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Inspection on 17/07/08 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 17th July 2008.

CSCI found this care home to be providing an Adequate service.

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

People are cared for in a pleasant environment, where their finances are protected and their health and safety needs are met. People are spoken to in a respectful manner.

What has improved since the last inspection?

A review of staffing levels has taken place and people are now cared for by enough staff with the right skill mix. There is a new enquiry pack for all enquirers which gives people a wide range of information. A quality audit has been undertaken which helps identify people likes and dislikes and how the service can imporve.

What the care home could do better:

The dining experience for people on the dementia unit is poor. The whole experience needs to be managed more effectively with individual needs considered. Care plans need to be fully completed to ensure care is reviewed and evaluated regularly and needs are realised. People who have changing needs must be reassessed in a timely manner. Action needs to be taken to make sure these needs can be met. Staff need to be trained in how to deal with challenging behaviour. This would help them respond more effectively to situations, which could escalate between people who use the service. Complaints are not dealt with effectively. Clear outcomes of investigations are not given to people, and the manager is unaware of investigations, which have been carried out by Four Seasons senior management. This means specific issues are not actioned appropriately.

CARE HOMES FOR OLDER PEOPLE Southfield Court Care Home Off Southfield Road Almondbury Huddersfield Yorkshire HD5 8RZ Lead Inspector Jo Bell Key Unannounced Inspection 17th July 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Southfield Court Care Home DS0000044509.V368343.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.V368343.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 southfield.court@fshc.co.uk www.fshc.co.uk Tamaris Healthcare (England) Ltd 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) 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.V368343.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). 7th June 2007 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 people needing general nursing, and the first floor is for up to twenty-six people 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 level access to the entrance of the home. In the home, access to the first floor is gained either by stairs or a passenger lift. There is a garden including a secure area where service users may sit. There is ample parking at the front of the home. The fees range from £399.47 to £565 per week (July 2008). Additional charges include hairdressing (£3.50 - £22) and private chiropody (£7). Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Southfield Court Care Home DS0000044509.V368343.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The Commission for Social Care Inspection inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. More information about the inspection process can be found on our website www.csci.org.uk The key inspection took place on Thursday 17th July 2008. An annual service review had been completed in May 2008, which highlighted a range of issues which led to a Key Inspection. Prior to the visit the information from the following sources was obtained and considered: The annual quality assurance assessment. Surveys from people using the service, relatives and staff surveys. Notifications (Regulation 37) relating to incidents in the home affecting people using the service. Details of complaints or concerns raised by people connected to the service. Progress of the previous requirement and recommendations made at the last site visit. At the site visit one inspector spent 7.0 hours at the home. During this time observations of care practices took place. People using the service were spoken with along with some staff. Discussions with the manager regarding meeting needs, mealtimes, protecting people and the environment took place. The lunchtime meal in the dementia unit was observed and time was spent inspecting four care plans, looking at individual rooms and reviewing a selection of health and safety information. Staffing and management issues were discussed along with previous complaints. Feedback was given to the manager at the end of the inspection. What the service does well: People are cared for in a pleasant environment, where their finances are protected and their health and safety needs are met. People are spoken to in a respectful manner. Southfield Court Care Home DS0000044509.V368343.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Southfield Court Care Home DS0000044509.V368343.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.V368343.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 is not applicable) Quality in this outcome area is good. People have their needs assessed prior to admission, which helps to ensure individual needs can be met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Prior to admission the manager or another registered nurse from the home completes a detailed pre-admission assessment. This may take place in hospital or in the person’s home. Where the person is funded through social services a further assessment will also be undertaken by a care manager. This helps to inform the individual care plan to ensure the home can met specific needs. Four assessments were inspected (two from the nursing area and two from the dementia unit). Assessments covered health, personal, social and mental health needs. It was evident that the level of information obtained varied depending on which person carried out the assessment. This needs to be consistent to ensure a decision can be made regarding whether a person’s needs can be met. Southfield Court Care Home DS0000044509.V368343.R01.S.doc Version 5.2 Page 9 The manager is aware of the type of clients she can admit to the home within the statement of purpose. Southfield Court Care Home DS0000044509.V368343.