Inspection on 26/06/06 for Southfield Care Home

This inspection was carried out on 26th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Southfield Care Home 23/03/06

Southfield Care Home 23/09/05

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 Care Home Belton Close Great Horton Bradford BD7 3LF Lead Inspector Steve Marsh Key Unannounced Inspection 26th June 2006 09:30a 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 Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southfield Care Home Address Belton Close Great Horton Bradford BD7 3LF 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) 01274 521944 sksouthfield@aol.com Southfield Health Care Limited Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd March 2006 Brief Description of the Service: Southfield is a care home offering personal care to male and female service users over the age of 65. It 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 a short walking distance of local shops and amenities. Accommodation is provided on two floors, there is a passenger lift. The home has 32 single and 5 double rooms, 24 rooms have 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 small lounge is a designated smoking area for residents. The home has a garden area and car parking is provided at the side of the building. The fees range from £318:15p to £354:76p per week. Additional charges are made for services such as hairdressing, private chiropody, toiletries, newspapers etc. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home, Health and Personal Care etc. An overall judgement is made for each outcome group based on the findings of the inspection. The judgement reflects how well the service delivers outcomes to the people using the service. The judgement categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded in the body of the report. More detailed information about these changes is available on our website – www.csci.org.uk This unannounced inspection was carried out by two Inspectors between the hours of 9:30am and 5:00pm. The last inspection took place in March 2006 and a number of requirements were identified at that time, four of which were outstanding from previous inspections. The purpose of this inspection was to assess what progress the service was making in meeting statutory requirements and to assess the impact of any changes in the quality of life experienced by people living at Southfield Care Home. The home have recently applied for a variation to the registration categories to allow them to admit ten residents with Alzheimer’s Disease or other types of dementia and this is currently being considered by the Commission. The methods used during this inspection included the examination of records, observation of care/work practices, discussion with residents, relatives, staff and management and a tour of the premises. Discussions were also held with a visiting general practitioner and district nurse. Survey questionnaires were provided to enable residents and/or their relatives to share their views of the service with the Commission. Of the thirty questionnaires left at the home (resident and relatives) six were returned. The questionnaires returned showed a high level of satisfaction with the service. Detailed feedback was given to the manager at the end of the visit. Requirements and recommendations made during this visit can be found at the end of this report. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Senior staff appear to have gained more confidence in their new role and have benefited from the support and training provided by the manager. Quality assurance systems have been implemented and it is anticipated that a quality assurance survey will be now completed at least annually to assess if the home is meeting stated aims and objectives. Induction training for new members of staff is now recorded and more emphasis has been placed on providing formal one-to-one staff supervision. Refurbishment work has started in some areas of the home although extensive refurbishment is still required before the environment meets the National Minimum Standards. The window to the treatment room has been made secure and a new medicine fridge purchased. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 7 Staff have furnished a room with items from the nineteen forties and fifties, which is used to stimulate discussion and to let the residents share their memories of that period. A great deal of time and thought has gone into creating this facility and credit must go to the staff team who have collected the memorabilia. There appears to be a genuine commitment by the registered provider to work with the Commission to improve standards within the home and provide a quality service. 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 Care Home DS0000029256.V302333.R01.S.doc Version 5.2 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 Care Home DS0000029256.V302333.R01.S.doc Version 5.2 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, 3 and 5, Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Prospective residents and their relatives have good information about the service so that they can decide whether the home is right for them. EVIDENCE: The manager described a robust pre-admission and assessment process that includes a full and detailed needs assessment, the home’s pre-admission assessment and introductory visits giving prospective residents and their relative the opportunity to meet and talk to existing residents, stay for a meal and if necessary an overnight stay. This was confirmed by a relative, who was impressed that she was able to visit the home unannounced and was given the space and time to talk to existing residents about their experience of life within the home. She said that she had visited other homes but had chosen this one for her mother because, “ I didn’t see a home for older people, I saw a home for individuals who were chatting to each other and staff who were spending time with them.” Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 10 One senior carer described a pre-admission in a hospital setting, where the information she gathered from the hospital conflicted with the needs assessment. Before making a decision about being able to meet the person’s needs she had returned to the home to debate the issue with the manager, who carried out a second assessment. This is good practice. The home’s pre-admission assessment record would benefit from a more detailed description of the person’s needs. For example, one person was incontinent of urine, but there was no information about any incontinence products used, or the need for frequent prompting to use the toilet. Information about not being resuscitated was transferred from one person’s hospital records to the home’s pre-admission assessment. There was no evidence that this had been discussed with the resident, her relatives or GP. The statement of purpose, service user guide and copies of inspection reports are all on display in the entrance of the home. Two residents care records were sampled and in both cases there was a contract and terms and conditions but neither were signed by the resident and/or their representative. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 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, 8, 9, 10 and 11 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The health and personal care needs of the residents are met, and whilst there is room for improvement in the level of detail recorded in care records, the manager has demonstrated a willingness and commitment to improve these. EVIDENCE: The care records of four residents were sampled. There was excellent pen pictures and life history information in some of the care plans, but it would be better if this valuable information was at the beginning of the care plan rather than at the end. From discussion with staff it was clear that they have a good understanding of people’s needs but this is not always documented in the care plan. The manager was making arrangements to rectify this during the inspection. Risk assessments were in place, but those for the use of bed safety rails did not clearly identify the risks involved. The manager produced an updated version that is being introduced along with other revised documentation such as new pressure area risk assessments. There was good evidence of care plans being updated, particularly following accidents or falls from bed and evidence of involvement from community nursing staff. During Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 12 the visit a community nurse was visiting to review the pressure relieving equipment being used by one resident. Visiting health care professionals such as community nurses and general practitioners were complimentary about the home. One community nurse said that standards had improved tremendously over recent months and she was confident that the resident’s healthcare needs were being met. She described a good level of communication with the home and said that staff always carry out instructions. A visiting general practitioner said that he had no concerns about the home, which in his opinion has improved greatly since the appointment of the current manager. He said the manager has a good knowledge of the residents’ needs and the staff team are consistent and knowledgeable. Two visitors said that they were always consulted and kept informed about any changes in their relative’s condition. On reviewing the medication system no discrepancies were noted and no concerns were raised. As required in the last inspection report the window in the treatment rooms has been secured and a new medicine fridge purchased. The manager confirmed that residents are encouraged to manage their own medication if at all possible and risk assessments are routinely carried out on admission. At present five residents administer their own medication and lockable facilities are provided in their rooms to ensure it is safely stored. Senior staff said that they had received training in the safe storage and administration of medication and would contact the pharmacist or general practitioner if they had any concerns. Staff were able to describe the different ways in which they protect the privacy and dignity of residents, and one senior carer explained how the cultural needs of one resident are respected, acknowledged and acted upon. The relatives of a deceased resident spoke about how staff cared for her dying mother with sensitivity, dignity and respect. She said “ Mum couldn’t have got better care anywhere, staff were with her 24 hours a day, and you don’t get that in hospital. I have only happy memories of the home, I wouldn’t come back otherwise”. She went on to describe how staff responded to any request her mother made, giving examples of making her a pudding at 9pm, and then when her mother said it wasn’t sweet enough they added more jam and sugar until she was content. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 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, 13, 14 and 15 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home responds to individual needs and choices. The manager is able to identify and respond to areas that could be improved. EVIDENCE: Care staff described the choices available to residents, and explained how they respond to individual likes and dislikes. Residents are encouraged to bring personal possessions with them into the home. This was confirmed by the relative of a resident recently admitted, and seeing the bedroom of an existing resident who was proud of her room, which she had personalised to her own taste. The home has a hairdresser who visits on a regular basis, but one visitor described how the home had arranged for another hairdresser to visit her mother because she preferred a “modern” hairstyle and her hair colouring. This resident said that the hairdresser had styled her hair and was bringing a colour chart so that she could select her own colour. Staff were aware of the religious and cultural differences of residents, and spoke about some of the cultural needs of one self-caring resident of the Moslem faith. They were however, less sure about meeting this person’s needs if she became unable to communicate, Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 14 therefore it is recommended that cultural