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Inspection on 15/08/06 for Southfield Court Care Home

Also see our care home review for Southfield Court Care Home for more information

This inspection was carried out on 15th August 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Southfield Court is a well-managed care home with a relatively stable core of experienced staff. Service users and visitors are welcomed to the home. Prospective service users are assessed before they are admitted to the home to ensure the home and the staff team can meet the service users` needs. Medications are managed well in the home. Members of staff interact well with service users and service users commented on how kind and helpful staff are. Complaints or concerns are dealt with appropriately. Service users and visitors commented on how approachable the manager is and that if they raised any concern with her, she quickly dealt with the matter. Service users` finances are managed safely and there are clear records available to show how funds have been spent by the service user or on the service users behalf.There is evidence that routine maintenance is carried out and that health and safety checks and tests are carried out.

What has improved since the last inspection?

Since the last inspection improvements have been made in the way medications records are maintained, these are now clear and when audited found to be correct. The areas identified in the last report as requiring redecoration or repairs have been addressed. And at the last visit the home was noted to have an unpleasant odour, this has improved. Records relating to service users personal money held by the home are now individualised and detailed.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Southfield Court Care Home Off Southfield Road Almondbury Huddersfield Yorkshire HD5 8RZ Lead Inspector Sally McSharry Key Unannounced Inspection 15th August 2006 07:30a 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 Court Care Home DS0000044509.V303336.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 Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southfield Court Care Home Address Off Southfield Road Almondbury Huddersfield Yorkshire HD5 8RZ 01484 432433 01484 432441 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) www.fshc.co.uk Tamaris Healthcare (England) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Michelle Prime Care Home 50 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (24) of places Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Six named persons under 65 years of age Ten unnamed persons between the ages of 55 and 65 years within the categories Dementia (DE) (5) and Physical Disabilities (PD) (5). 23rd February 2006 Date of last inspection Brief Description of the Service: Southfield Court is a modern, purpose built care home providing nursing care for older people. The ground floor provides accommodation for up to twentyfour general nursing care service users, and the first floor is for up to twentysix service users suffering from dementia. The home is situated behind the shops in Almondbury village. It is approximately two miles from Huddersfield but within a couple of minutes walk of all local amenities, including the bus stop. There is a garden, including a secure area where service users may sit. There is ample parking at the front of the home. The provider informed the Commission for Social Care Inspection on 22/06/06 that fees range from £390.00 to £530.00 per week. Additional charges include hairdressing ( £5.50-£21.00) and private chiropody (£7.50). Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by one inspector. The inspector arrived at the home at 7.30am and left at 2.45pm. During this visit the inspector spoke to some of the service users, some of the staff and the home’s management. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the building. Prior to the inspection sixteen service user questionnaires were sent to service users at Southfield Court to obtain the views of service users living at the home. Four completed questionnaires were returned. There were fifty service users living at the home on the day of this inspection. Surveys were sent to sixteen relatives and friends of service users, six GP’s and two other health care professionals. At the time of writing, six responses had been received from relatives and from GP’s. There were no responses from other health professionals. Other information used as part of the inspection process included notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, a monthly management report and a pre inspection questionnaire completed by the manager. The inspector would like to thank everyone for their assistance during the inspection process. What the service does well: Southfield Court is a well-managed care home with a relatively stable core of experienced staff. Service users and visitors are welcomed to the home. Prospective service users are assessed before they are admitted to the home to ensure the home and the staff team can meet the service users’ needs. Medications are managed well in the home. Members of staff interact well with service users and service users commented on how kind and helpful staff are. Complaints or concerns are dealt with appropriately. Service users and visitors commented on how approachable the manager is and that if they raised any concern with her, she quickly dealt with the matter. Service users’ finances are managed safely and there are clear records available to show how funds have been spent by the service user or on the service users behalf. Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 6 There is evidence that routine maintenance is carried out and that health and safety checks and tests are carried out. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 No service user moves into the home without having had their needs assessed and been assured their needs can be met. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users and relatives confirmed when spoken to and in questionnaires that they had information about the home before they came to live there and that their needs had been assessed. The sample of case records audited showed that service users admitted to the home recently had been assessed prior to admission. One service was able to confirm that they had actively been involved in choosing the home, and had visited other homes in the Kirklees area before they made the decision to stay at Southfield Court. The home has admitted service users with a diverse range of needs and from a variety of cultural backgrounds. Southfield Court does not currently provide intermediate care. Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): ,8,9 and 10 Some of the service users’ health, personal and social care needs are set out in an individual plan of care. Suitable risk assessments are carried out and monitored. Some of the service users are able to make decisions about their lives with the support of staff. Medications are managed safely. Service users are treated with respect, their privacy and dignity is maintained by the staff in the home. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Care plans audited during this visit identified some of the service users’ needs and how they are to be met by the staff in the home. However not all needs were identified in the care plan and some of the information in care plans was not specific. For example, the specific hoist and sling to be used when moving and handling service users was not recorded and the specific continence aid to be used for each individual was not recorded. Some information recorded in assessments contradicted information in the care plan. These issues should be addressed. All service users needs should Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 10 be identified in a care plan. The care plan should be specific, detailed and accurate. Some risk assessments are in place for the individual service users. However specific falls risk assessments were not in place for all service users. It is recommended these be introduced. Where a risk is identified a care plan should then be produced. Care plans and risk assessments are reviewed at least monthly. Care plans do not fully reflect service users’ individual preferences, cultural and spiritual needs and it remains a recommendation of this report that care plans be further developed. Where risk assessments have identified a health risk, staff at the home seek specialist advice. All five questionnaires returned by visiting GPs acknowledge a good standard of care and the level of communication with staff. There is some written evidence to show that some service users and relatives have been actively included in the care planning process, however this could be further developed particularly on the ground floor unit. This has been made a recommendation of this report. The daily record relates to the care plan and the actual care given each day, information is vague and some entries lack detail. The daily record should reflect the needs identified in the care plan and the actual care provided each day. The medications management for four service users’ were audited and found to be correct. There were no signature omissions and the standard of medications management remains good. Arrangements have been made for the safe disposal of medications. Staff were observed caring for service users throughout the day of the visit. Staff were interacting with service users well. Service users appeared relaxed and comfortable with the staff, enjoying appropriate jokes and banter. Service users were well dressed and clean. Staff were observed respecting service users’ privacy and dignity and offering some service users choice and encouraging service users to maintain independence where able. Service users who spoke to the inspector said that the staff were very good and caring. One service user said “ I cannot fault the staff”. Relative questionnaires confirmed that respondents are satisfied with the care provided in the home. Comments were positive and included statements such as “ My family and I are very happy with all the care and attention received at Southfield Court”. Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 11 The staff were observed to work competently and with confidence at the time of this visit. Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Some of the service users’ social, cultural, religious and recreational needs are being met; they are helped to maintain contact with their families and the local community. Some service users are able to exercise some choice and control over their lives, action should be taken to ensure choice is offered to all service users . Meals provided are varied. The area where meals are served should be improved. Service users who need support receive the assistance they require. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users and records confirmed that some activities and entertainment is offered in the home. However one relative felt that more imagination could be directed towards activities and commented that, “service users could be taken out more during the good weather”. The registered manager confirmed that a new activities organiser is being recruited to work 20 hours per week in the home. It is recommended that Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 13 service users and relatives be consulted about the range of activities offered in the home to ensure that the programme of activities offered meets the service users’ expectations. Service users are able to maintain contact with their family, friends and the community. All relatives and friends completing questionnaires said they are made to feel welcome when visiting the home. Southfield Court is ideally placed for access into Almondbury and to maintain links with the local community. Religious ministers visit service users in the home and the registered manager said that she is trying to develop closer links with the local church. More able service users confirmed that they are able to make choices about their lives in the home and that staff respect and maintain those choices. However less able service users are not being fully supported and assisted to make choices. Although there is a choice available at meal times service users on the first floor unit are not offered the same choice as those service users who may be more mentally alert accommodated in the ground floor unit. This must be addressed. Service users who are mentally frail or forgetful must be supported to make choices, such as at meal times. Offering an immediate visual choice, for example showing service users what is available at meal times and then letting the service user choose, can do this. Menus served in the home are varied and appear nutritious. There is a choice available at meal times, however as previously mentioned not all service users are currently being offered a full choice at each meal. The registered manager advised that the company is reviewing menus and new menus are going to be introduced. It is recommended that menus reflect the cultural diversity of service users in the home. At the time of the visit the ground floor dining room was being redecorated and was out of action. The dining area on the first floor has been redecorated recently and was clean and tidy. However breakfast was served in an ad hoc manner and dining tables although clean were not formally set. Service users on the first floor unit were only offered hot drinks in plastic cups and mugs. Care should be taken to ensure dining areas are attractively set and that there is a choice of appropriate crockery to all service users in the home. Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Service users and their relatives and friends are confident to make complaints and that these will be listened to and taken seriously. Service users are protected from abuse. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Most service user and relative questionnaires said that they were aware of the complaints procedure and how to make a complaint. Service users who spoke with the inspector felt that if they need to they would be confident to raise any concerns they might have. Service users specifically said that the manager is helpful and approachable. One relative said in a returned questionnaire that “ I always talk with the homes manager about any point I feel could be improved upon. This gets dealt with quickly”. Another relative said, “ The only complaints are small ones e.g. Laundry- missing items. Always put right when staff are made aware of the situation”. The manager maintains a record of all complaints and concerns raised. This includes outcome of the complaint and the action taken by the home. Service users are protected from abuse in the home. Staff have had adult protection training and there have been two recent incidents in the home where members of staff have alerted the manager to possible poor practice. These incidents have been appropriately referred and investigated. Where necessary protection of vulnerable adults (POVA) referrals have been made. Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 15 The inspector spoke to four members of staff on duty at the time of the visit, all had received adult protection training and were aware of what to do if they had any concern that service users were being abused in any way. Southfield Court Care Home DS0000044509.V303336.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 and 26. Service users live in a safe and maintained environment. The home is clean and hygienic. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: At the last inspection it was identified that some areas of the home had an unpleasant odour. This has been addressed and the home generally smelt fresher. The registered manager also reported that new floor coverings are to be provided in communal areas of the home. At the time of the visit the ground floor dining room, lounge and corridor areas were in the process of being redecorated. The lounge and dining room on the first floor had already been redecorated. However one relative raised some concerns about the standard of decoration in service users rooms. A sample of rooms was looked at and the standard of decoration in service users rooms on the first floor was of a poor standard. The registered manager reported that rooms are being redecorated when they become vacant, however a more Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 17 proactive approach needs to be taken as the standard of décor in service users rooms and bathrooms is slipping. Southfield Court Care Home DS0000044509.V303336.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. Suitable numbers of staff are employed. Members of staff receive induction and foundation training and are competent to work in the home. Staff recruitment policies and records protect service users. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Staffing levels are adequate to meet the current service users needs. All service user questionnaires returned said staff listen to what service users are saying. Two of the four service user questionnaires said that staff are always available when they needed them and two said staff are usually there when needed. However four of the six relative questionnaires returned to the CSCI prior to the inspection stated, in their opinion there was not always sufficient staff on duty. One questionnaire said there wasn’t always sufficient staff on duty at meal times to assist service users. This was discussed with the manager, who is to monitor the situation. Training in the home has progressed and now there are 40 of the care staff with National Vocational Training (NVQ) level 2 or above. Work should continue with a view to having 50 of care staff with NVQ level 2. The recruitment and training records of four members of staff were audited. Recruitment records were complete and included all the required references and checks. Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 19 Training records included details of induction and on going training for staff. Those staff that spoke with the inspector confirmed that they had had a detailed induction and had attended movement and handling training, fire training, and protection of vulnerable adults training. Other training sessions covered included food hygiene, infection control, death and dying, control of substances hazardous and harmful. Southfield Court Care Home DS0000044509.V303336.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): 31,33,35 and 38. Service users live in a home with an experienced and competent manager of good character. The home is run in the best interest of service users. Service users financial interests are safe guarded. The health, safety and welfare of service users and staff are promoted and protected. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Ms Prime is a first level registered nurse. She is an experienced manager and has obtained the Registered Manager’s Award. Feed back from service users, relatives and staff indicated that Ms Prime is approachable and an effective manager. One relative commented, “ If I have any important matters to Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 21 discuss regarding my wife I consult the home manager, who deals with them. Also matters can be discussed at the three monthly residents meetings”. The registered manager advised that a new quality audit is to be carried out within the next two months. The results of this audit should be published and made available to participants. An action plan should be developed to address any issues identified. Regular monthly management reviews take place and minuted resident meetings are also held. Relatives wishing to discuss specific issues are able to see the manager. No one at the home acts as appointee for any of the service users. The majority of service users have some money that is held by the home. This money is banked in a communal resident’s bank account. Individual balances are kept for all service users. These can be audited and show deposits and withdrawals from the account. Receipts are also available to show how the money has been spent on the service users’ behalf. The home carries out weekly fire safety checks and these are recorded. There is evidence of routine maintenance and servicing of equipment in the home. Southfield Court Care Home DS0000044509.V303336.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Southfield Court Care Home DS0000044509.V303336.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 OP14 Regulation 12 (2) (3) Requirement Service users who are mentally frail or forgetful must be supported to make choices, such as at meal times. All areas of the home must be audited in relation to the standard of décor and a redecoration program be developed and implemented. All service users rooms on the first floor that are in need of redecoration must be addressed with in six months. Timescale for action 30/09/06 2 OP19 23 (2) 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP7 Good Practice Recommendations Care plans should be further developed to ensure that they are specific to the service users needs. All service users needs should be identified in a care plan. The care plan should be specific, detailed and accurate. DS0000044509.V303336.R01.S.doc Version 5.2 Page 24 Southfield Court Care Home 3. 4. 5. 6. OP7 OP7 OP8 OP12 7. 8. 9. OP15 OP15 OP28 All service users and relatives should be encouraged to be included in the care planning process. The daily record should reflect the needs identified in the care plan and the actual care provided each day. Detailed falls risk assessments should be completed for service users. Where a risk is identified a care plan should then be produced. It is recommended that service users and relatives be consulted about the range of activities offered in the home to ensure that the programme of activities offered meets the service users expectations. It is recommended that menus reflect the cultural diversity of service users in the home. Care should be taken to ensure dining areas are attractively set and that there is a choice of appropriate crockery to all service users in the home. Work should continue with a view to having 50 of care staff with NVQ level 2. Southfield Court Care Home DS0000044509.V303336.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 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 Court Care Home DS0000044509.V303336.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. 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!