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience adequate quality outcomes in this area. Whilst some care needs are met, this is not consistent throughout the home. Staff also need to maintain people’s privacy at all times. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People have a detailed plan of care to identify their needs. Four plans were inspected, two from the nursing unit and two from the dementia unit. The plans contained a range of information. Though due to the format it was difficult to easily identify the needs of different people. There were some blanks on the forms and evidence that not all needs are being met. For example one persons plan discussed the need to have ear syringing, however no action had been taken to address this. Risk assessments relating to moving and handling, nutrition and the prevention of pressure sores were all completed. Some plans needed to be reviewed more often and some people on the dementia unit need to have their needs reassessed. Two people on the nursing unit were in bed during the visit. Staff felt this was because there were insufficient suitable chairs for these people to use so they Southfield Court Care Home DS0000044509.V368343.R01.S.doc Version 5.2 Page 11 had to remain in bed. However, other staff felt this was in their best interest. This needs to be clarified to ensure people are only cared for in bed for a relevant reason. People did have input from doctors, specialist staff and the community mental health team. Staff were aware of how to fortify food where people were underweight. A complaint had been made regarding poor care practices (see complaints and protection outcome). This was partly substantiated. People did look clean and well cared for this was observed on both units. The home is aware of how to report accidents and incidents (through Regulation 37 notifications). There have been some falls in the home. One person had six in the month of June. As a result of this the home is carrying out a falls audit to identify where the falls occurred, who is affected and what are the reasons for these incidents occurring. One serious fall resulted in the health and safety executive being involved. The medication system was inspected on both units. There has been a previous issue where people were not completing the medication charts correctly. Four medication charts were examined and these were generally completed correctly. Staff need to be consistent in offering pain killers when required as some people put the code for not given whilst other staff left this blank so it was unclear which medication had been offered. The home completes weekly stock balances and daily fridge temperatures. Controlled drugs are effectively recorded and the clinical manager on the dementia unit was extremely knowledgeable in how to administer, record, store and dispose of medication. The nurse on the nursing unit was observed administering medication in a professional and effective manner. The monitored dosage system is used and medication audits take place. Privacy and dignity was discussed. Staff were observed addressing people in a friendly and suitable manner. Staff were observed knocking on doors prior to entering. On one occasion a person took their trousers down to their knees and sat down at the dining table. Staff did not appear to notice this until it was highlighted by the inspector. Staff must be vigilant in maintaining people’s privacy and dignity. Southfield Court Care Home DS0000044509.V368343.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience adequate quality outcomes in this area. People have access to a range of activities and people are welcomed into the home. Whilst some autonomy and choice is offered the dining experience on the dementia unit is extremely poor and needs urgently reviewing. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home has two activity organisers who both work part time. One organiser planned activities, which included music therapy, hand massage, a summer fair and one to one sessions. The annual quality assurance assessment stated that “residents are supported to visit family in the community, and there are Regional meetings for activity workers to ensure updating their knowledge”. This was confirmed by members of staff. People enjoy spending time in the garden, reading newspapers and watching television. The home does not have a minibus though a small number of people can go out with the activity organisers. One survey returned stated that “there are very few activities, people must be bored”. Some details of activities were completed in the care plans but this was not consistent throughout the home. Visitors are welcomed which was confirmed when reading the visitors book. Religious needs are not Southfield Court Care Home DS0000044509.V368343.R01.S.doc Version 5.2 Page 13 always cdiscussed in the care plan though a weekly church service takes place and a priest visits one person who is roman catholic. Autonomy and choice is offered regarding people’s daily routines. For example people can get up and go to bed when they want. The routine in the home is genrally led by the people using the service and not the staff. However the dining experience did not offer people choice regarding meeting individual needs in a pleasant and calm atmosphere. The dining rooms on both the nursing and dementia unit were inspected. The environment was pleasant and welcoming on the nursing unit with a light and airy dining room with the menu on the wall. Tables and chairs were suitable and material cloths, napkins and floweres were observed on the table. The lunchtime meal was observed on the dementia unit. The dining room was relatively clean with tables and chairs available in sufficient numbers. Some tables had table cloths and salt and pepper whilst others had not been laid. Nine people were observed in the dining area with a further two people sat in chairs in the lounge