Inspection on 03/02/06 for Southfield House Care Home

This inspection was carried out on 3rd February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southfield House Care Home 09/01/07

Southfield House Care Home 31/08/05

Southfield House Care Home 18/02/05

Southfield House Care Home 22/06/04

Southfield House Care Home 24/02/04

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

CARE HOME ADULTS 18-65 Southfield House Care Home Albert Street Brigg North Lincolnshire DN20 8HU Lead Inspector Stephen Robertshaw Unannounced Inspection 3rd February 2006 09:30 Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 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 House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 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 Adults 18-65. 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 House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Southfield House Care Home Address Albert Street Brigg North Lincolnshire DN20 8HU 01652 653708 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) Prime Life Limited Mrs Sandra Robinson Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2005 Brief Description of the Service: Southfield House provides accommodation for up to 8 younger adults who experience mental health problems. The home is a converted two-storey property situated in Brigg. It is within easy walking distance of local shops, and amenities. The home is not registered to provide nursing care, however the home has developed good working relationships with local health care professionals and agencies. All bedrooms are for single occupation. Additionally the home has a range of communal facilities, which service users and visitors can access. The home has a large rear garden complete with patio and flowerbeds. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 03 February 2006. The inspection was over seven hours. The service users appeared to be very happy at the home and were very open in their communications with the inspector. What the service does well: What has improved since the last inspection? All staff working in the home have received infection control training. The staff supervision programme in the home is improving and they are working towards the recommended minimum for formal recorded supervision. The homes adult protection policies and procedures have been updated. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 6 The home has achieved 50 of the care staff to having completed the NVQ 2 in care. The homes care plans have improved in the quality of the information that is recorded. Good contact is maintained with the service users care management teams and also with healthcare professional that are based in the community 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 House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Prospective service users are provided with the opportunity to visit the home to see if it will meet their needs and are provided with choice throughout their daily lives at the home. EVIDENCE: The home had a statement of purpose and service users guide. The documents did not include the written room sizes but did include a plan of the home. This could be confusing for prospective service users wanting to identify the size of their room. There were eight service users living at the home at the time of the inspection and the inspector observed the case file records of two of the service users. These files showed that the service users had received a full assessment of their needs before they were admitted in to the home. The assessments were a combination of the homes pre-admission assessment and the care management assessment provided by the funding authority. The assessments were supported by Care Programme Approach risk assessment and management plans. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 9 Service users spoken to by the inspector confirmed that the home has the capacity to meet all of their needs. The records of the staff training programme and the records in relation to the service users care maintained by the home supported this standard. The service users also confirmed to the inspector that they had been given the opportunity to visit the home before they actually went to live there. In the case information seen by the inspector visits to the home had been accurately recorded. The case files for the service users included the terms and conditions of their residency provided by their funding authority. However they did not include individual terms and conditions of their placements between the service users and the home. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 and 10 Service users individual needs are identified at the home. EVIDENCE: Both case files observed by the inspector for the service users included care plans that reflected how the individual assessed needs of the service users must be met. The care plans were clearer than previous care plans seen by the inspector at the home however they had not all been evaluated and reviewed on a regular basis. There was evidence in the home that the service users are supported and encouraged to make decisions in relation to their daily lives and the activities that they become involved in. Regular service user meetings are held at the home to give the service users an opportunity to discuss their own ideas and the development of the services at the home. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 11 All of the care plans seen by the inspector had been signed by the service users or their representative to agree to the services and support that were being offered to them. Choices were also observed to be available at meal times in the home. Service users finance records showed that they have choice how they wish to spend their monies and care plans showed where service users required support to maintain their personal finances. The service users are provided with the freedom of movement unless a risk assessment identifies that something may cause a risk to them or others. The care plans included full risk assessments and risk management plans for individual service users. There was evidence that the risk assessments had been completed through a multi disciplinary agreement. The majority of the homes records are stored in accordance with the Data Protection Act 1998. The service users case file records and archive material is in box files in the main office which has recently had a lock put on the door. These records would be better stored in a lockable unit in the office in the event that the office door is left open for any reason. The records would currently be open to access to anyone if this happened. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,13,14,15,16 and 17 The service users are supported to maintain and develop their personal lifestyles while living at the home. EVIDENCE: National Minimum Standards 11 and 15 were exceeded by the home. The care plans observed by the inspector and discussion with the service users showed that they are provided with support and encouragement to maintain and develop their social, emotional, communication and living skills at Southfield House. The service users spoken to by the inspector stated that they had good access to the community and activities in the community. They said that ‘the staff are helpful’ when they need support to go in to the community. The service users went on holiday to the coast last year and they said that they ‘really enjoyed it’. Through a service user meeting they agreed to go on holiday to the same resort this year and stay in a hotel with all the meals Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 13 provided. Prime Life have indicated that they will contribute up to £100 per week per service user for their holiday and the service users must make up the reminder of the cost themselves. Standard 14.4 states that ‘service users in long term placements have, as part of the basic contract price, the option of a seven-day annual holiday outside of the home, which they help choose and plan’. Previous holidays from the home have been part financed by the service users themselves. Care files clearly show how contact is maintained and supported between the service users, their families and friends. The records also indicated how the staff at the home had supported a service user to re-establish their relationship with their family after an absence of several years. Discussions with service users and direct observations made by the inspector showed that the staff promote their independence and choice. Any restrictions in the movements of service users are identified through their care plans and risk assessments. Records of service user meetings supported that they are encouraged to decide what is to be included on their menus. The service users stated to the inspector that they ‘enjoyed’ all of their meals at the home. Care plans included an assessment of the service users nutritional needs. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 and 21 The personal and healthcare needs of the service users are met. EVIDENCE: The home does not provide nursing care. Individual service user records showed the contact they have with professional healthcare workers that are based in the community. This included GP’s, dentists, psychiatrists and community nurses. Service users confirmed to the inspector that when health care workers see them they are always seen in private unless they request support from a member off staff. Staff administering medication at the home have all received accredited medication training. All of the medication records were up to date and were accurately recorded. Clear records were maintained of medication returned to the pharmacy. There was no controlled medication in the home at the time of the inspection. All of the case files observed by the inspector included the last wishes of the service users in the event of their deaths. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The service users welfare is maintained and protected at the home. EVIDENCE: The homes policies an procedures for the protection of vulnerable adults have been updated and now refers to suspected abuse being reported to the appropriate adult protection authority who will then establish how the suspected abuse will be investigated. Staff interviewed by the inspector were aware of the policies and procedures to protect the service users. There had been no complaints registered at the home since the last inspection. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,29 and 30 The environment of the home provides choice for the service users and where they wish to socialise. The home is in need of general refurbishment to improve the atmosphere and presentation of a homely environment. EVIDENCE: The home does not provide low temperature surfaces on the radiators. This practice is supported by a risk assessment, however the risk assessment does not reduce any of the significant risks to the service users it merely states that contact with the surfaces could cause injury. The registered person must provide an appropriate risk assessment and action plan and implement them where there is a possibility of service users being burned through contact with hot surfaces. The environment of the home is very run down. The lounge carpet is badly worn and needs replacing. The bathrooms as stated at the last inspection require updating and replacing. The service users stated that they ‘do not like the bathrooms’ but they had ‘no Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 17 other choice’. The floor coverings in the bathrooms also require attention and possibly replacing. The lighting and furnishings at the home are domestic in character. A tour of the premises by the inspector and being invited to look at several of the service users rooms supported the evidence that they are encouraged and supported to personalise their rooms to their own tastes and preferences. Service users spoken to by the inspector stated that they were ’very happy’ with their personal rooms. All of the rooms in the home are for single occupation. At the time of the inspection the home had not received its annual audit for maintenance provided by the company. The inspector observed some plans that have been put forward to the local authority-planning department to expand the home. It is possible that some of the existing environment problems would be improved at the same time as any new development commenced. The service users can choose a communal area to use from the dining/conservatory to the television lounge. Any further development would include additional communal areas. The home has not had an overall assessment of its abilities to meet the assessed needs of the service users however individual service users care plans showed that they had been assessed for their mobility and movement needs. No service users living at the home require and aids or equipment to support them with their mobility needs. Since the last inspection training records and discussions with staff confirmed that they have now completed infection control training. Observations by the inspector supported that infection control policies and practice were in place in the home. