CARE HOMES FOR OLDER PEOPLE
Southfield Court Care Home Off Southfield Road Almondbury Huddersfield Yorkshire HD5 8RZ Lead Inspector
Sally McSharry Key Unannounced Inspection 7th June 2007 10:15 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.V333442.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.V333442.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.V333442.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). 15th August 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 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 provider informed the Commission for Social Care Inspection on 11/04/07 that fees range from £399.47 to £565 per week. 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.V333442.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 to the home by an inspector on 7 June 2007. The visit commenced at 10:15 am and the inspector left the home at 5:30 pm. During this visit, the inspector spoke to some of the people living in the home, visiting relatives, 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, carried out a brief tour of the building and observed staff caring for people and serving lunches. Prior to the inspection, twenty five people living in the home were sent surveys to obtain their views about living at the home. Five completed surveys were returned. Some people living in the home are very frail and may have difficulty completing a survey. There were forty nine people resident in the home on the day of this visit. Relatives’ surveys were sent out to 25 relatives or friends of people living in the home. Six family doctors attend the home and surveys were sent to them. When writing this report, eleven relatives and friends had returned surveys and 3 responses had been received from family doctors who visit the home. Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider, minutes of residents’ meetings and a pre inspection questionnaire completed by the provider and manager. The inspector would like to take this opportunity to thank everyone who participated in the inspection process. What the service does well:
Generally, before a new person is admitted to the home, a member of staff from Southfield Court visits the person to assess their health and welfare needs. This helps the staff at the home prepare for the person’s admission and ensure that Southfield Court and the staff team are able to meet the person’s health and welfare needs. Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 6 Each person living in the home has a written care plan that tells staff what their health care and welfare needs are and how these are to be met whilst resident at the home. Medications are recorded, administered, stored and managed well. Staff in the home support people to maintain their privacy and dignity whilst maintaining their independence. People are able to make choices about their life in the home and this helps people to maintain their independence and self-estem. Meals provided at the home are varied. People living in the home said the meals were good and that there is a choice available. The meal being served at the time of the visit looked and smelt appetising. Relatives also said in returned surveys that they felt the meals were of a good standard. Generally, people knew how to make a complaint and felt concerns were listened to. The home’s complaints procedure is available in the Statement of Purpose in the home in each person’s room. The standard of accommodation and decoration is good. The manager has plans to develop “themed corridors” on the first floor, to help to provide things of interest for the people living in the home to look at and discuss; for example a corridor about gardening with artificial flowers, pictures of gardens and gardening tools. Redecoration and refurbishment work continues. New chairs have been ordered for the first floor lounges and there are plans to develop the dining room. A varied programme of staff training is offered and members of staff confirmed that they are encouraged to access training, including National Vocational Training (NVQ). This helps to ensure the staff at the home are trained and skilled in providing care and meeting people’s needs. The staff recruitment process is thorough and the required checks and references are made to ensure that people are safeguarded from potentially unsuitable members of staff. The home has an experienced manager and the company carries out regular quality assurances surveys giving people opportunity to comment on the services provided. Resident and relative meetings are also held to give people the chance to discuss how the home is run and any issues. People’s personal finances are managed appropriately in the home. Records can be audited and show how people’s money has been used on their behalf. Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 7 There is a planned maintenance programme in place that ensures the home is maintained to a good standard and the fixtures and fittings are in good working order. What has improved since the last inspection? What they could do better:
When a person is admitted in an emergency, staff at the home should ensure that the resident and their family have all the information they need about the home, and the services it provides, within 24 hours of admission. The majority of people completing surveys said the home lacked activities and stimulation for people living there. Recently, two activities co-ordinators have been employed and activities were being offered on the day of this visit. However, this should be monitored to ensure all people living in the home have regular access to activities of their choice. Care should be taken to ensure unpleasant odours in some rooms are addressed and that the standard of the laundry service is monitored. Care must be taken to ensure there are sufficient members of staff on duty at all times as the majority of surveys returned raised staff shortages as an issue. People said that good basic care was provided in the home but that staff shortages meant that staff didn’t have the time to spend talking to people or taking them out into the garden or the village.
Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 8 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.V333442.R01.S.doc Version 5.2 Page 9 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.V333442.R01.S.doc Version 5.2 Page 10 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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Before people move into the home, a member of staff carries out a preadmission assessment to make sure Southfield Court and the staff are able to meet their health and welfare needs. EVIDENCE: People living in the home told the inspector that, before they had been admitted to the home, someone from the home had met with them and assessed their needs. This was done before admission to the home to make sure the home and its staff were able to meet the health and welfare needs of the prospective resident. The inspector also saw copies of pre-admission assessments in individual people’s care records. Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 11 Relatives’ surveys confirmed that they were able to visit the home prior to making the decision to place their relative. One stated, “After looking at several nursing homes within the Huddersfield area we found Southfield Court to be the best”. In one survey a relative felt that, because their relative’s admission had been an emergency admission, they had not been fully introduced or informed of the home’s procedures and services. This was discussed with the manager and it is recommended in this report that both the resident and their family are provided with full details about the home within 24 hours of an emergency admission to the home. The home welcomes people from differing cultural backgrounds. There is a multi cultural staff team and residents are from different cultural backgrounds. Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 12 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 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s health and welfare needs are clearly set out in a written care plan. This tells members of staff how to care for each person appropriately. Medications are managed well and people are treated with respect and their privacy and dignity maintained. EVIDENCE: New care plans have been developed since the last inspection. The care records seen during this visit identified each person’s health and welfare needs. They tell staff clearly, and in detail, how each person’s needs are to be met whilst living in the home. The care plans include specific detail about individuals’ care and their personal preferences, for example whether they like bubble bath in the bath or specific dietary likes and dislikes. This detail should help members of staff to provide consistent personalised care.
Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 13 Risk assessments have been carried out to identify any risks to the individual. Where a risk has been identified, a care plan is produced to minimise the risk. Each care plan and risk assessment is reviewed at least monthly. People living in the home said that they have access to other health care professionals such as family doctors, chiropodist, physiotherapists and opticians. Care records also record visits and support given by other health care professionals. The home has a named nurse and key worker system and there is a picture of each person’s named nurse and key worker in their room. Some people who spoke to the inspector felt this was a good thing as their key worker got to know them well and they had built up good relationships with them. The home has the necessary equipment to meet people’s needs and specialist equipment has also been obtained such as specialist pressure relieving equipment to help reduce the risk of people developing pressure ulcers and specialist communication systems to help severely disabled people make telephone calls independently. A sample of four people’s medications was checked during the visit. This showed there to be good systems in place for the recording, storing, administration and disposal of medications. Members of staff on duty at the time of the visit had a good knowledge of the medications policy and procedure and were able to tell the inspector how the system worked. People living in the home who talked to the inspector were generally complimentary about the home and the staff. People said they felt safe and that staff were kind and caring. They said that staff were polite and respectful. Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 14 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 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living in the home are offered some activities, they are able to exercise choice and control over their lives and maintain contact with their family and the community. Meals provided are good, varied and served in a pleasant environment. EVIDENCE: Surveys from people living in the home, and relatives, returned before the visit clearly stated that there were insufficient activities offered in the home. The manager of the home advised that, until very recently, there had been no activity organiser employed at Southfield Court. However, the home now has two part time activity organisers, both were on duty on the day of the visit. Both new members of staff are receiving training and the manager advised that two, two hours sessions of activities are to be provided on each floor; one session in the morning and one session in the afternoon. During this visit, some people had been making greeting cards and woollen “pom-poms”.
Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 15 The activities organisers were also seen to have one-to-one sessions with some people, talking and giving hand massages. The recent lack of activities was discussed with the manager and it is a recommendation of this report that activities be monitored to ensure all people living in the home have access to activities of their choice. People living in the home confirmed that there are no restrictions to visiting the home and that their families and friends are able visit at any time. Relatives visiting at the time the inspector was in the home said they had been made to feel welcome and that hospitality had been offered to them. Since the last inspection in August 2006, staff at the home have worked to develop closer links with the local community. The local church minister now visits the home regularly and holds a small service for the people living in the home. Staff at the home have also made greater effort to ensure all people living in the home have choices and control over their lives. People with dementia are now offered a choice of menu at each meal. Care records include details about people’s personal preferences, such as when they usually get up in a morning and go to bed at night and any specific preferences they have. People living in the home confirmed that they could choose whether to take part in activities or not, whether they spent time in their rooms or came to sit in the communal areas or not, what time they got up in the morning and when they went to bed at night. The meal being served at the time of the visit looked and smelt appetising and there was a choice of menu on offer. Staff were attentive to people’s needs, giving support and assistance when required. Dining areas were pleasantly set out and table laid with tablecloths. Kitchen staff served individual meals taking into account people’s preferences and appetites, adjusting portion sizes accordingly. Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 16 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 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living in the home and their relatives and friends are confident to make complaints and that these will be listened to and taken seriously. People are protected from abuse. EVIDENCE: Most people living in the home, and relatives’ surveys, said that they were aware of the complaints procedure and how to make a complaint. People living in the home who spoke with the inspector felt that, if they need to, they would be confident to raise any concerns they might have. Some people specifically said that the manager is helpful and approachable. The manager maintains a record of complaints and concerns raised. This includes the outcome of the complaint and the action taken by the home. Since the last inspection there have been four complaints made via the home’s complaints procedure. All were responded to within 28 days and addressed appropriately. People are protected from abuse in the home. Staff have had safeguarding adults training and there have been two recent incidents in the home where
Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 17 adult protection referrals have been made to protect vulnerable adults in the home. These incidents have been appropriately referred and investigated. Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 18 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 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People live in a clean, well maintained home. EVIDENCE: Since the last inspection a redecoration programme has been implemented. Some corridors and bedrooms have been redecorated. Some new carpets have been provided. Four of the five surveys from people who live in the home felt that the home is kept clean and fresh. One said that some carpets are not kept clean. One relative survey also said that more care and attention was need with the domestic services and that the laundry service was poor. Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 19 During this visit, areas of the home seen by the inspector appeared clean and tidy. A small minority of bedrooms had an unpleasant odour and action should be taken to address this to ensure that all people living in the home have a clean and fresh bedroom. These issues were discussed with the manager who was aware of the some of the concerns raised about the laundry system. Some relatives had raised these during relatives’ meetings held at the home. The manager reported that a housekeeper had been appointed to help address these problems and that these services are to be reviewed again with the company sending out its own surveys to people living in the home and their relatives. Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 20 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 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Suitable numbers of staff are employed. The staff receive induction and foundation training and are competent to work in the home. Staff recruitment policies and records protect people living at the home. EVIDENCE: Staffing levels are generally sufficient to meet the current needs of people living in the home. However, the majority of returned surveys from relatives stated that they felt, at times, there are insufficient staff on duty. One survey indicated that staff shortages were more noticeable in the afternoon. Duty rotas and records show that there are four care staff and one qualified nurse on duty on the ground floor during the morning and three carers and a qualified nurse on duty during the afternoon. On the first floor unit, there are five carers and a qualified nurse on duty during the morning and four carers and a qualified nurse on in the afternoon. At night, there is a qualified nurse and a carer on each floor and a third carer works between the two units. The registered manager and provider must review staffing levels to ensure there are sufficient numbers of staff on duty at all times to meet the needs of people living in the home.
Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 21 Members of staff spoken with at the time of the visit confirmed that induction and ongoing training is provided. Training records support this. Staff felt that there is a good team spirit at the home. People who live in the home and relatives were generally complimentary about the staff and the care they provide. Staff are recruited from diverse and varied cultural backgrounds. Some people living in the home commented on how polite and helpful staff are. The recruitment files of four members of staff were audited in detail and found to contain the required information and recruitment checks. These checks are necessary to help protect people from potentially unsuitable staff. NVQ (National Vocational Qualification) training is progressing and there is currently 39 of care staff that have NVQ level 2 in care. The company should continue to support staff in NVQ training with an aim of having 50 of the carer staff trained to NVQ level 2 or above. This will help ensure trained and skilled members of staff care for people. Training in the home has progressed and training records show that recent training has included induction, fire safety, infection control, safeguarding adults, control of substances harmful and hazardous, health and safety, food hygiene, movement and handling and care of the dying. Records show that there are few members of staff with first aid training. This must be addressed; there should be a member of staff trained in first aid on every shift. The manager advised training sessions have been booked. Written confirmation should be provided to show that sufficient members of staff have been trained in first aid. Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 22 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 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home has an experienced and competent manager. The home is run in the interests of people living there. People’s financial interests are protected. Staff are being formally supervised. The health, safety and welfare of people living in the home, and staff, are protected. EVIDENCE: Mrs Prime, the manager, is an experienced registered nurse. She has achieved the Registered Manager’s Award and continues to attend training sessions to further her professional education.
Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 23 The home operates a quality assurance system. Questionnaires have been sent out to people living in the home and relatives to ask their views about the service provided. The results of questionnaires are summarised by the home and a report produced. Findings are also discussed at resident and relatives’ meetings. Copies of the minutes of these meetings are available in the entrance of the home. Following the issues raised in the last survey, the company is due to send out questionnaires again to see if the issues raised have been resolved appropriately. The company also operates an audit system, looking at the services provided by the home, to monitor whether they are of an acceptable standard. The manager and staff have also recently taken part in a national “Gold Standard Framework” care scheme. This scheme is run by the Macmillan Nurses and looks at the support and care provided to people at the end of their lives. Southfield Court has been awarded with the standard. The Macmillan nurses will continue to assess and monitor the home. The home does not act as appointee for any people living at the home. Some people have small amounts of personal money that is held safely at the home by staff. Records are available to show when money is deposited on behalf of people. The records show the individual cash balance for each person and how their money is used on their behalf, including receipts for goods and items purchased. Three people’s finances were checked during the visit and were found to be correct. A lockable drawer is available in each person’s room, to enable them to keep some valuables safely. Formal staff supervision is ongoing in the home. Staff confirmed this when spoken to and a note of supervision dates is recorded. Individual staff supervision notes are held in staff files. Regular fire safety checks are carried out and recorded and there is a system of planned maintenance checks to ensure the building and equipment used remain safe for people living in the home and staff. Accidents are recorded in the home and are analysed monthly to try and identify any trends or specific issues. The use of bedrails has been reviewed in the home and unnecessary bedrails removed. This is seen as good practice as people’s safety is being maintained whilst the unnecessary use of restraints and restrictions is kept to a minimum. Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 24 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 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.V333442.R01.S.doc Version 5.2 Page 25 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 OP27 Regulation 18 (1) Requirement The registered manager and provider must review staffing levels to ensure there are sufficient numbers of staff on duty at all times to meet the needs of people living in the home. Timescale for action 30/06/07 Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 26 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 OP3 Good Practice Recommendations When people are admitted in an emergency, the manager should ensure that the resident and their family have all the information they need about the home within 24 of the admission. It is recommended that people living in the home, and relatives, be consulted about the range of activities offered in the home to ensure that the programme of activities offered meets people’s expectations. Work should continue with a view to having 50 of care staff with NVQ level 2. The home should be kept free from unpleasant odours. The manager should continue to monitor the cleaning and laundry services to ensure they are efficient. Written confirmation should be provided to the Commission for Social Care Inspection that staff have received first aid training. 2. OP12 3. 4. 5. 6. OP28 OP19 OP28 OP30 Southfield Court Care Home DS0000044509.V333442.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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
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