who needed assistance with their food and drink. The dining experience was chaotic with people screaming and shouting and swearing. People were getting up and down from the table. There were enough staff but the whole dining experience was not managed effectively. One person had been sat in a reclining chair for one hour with a napkin around her neck before the food arrived. One person who was agitating another person became more and more abusive, a carer was sat behind assisting another person with their meal. Eventually the person started shouting and poking the individual who then started crying. The person crying got up very distressed and threw her glasses on the floor. The carer then had to stop assisiting one person to deal with this incident. This situation could have been better managed. Staff need to be pro-active rather than reactive after an event has occurred. The food offerd was a cornish pasty (not home-made) and chicken casserole with a mix of fresh and frozen vegetables. The mashed potato has lumps in and one person refused to eat this. The gravy was watery with lumpy granules in and whilst the portion sizes were adequate no drinkw were offered until after the main course was completed. One person was observed with a cold mug of tea from the morning drinks round. This had been sat on the table for over two hours. This was discussed with the clinical manager who was aware that the dining experience for people was poor. Southfield Court Care Home DS0000044509.V368343.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience adequate quality outcomes in this area. People are protected from harm and the home have a robust complaints procedure. However, because complaints are not dealt with effectively outcomes for people do not improve. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home has a complaints procedure in place. People using the service and their relatives are aware of this. Surveys returned also confirmed this. Since the last inspection the home have dealt with two complaints and a concern, which the CSCI were made aware of. One related to poor care practices and was partly substantiated and the other two were unsubstantiated and related to smoking and staffing levels. A further anonymous complaint was made to the CSCI regarding a serious incident which has been referred to the health and safety executive. This was Currently the home’s line manager or responsible individual deals with complaints. One issue had been raised last December regarding the lack of response from Four seasons regarding a complaint. At the visit a copy of the response given to a complainant relating to a recent complaint was inspected. This did not identify what the complainant’s issues were, the details of the Southfield Court Care Home DS0000044509.V368343.R01.S.doc Version 5.2 Page 15 investigation or the outcome. The manager did not have a copy of the investigation even though this related to one of the people living in the home. This would mean any further discussion with the family would be difficult. The home have procedures in place for staff to follow if an allegation of abuse is made. Some staff have recently had protection of vulnerable adults training. This included viewing a video and completing a questionnaire. Staff do need reminding of the appropriate action to take and the different types of abuse a person may be susceptible to Generally people in the home looked safe. Though it was evident on the dementia unit that some people using the service looked intimidated by a person who was also using the service. Staff were aware that they needed to minimise the risk of harm to this group of people. Southfield Court Care Home DS0000044509.V368343.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. People enjoy living in the home with many areas of the home well decorated and kept clean. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People enjoy living in the home. All areas inspected smelt clean and fresh. There is a routine maintenance plan within Four Seasons and refurbishment is undertaken when needed. One dining room has been refurbished and additional furniture purchased for the dementia unit. There is a themed corridor also on the dementia unit. This is to aid orientation. This is discussed in the annual quality assurancve assessment. Furniture is a good standard and people have ensuite rooms. Consideration is being given to decide whether locks are needed on bedroom doors. People should be given the choice regarding use of a key. Southfield Court Care Home DS0000044509.V368343.R01.S.doc Version 5.2 Page 17 Staff were observed wearing protective clothing, washing their hands inbetween attending to people and using different coloured bags for laundry. The manager is aware of a laundry issue at the moment, which has meant that sometimes there is a delay when clothes are being washed and ironed. This is being addressed. Staff confirmed that infection control training has been completed. Sluice areas were kept clean and the domestic staff were aware of how to maintain hygiene needs. Staff have also undertaken food hygiene which helps prevent cross contamination when serving food and drink. Southfield Court Care Home DS0000044509.V368343.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 People who use the service experience good quality outcomes in this area. People are cared for by enough staff that are effectively recruited, and suitably inducted into their roles. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People are cared for by enough staff. There is a mix of registered general nurses, mental health nurses, carers and clinical managers. The home had forty-six people using the service, and can have a maximum of fifty. There is a key worker system though due to recent staff changes this is not fully operational yet. Care plans are not fully completed regarding input from key workers, though this will be resolved shortly. People were observed answering call bells and supervising people effectively. The nursing unit has a clinical manager and the dementia unit has two clinical managers. A new appointment has been made on the dementia unit. This is a mental health nurse who will offer the unit strong leadership and direction. People’s needs are being met on the nursing unit and evidence of input from tissue viability nurses and continence nurses was evident. On the dementia unit input from the community mental health team and consultant psychiatrists was in place. It was evident that some people needed to be reviewed on this unit to ensure their needs can still be met. People clearly had challenging behaviour; the unit was noisy with staff reacting to situations. Staff need to have restraint and Southfield Court Care Home DS0000044509.V368343.R01.S.doc Version 5.2 Page 19 challenging behaviour training. This would give them a greater awareness of how to deal more effectively with this client group. Staff have completed a range of training. This includes NVQ, induction training and dementia training. This was confirmed through staff records and speaking with staff. The induction programme is very detailed and covers aspects of care practices and safety. Staff have regular supervision and the three recruitment files checked confirmed that two written references are obtained, and a police check along with a protection of vulnerable adults check prior to starting work at the home. Registered nurses have checks in place to ensure they are registered to practice and evidence showed staff were up to date with their nursing qualifications and registration. Southfield Court Care Home DS0000044509.V368343.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 People who use the service experience good quality outcomes in this area. The health and safety of people is maintained and finances are protected. The nursing area is run in the best interests of people though more improvements are needed to ensure this happens on the dementia unit. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: A general nurse who is registered with the CSCI manages the home. She has undertaken training in dementia care mapping, is a qualified district nurse and has many years experience caring for older people. People spoken with felt she was approachable, professional and effective in her role. The manager in discussion was aware that whilst the nursing unit is running effectively there are improvements to be made on the dementia unit. This relates to meeting people’s needs and creating a more relaxed environment. Southfield Court Care Home DS0000044509.V368343.R01.S.doc Version 5.2 Page 21 Four Seasons have a detailed quality insurance system in place. This includes sending out surveys to people, having resident and staff meetings and completing monthly visits known as Regulation 26 visits. A range of audits are in place, which include care plan, medication, health and safety and accident audits. Once surveys are completed the information is collated and acted upon. This helps to improve the service. People’s finances are dealt with effectively. Invoices are sent to people regarding hairdressing, chiropody or toiletries. People can keep a small amount of money in the home and this is clearly recorded on an individual basis. Records were checked and discussed with the administrator. People are encouraged to maintain their own finances and this may involve relatives. This is discussed when people are first admitted to the home. Aspects of Health and safety were inspected. Details of policies and procedures were recorded in the annual quality assurance assessment and this confirmed regular reviews of policies take place. The home have recently had an investigation from the health and safety executive. This related to an accident, the outcome was inconclusive though measure were put in place to minimise this type of accident reoccurring. Staff have mandatory training, which includes fire training, moving and handling, first aid, food hygiene, infection control and protection of vulnerable adults. Records showed individual training records and details of when training is next due. The home have a fire risk assessment in place, weekly fire drills are in place and unannounced fire drills are conducted. Some recommendations were made by the fire officer and whilst the home have completed this work (verbal information given) this will also be followed up in writing. The electrical wiring certificate was satisfactory and in date and the gas safety certificate showed that some areas need to be checked in more detail. The manager has arranged for this to take place. People were safe in the home and checks regarding lifts, call bell systems and equipment are all in place. Southfield Court Care Home DS0000044509.V368343.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 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Southfield Court Care Home DS0000044509.V368343.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 OP7 Regulation 15 Requirement Care plans must be fully completed and reviewed and evaluated on a regular basis. People must have their privacy needs maintained at all times. A review of the quality of food served must take place. A complete review of the dining experience on the dementia unit must urgently take place. People must have their individual needs met. Complaints must be dealt with effectively with a clear investigate and outcome. The manager needs to be aware of the details of any investigation. This will help the home communicate more effectively with any complainants. Timescale for action 17/07/08 2. 3. 4. OP10 OP15 OP15 OP14 12 16 12 17/07/08 17/08/08 17/08/08 5. OP16 22 17/07/08 Southfield Court Care Home DS0000044509.V368343.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. Refer to Standard OP27 Good Practice Recommendations Staff would benefit from having challenging behaviour training. This would help them when an issue arises where a person becomes agitated or aggressive. Southfield Court Care Home DS0000044509.V368343.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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