manager’s Award. She ensures her continued professional development, and is due to attend some additional management training courses in the near future. The manager and her staff have been working towards achieving the ISO quality assurance standard, and should be commended for their success. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 21 There was clear evidence that health and safety issues are addressed well in this home, with written policies, procedures and risk assessments, provision of necessary equipment and staff health and safety training, and fire safety training and drills. Recommendations made following a Fire Officer inspection are currently under consideration by the home. There are nine members of staff currently qualified to provide First Aid, and appropriate First Aid facilities are provided. All necessary safety checks and maintenance of equipment and utilities is undertaken in a timely fashion. The arrangements regarding maintenance of the chair lift are currently under review. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 22 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 2 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x x x 3 Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 23 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 OP1 Regulation 4(2) 5(2) Requirement The home must send the revised copies of the Statement of Purpose and Service User Guide to the CSCI upon completion. Staff must ensure that all elements of care planning are fully detailed, in order to clearly demonstrate how residents needs are to be met; this is with particular reference to mental health needs on this occasion. (previous timescale of 31/8/05 not met in full) Staff must devise written care plans for all residents who are assessed as being at risk of developing pressure sores. Staff must ensure that there are clear instructions regarding the use of ‘PRN’ and external medications on the medication charts. The home must avoid the use of ‘As Directed’ instructions on medication charts. The registered person must ensure that in cases where a worker commences employment DS0000064615.V275599.R01.S.doc Timescale for action 31/05/06 2. OP7 15(1) 28/02/06 3 OP7 15(1) 28/02/06 4 OP9 13(2) 28/02/06 5 6 OP9 OP29 13(2) 19 28/02/06 31/01/06 Southfield Version 5.1 Page 24 pursuant to the receipt of a CRB disclosure, that POVA clearance is first obtained. 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 OP9 Good Practice Recommendations The directions for the use of ‘PRN’ and/or external medications should be recorded and linked in to a relevant plan of care. Southfield DS0000064615.V275599.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 DS0000064615.V275599.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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