Inspection on 23/09/05 for Southfield Care Home

This inspection was carried out on 23rd September 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 Care Home 26/06/06

Southfield Care Home 23/03/06

Southfield Care Home 13/07/05

Southfield Care Home 04/03/05

Southfield Care Home 06/08/04

Southfield Care Home 16/06/04

Southfield Care Home 13/05/04

Southfield Care Home 22/04/04

Southfield Care Home 11/12/03

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Southfield Nursing Home Belton Close Great Horton Bradford BD7 3LF Lead Inspector Mary Bentley Unannounced 23 September 2005, 09.15 rd The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Southfield Address Belton Close Great Horton Bradford BD7 3LF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 521944 Southfield Health Care Ltd Care Home with Nursing 42 Category(ies) of Physical Disability Over 65 (42) registration, with number of places Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 19 August 2005 Brief Description of the Service: Southfield is a care home with nursing and is a Grade 2 listed building; the premises were formally a school and opened as a care home in 1995 following conversion of the property. It is located in the Great Horton area of Bradford and is within easy access of local shops and amenities. Accommodation is provided on two floors with access to all internal areas being provided by a passenger lift. The home has 32 single and 5 double rooms with 24 of these rooms providing en-suite facilities. Communal space is provided on the ground floor and consists of a large dining room, a conservatory and a small lounge. The home is registered to provide nursing and personal care for up to 42 older people with physical disabilities. The home has a garden area and car parking is provided at the side of the building. Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that time, the CSCI is required to carry out a minimum of two inspections of all care homes. The first inspection took place on July 13th 2005 and was unannounced. Since then two additional visits have been made to the home on July 26th 2005 and August 19th 2005 to investigate complaints and to follow up concerns about staffing levels. Letters were sent to the provider following the visits on July 13th 2005 and August 19th 2005 in which the CSCI raised serious concerns, these included concerns about staffing levels. Copies of the complaint investigation report and the additional visit report can be requested from the CSCI office at Rodley. The registered manager left the home in July 2005; the provider is meeting with the CSCI next week to discuss his proposals for the management of the home. The inspection was unannounced and was carried between 9.15 am and 2.00pm on 23rd September 2005 by two inspectors. What the service does well: What has improved since the last inspection? Some improvements have been made to the environment since the last inspection, a new carpet has been fitted in the conservatory and new bedding and towels have been made available. We were informed of further work planned for the near future, which will include some new bedroom carpets. There has been some improvement to staffing levels however there are still several shifts when there are not enough staff on duty to meet residents needs. The records seen showed that there has been an improvement in the recruitment procedures. Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 6 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 Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 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 standard(s) 2 & 3 The pre-admission assessment procedures are not robust enough to assure future service users and/or their representatives that the home can meet their needs. EVIDENCE: The terms and conditions seen did not make it clear what the optional top up fee of £7.10 actually covers, some of the terms and conditions seen did not state what the fee was and had not been dated or singed. In the file on one newly admitted service user there were no terms and conditions. The pre-admission assessments that had been done did not have enough information about who was involved in the assessment. Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 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 standard(s) 7 & 8 The health and personal care needs of service users are not properly met; specific areas of concern are pressure area care, the management of nutrition, the management of continence and the care of people with dementia. Service users and their representatives have little opportunity to be involved in planning care. EVIDENCE: The care records of a service user with a pressure sore showed that no pressure relief equipment was being used, there was no evidence of a turn chart or other actions to reduce the risk of further tissue damage. The care plans about the pressure sore did not say what dressings were to be used. The weight records showed a steady weigh loss over recent months, but the nutritional assessment had not been reviewed since November 2004 and there was no care plan for eating and drinking, fluid balance charts were in place but were not filled in properly. In the care records of a service user with a diagnosis of dementia there were no care plans to show how this aspect of care would be managed. The daily records showed that there were issues about personal care and behaviour and the care plans did not give guidance to staff on how to deal with this. There Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 10 was no information on how continence would be managed despite the fact that the bedroom had a strong smell of urine. In the records of three service users recently admitted to the home there were no nutritional assessments and in one case no weight had been recorded at the time of admission. A risk assessment about bed rails had been completed for one service user but there was no evidence of consultation with the service user or a representative. Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 11 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 standard(s) These standards were not inspected. EVIDENCE: Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 12 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 standard(s) These standards were not inspected. EVIDENCE: Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19, 22, 24, 25 & 26. Despite the fact that some improvements have been made since the last inspection there are parts of the home that are not clean. Offensive smells in many of the bedrooms create an unpleasant environment for service users. Poor working practices place service users at risk. EVIDENCE: A new carpet has been fitted in the conservatory, however the fitters have made a join across the main doorway from the dining room and in time this will fray and create a trip hazard. Thirty new sets of bedding have been purchased along with new towels and material has been purchased to make new bed covers and curtains. Many of the rooms still had an unpleasant smell and in some rooms the toilet bowls were badly stained. Some mattresses and beds had been removed and the acting manager said that six bedrooms were to have new carpets fitted next week. Part of the ground floor corridor and the first floor corridors are to Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 14 be measured for new carpets, (next week), a new carpet-shampooing machine has been ordered. The situation with the call bells remains unchanged, with no call bells available for residents in many parts of the home, we were told that the company who maintains the call bells was due to visit next week. The ground floor sluice was stained and dirty commode pans and urine bottles were left piled up on the side. A used incontinence pad was discarded in one of the toilets. Bars of soap were seen in communal bathrooms and toilets; the use of communal soap creates a risk of cross infection. There was a strong smell of detergent in the laundry suggesting a lack of proper ventilation. Nothing has been done about the extractor fans that are broken and bath thermometers were not available in all the communal bathrooms. Nothing has been done about changing the system for naming service users personal clothing. Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 There are not always enough staff working in the home to meet the needs of service users. EVIDENCE: The provider and the CSCI have agreed minimum staffing levels for the home. During the inspection on 13th July 2005 it was evident that these staffing levels were not being maintained. There were no kitchen assistants working in the home and therefore care assistants were being taken away from care duties to attend to kitchen duties. After that inspection the CSCI wrote to the provider to inform him that the agreed minimum staffing levels must be maintained. During the visit on August 19th 2005 we found that staffing levels had not been maintained and an immediate requirement notice was issued. During this visit we checked the duty rosters from August 19th to September 23rd 2005. Some improvement has been made for example during the week commencing 29th August 2005 there home was short staffed every morning and during the week commencing 19th September 2005 all but one of the morning shifts were fully staffed. In this time afternoon shifts were short staffed on at least two days every week meaning that there were only three care assistants on duty. On at least one occasion one of the three was a care assistant who had only been working in the home for 2 days. Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 16 We looked at the file of care assistant recently employed; all the required checks were done before she started work in the home. Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 & 38 The management approach to the home does not make sure that service users receive a consistently good level of care. This results in some practices that do not promote and safeguard the health, safety and wellbeing of the people using the service. EVIDENCE: The acting manager is working full time as a nurse and has no time allocated for management duties. While she is clearly committed caring for service users this arrangement means that she does not have the time to carry out either role effectively. There are no records of the provider’s visits to the home although the acting manager said she has regular contact with him. The fire exit in the basement is obstructed, there are sheets of wood stored there and ladders hung on the wall. Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 1 x x 2 x 2 2 1 STAFFING Standard No Score 27 1 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 1 2 x x x x x 2 Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 19 Yes 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 1 Regulation 4 Timescale for action The registered persons must 25 operate the home within the November agreed categories of registration. 2005 Previous timescale 10/08/05. The terms and conditions must include information on the fees payable and the method of payment. 25 November 2005 Requirement 2. 2 5 3. 3 14 Previous timescale 10/09/05.. The pre-admission assessment 25 records must provide information November on who has carried out the 2005 assessment and provide evidence of consultation with service users and/or their representatives. Previous timescale 10/08/05 The care plans must provide evidence of consultation with service users and/or their representatives. Previous timescale 10/09/05. The care plans must set out in detail how all needs identified during assessment will be met. 25 November 2005 4. 7 15 Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 20 5. 8 17(1)(a) Schedule 3, 3(m) Service users plans must include information on how nutrition needs are being identified and met. Previous timescale 10/09/05 Service users plans must include details of pressure area care and continence care. The registered persons must make sure that service users receive the necessary treatment and/or advice from other health care professionals. Previous timescale 23/09/05 not met. The registered persons must make arrangements for the naming of service users personal clothing to make sure that resdients are wearing their own clothes at all times. 18 November 2005 6. 8 13(1)(b) 25 November 2005 7. 10 12(4)(a) 25 November 2005 8. 12 13(4) Previous timescale 10/09/05 The registered persons must 28 October make sure that proper 2005 arrangments are made to protect the health and welfare of service users when they go on organised outings. Carried forward from the last inspection. The registered persons must sure that fire exits routes inside and outside the home are kept free of obstructions and maintained in a safe condition at all times. Previous timescale 10/08/05. Access to the call bell system must be provided in all areas used by service users. Previous timescale 10/09/05. 9. 19 23(2)(b) 28 October 2005 10. 22 23(2)(c ) 18 November 2005 Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 21 11. 25 23(2)(p) 13(4) The extractor fans in the communal toilets and en-suite facilities must be repaired or replaced. Bath thermometers must be provided in all bathrooms used by service users. 25 November 2005 12. 26 16(2)(k) Previous timescale 10/09/05. The home must be kept clean and free of offensive odours. Previous timescale 10/08/05. The registered provider must ensure that there are at all times sufficient staff working in the home to meet the needs of service users. Previous timescale of 19/08/05 not met. The registered persons must submit proposals for staffing levels for service user numbers of 31 upwards. Previous timescale of 29/04/05 and 18/07/05. A minimum of 50 of care staff must achieve NVQ level 2 or equivalent within the target timescale. Previoulsy agreed timescale of 31/12/05 The acting manager must be allowed supernumerary time to carry out her management responsibilities. The registered persons must provide evidence that visits to the home are made in accordance with this regulation. Previous timescales of 8/11/04, 25/02/05, 31/05/05 and 10/09/05. 27 September 2005 27 September 2005 13. 27 18 14. 28 18 31 December 2005 15. 31 10 & 18 27 September 2005 25 November 2005 16. 32 26 Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 22 17. 36 18 Staff must receive formal supervision at least six times a year. Carried forward from the last inspection. A detailed record of all accidents and incidents involving service users must be maintained. Carried forward from the last inspection. 10 October 2005 18. 38 17(1)(a) Schedule 3. 3(j) 25 November 2005 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 8 Good Practice Recommendations The home should obtain a copy of the local Primary Care Trusts policy on the prevention and treatment of pressure sores. Carried forward from the last inspection. Consideration should be given to the appointment of an activities organiser. Carried forward from the previous inspection. With the permission of service users, consideration should be given to the creation of an identity card for those service users who go out alone, to carry in case of accident or emergency. Carried forward from the previous inspection. The registered persons should make sure that service users representatives are made aware of the homes complaints procedures. Carried forward from the last inspection. Consideration should be given to converting one of the first floor bathrooms to a shower room. Carried forward from the previous inspection. It is recommended that a system of numbering receipts to correspond with the running record of entries be J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 23 2. 12 3. 13 4. 16 5. 21 6. 35 Southfield Nursing Home implemented to make auditing and checking the records of transactions more straightforward. Carried forward from the last inspection. Southfield Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Nursing Home J52 J03 S29256 Southfield V245025 230905 Stage 4.doc Version 1.40 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!