awareness training is arranged for the staff team. During the day the staff spent time with residents, and a variety of activities were taking place. One visitor was surprised that her mother had agreed to go for a walk outside with staff, because at home she had not been outside for three years. The manager said she was aware of a lack of physical activities for residents and had arranged for staff training in this to take place. Visitors said that they were always welcome to visit at any time and were offered refreshments and a meal if visiting at meal times. Residents confirmed that the meals provided were good and they were always offered an alternative if they did not like what was on the menu. The home offers a choice of cooked or continental breakfast in the morning and there are always two choices available at both lunch and teatime. The cook on duty appeared to have a good understanding of the resident’s dietary needs and confirmed that Halal meals were always prepared for the one resident living at the home of the Muslim faith. Aids such as plate guards were being used by some residents to help them maintain their independence whilst eating and staff were observed to offer support and assistance to residents as and when required. Hot and cold drinks are freely available to residents throughout the day and night. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents can be assured that the manager will take their concerns/complaints seriously and take action to resolve matters. EVIDENCE: Staff were aware of the different types of abuse and clear about how and when to report any suspicion of abuse. The manager had a good understanding on how to use the multi-agency adult protection procedures. There is a complaints policy on display in the entrance to the home, but the manager could not find a procedure for staff on how to deal with complaints on the day of the visit, although one was later forwarded to the Commission. There have been no complaints received since the last inspection. Residents and visitors said that they would have no hesitation in making a complaint if necessary. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 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, 20, 21, 22, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Although the home still requires extensive refurbishment, the registered provider appears committed to improving the environment for the residents and has set realistic timescales for completion of the work. EVIDENCE: Internally the home continues to require extensive refurbishment, although the communal areas including the dining room, small lounge and conservatory have recently been decorated and are now bright and airy. Residents appeared happy with the standard of décor and furnishing in the communal areas and it was evident through discussion with staff that they are trying hard to create a warm, comfortable and homely environment for them. Following the inspection a meeting was held with the registered provider and manager and a planned schedule of refurbishment work was provided and accepted by the Commission. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 17 Bedrooms are situated on two floors of the building and consist of both single and double rooms, the majority having en-suite facilities. Many of the bedrooms require decorating and old worn/tired furniture replacing. Residents however appeared to be generally happy with the standard of accommodation and there was evidence of lots of personal possessions in every room. Due to the present low occupancy level two corridors on the first floor of the building are closed and work has started to decorate and re-carpet them. As previously mentioned in this report the home is presently negotiating with the Commission to allow them to care for residents with Alzheimer’s disease or other types of dementia. If successful the nine bedrooms on these corridors will be used for this purpose although, communal areas and other facilities will be shared by all residents living at the home. Concerns have been raised at previous inspections about the lack of emergency call alarms available in some rooms. However, the manager confirmed that there are sufficient alarms for the present number of residents and the home was in negotiations to upgrade or replace the present system prior to additional residents being admitted. In addition to the en-suite facilities in many rooms communal bathrooms and toilets are conveniently located throughout the building. The general standard of décor, fixtures and fittings varies and some areas require including in the refurbishment programme. The laundry is situated on the lower ground floor of the building away from areas used by the residents. On the day of the visit the laundry room was found to be clean and well organised. The general standard of hygiene and cleanliness throughout the home was found to be good and no odour problems were noted. Externally the grounds would benefit from landscaping and making more secure and the Commission have received assurances from the registered provider that this matter will be addressed as part of the refurbishment programme. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 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 and 30 Quality in this outcome area is good. This judgement has been made using all available evidence including a visit to the home. Residents are protected by robust staff recruitment and selection procedures, which include Criminal Record Bureau checks. There appears to be a good skill mix within the staff team and a genuine commitment to ensuring that resident’s are cared for by experienced and trained staff. EVIDENCE: A staff rota was taken, which showed that sufficient staff are employed on day and night duty to care for the residents and meet their needs. Between the hours of 7pm and 11pm the home also have one additional member of staff on duty to assist the residents to bed, which is good practice. There are sufficient catering and cleaning staff to meet the resident’s dietary needs and keep the home clean. However the manager is aware that should the number of residents increase significantly