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 Staff working at the home have the appropriate skills and knowledge to meet the needs of the service users. EVIDENCE: Staff interviewed by the inspector confirmed that they had received job descriptions and work specifications before they began work at the home. They were also very aware of their own responsibilities and those of their colleagues. They also confirmed that they had received individual copies of the General Social Care Council’s codes of conduct and practice. The staff training records showed that the staff receive all of the appropriate mandatory training and regularly receive refresher training. The manager and staff working at the home have a positive attitudes and approach towards their NVQ training. Three of the six staff employed have already achieved NVQ 2 in care this equates to 50 of the staff with the qualification. Two other staff have completed the award but are awaiting the final verification of their work. One member of staff has registered on the award. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 19 The manager of the home stated that staff rotas are developed through the times required by the Residential Forum. There were no staff working at the home that were under twenty-one. The staff personnel files showed that the home operates a thorough recruitment procedure that is based on equal opportunities and the protection of service users. All staff receive a minimum of a POVA first clearance before commencing work at the home. Staff confirmed that they completed and submitted an application form to the home, then were interviewed and their references were taken up before they were employed. Training records showed that new staff receive induction and foundation training that meets the requirements of the Sector Skills council workforce training targets. All staff completed the safe handling of medication course in March 2005 and Infection control training was recently completed. At the time of the inspection they were waiting for their certificates. The staff supervision records show that the home is working towards the recommended minimum but not all staff working at the home received supervision on a regular basis. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41 and 42 The management of the home supports the welfare and protection of the service users. EVIDENCE: The manager of Southfield House has completed the Registered Managers Award and is working well towards completing the NVQ 4 in care. The management approach to the home is very open, positive and inclusive. This standard was exceeded. The service users stated that the manager is always ‘available’ to them and ‘listens’ to what they have to say. There were no records in the home that supported that the home has an effective quality assurance and monitoring system. The homes policies and procedures were updated in April 2005. Appropriate policies and procedures were in place for reporting suspected or alleged abuse. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 21 Staff interviewed by the inspector were aware of issues that could provoke an investigation for suspected abuse of the service users. The home receives monthly regulation 26 visits from an external manager from Prime Life. These visits are recorded and a copy is left at the home. Internal memorandum suggested that the home is being considered for a seven-bedroom extension in the near future. The home had an up to date business and financial plan. Prime Life audits the service users monies on a monthly basis. Many of the service users still have their monies in a Prime Life pooled account. The account is transparent. However as some of the service users savings are quite high they should be in individual accounts accruing interest. The home met most of the requirements in relation to the health, safety and welfare of the service users. However the home did not have an up to date certificate verifying the safety of the electrical systems. The registered person must ensure that the homes insurance cover is valid without having this certificate in position. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 1 25 3 26 X 27 1 28 2 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 4 12 X 13 3 14 2 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 3 2 4 1 3 3 1 X Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 16 Requirement The registered person must ensure that all radiators, and hot water pipes are protected with low temperature surfaces, or an appropriate risk assessment is provided to ensure the safety of the service users. Original timescale of 20/07/04 has not been met. The registered person must ensure that a maintenance and redecoration plan is put in to effect in to the home, and improve on the current standard of redecoration. Original timescale of 30/09/05 has not been met. The registered person must improve the bathroom facilities available at the home. Original timescale of 30/11/05 was not met. The registered person must ensure that the home has an effective quality assurance and monitoring system in position. The registered person must ensure that the home has a current certificate evidencing the safety of the electrical system, DS0000002817.V272525.R01.S.doc Timescale for action 30/03/06 2 YA24 16 30/03/06 3 YA27 16 30/04/06 4 YA39 24 30/04/06 5 YA43 16 30/03/06 Southfield House Care Home Version 5.1 Page 24 or written confirmation from their insurance company that they do not require this to meet their insurance requirements. The original timescale of 22/07/04 has not been met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 5 6 7 8 Refer to Standard YA5 YA6 YA10 YA14 YA24 YA28 YA36 YA37 Good Practice Recommendations The registered person should make sure that all service users are provided with a copy of their terms and agreements of their residency at the home. Service users care plans should be evaluated and reviewed on a regular basis. The registered person should ensure that the service user case file information in the main office is safely secured and is inaccessible to the general public.. The registered person should make sure that the service users are provided with the opportunity of a seven-day holiday as part of the basic contract price. The registered person should ensure that the environmental risk assessment protects the welfare of the service users. The registered manager should consider replacing the carpet in the lounge area of the home. The registered person should make sure that all care staff working in the home receive regular formal recorded supervision. The registered person must ensure that the homes manager has completed the NVQ 4 in care or equivalent. Southfield House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 House Care Home DS0000002817.V272525.R01.S.doc Version 5.1 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!