the number of cleaning hours must be reviewed in line with the needs of the service. A part time administrator and maintenance man are also employed. The recruitment and selection procedure for new employees is thorough and includes formal interviews, obtaining at least two written references and a Criminal Record Bureau (CRB) checks prior to employment. On reviewing the Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 19 employment files for two recently appointed staff all the relevant information was found to be in place and no concerns were raised. Staff confirmed that they had not been offered employment until the home had received references and a satisfactory CRB for them and said that they had received a written job description and contract of employment. All new members of staff receive comprehensive induction and foundation training, following which there is an expectation that they will study for a National Vocational Qualification (NVQ) at level two or above depending on the post they hold. At present about 40 of care staff have achieved the award, while others are still studying or waiting for a start date. Additional training, both to meet the needs of the residents and for personal development is also encouraged by the manager and the staff training records give clear evidence of the homes commitment to having a trained and skilled workforce. During discussions with senior staff it was apparent that the recent change to the home’s registration had changed their role significantly and had given them more responsibility. However, they confirmed that the training and support provided by the manager had made the transitional period easier and they now felt confident in supervising the staff team. The manager and staff confirmed that they receive a minimum of three paid days training per year in line with the National Minimum Standards. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The wellbeing of the residents remains very important to the manager and she continues to work hard to make sure that they are cared for in a safe and proper manner. EVIDENCE: Ms Yvette Barrow has been the manager of Southfield Care since October 2005 prior to that date she was the registered manager of another care home for older people in the Bradford area. Ms Barrow has made an application to become the registered manager of the home and the Commission is presently dealing this with. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 21 The manager has many years experience in the caring profession and has achieved a National Vocational Qualification (NVQ) at level four in management and care. Staff confirmed that the manager has an open and approachable management style and provides them with leadership and direction they have lacked in the past. Staff also said that they enjoyed working at the home and felt that the general atmosphere within the home had improved greatly since the new manager was appointed. The manager ensures clear channels of communication with the staff by holding regular staff meetings and formal one-to-one supervision. Resident and family meetings are also held approximately every two months to ensure that they have the opportunity to air their views and opinions of the service. Effective quality assurance monitoring systems are in place and a summary of a recent survey of residents, relatives and visiting professional clearly indicated that the quality of care/service has improved significantly since Ms Barrow’s appointment. The registered provider also continues to visit the home on a regular basis and provides the Commission with a monthly report on the conduct of the home. The manager confirmed that the home no longer takes responsibility for managing residents’ finances and to reduce the number of cash transaction the home continues to encourage all new residents to pay their fees by standing order. Money is still however held in safekeeping for a number of residents and transaction sheets are available indicating income, expenditure and a balance. Receipts are always obtained for items purchased by staff on behalf of residents and a record is kept of valuables held in safekeeping. Policies and procedures are in place to ensure the health and safety of the residents, visitors and staff and they are reviewed on a regular basis to ensure they comply with present legislation. To ensure safe working practices mandatory training includes moving and handling, infection control, fire safety etc, however it was recommended to the manager that additional members of staff especially night staff are trained in first aid. Maintenance contracts/records showed that the equipment used by the staff and/or residents is serviced on a regular basis. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 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 3 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP2 Regulation 17(2) Requirement The manager must ensure that the residents and/or their representative sign contracts/terms and conditions of occupancy. The registered provider must ensure that the home is refurbished within the agreed timescales. The registered provider must ensure that all bathrooms and toilet areas are refurbished within the agreed timescales. The registered provider must ensure that bedrooms are refurbished within the agreed timescales. Timescale for action 31/08/06 3 OP19 23 31/08/07 3 OP21 23 06/05/07 4 OP24 23 06/05/07 Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 24 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 3 Refer to Standard OP3 OP12 OP38 Good Practice Recommendations It is recommended that the pre-admission assessment record provide a more detailed description of the person’s needs. It is recommended that cultural awareness and diversity training is made available to the staff team. It is recommended that additional members of staff be trained in first aid. Southfield Care Home DS0000029256.V302333.R01.S.doc Version 5.2 Page 25 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 Care Home DS0000029256.V302333.R01.S.doc Version 5.2 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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