Inspection on 31/08/05 for Southfield House Care Home

This inspection was carried out on 31st August 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Southfield House Care Home 09/01/07

Southfield House Care Home 03/02/06

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 Albert Street Brigg North Lincs DN20 8HU Lead Inspector Stephen Robertshaw Unannounced 31 August 2005 st 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 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 Stationary 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 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Southfield House Address Albert Street Brigg North Lincs Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01652 653708 Prime Life Ltd Mrs Sandra Robinson Care Home 8 Category(ies) of MD (8) registration, with number of places Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no condirtions to the homes registration. Date of last inspection 18th february 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 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector completed an unannounced inspection on Southfield House on 31st August 2005. This was the second attempt to inspect the hope. The inspector initially visited the home unannounced on 25 August 2005 however all of the service users and the staff were out of the home on an organised day trip to the coast. The inspection was over a six and a half hour period, and the inspector spoke with all of the service users at the home, both individually and in groups. The inspector also spoke to staff at the home and observed records. The service users stated that they are `very happy at the home and the staff are ‘very helpful’ to them. What the service does well: What has improved since the last inspection? The service users now receive the option of a seven days holiday provided through their contract agreement with the home. The management and staff at the home are working well towards their commitment to NVQ training. This means that they will have a good knowledge and understanding of the needs of the service users. The company’s records of regulation 26 visits to the home have improved in the detail of the actual visits. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 6 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 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 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 standard(s) 1,2 and 3 The service users have full assessments of their needs before they are admitted in to the home. This makes sure that the home can meet their needs, and also makes sure that the service users receive the care that they require. EVIDENCE: The homes statement of purpose was updated in February 2005. This clearly identified the services that are available to the service users at the home. It was identified that the home does not provide nursing care. There were seven service users in the home at the time of the inspection and the inspector examined all of the written information that the home had in relation to three of the service users. All of the case files observed by the inspector included comprehensive assessments of the service users needs. This included the homes preadmission assessment, and a care management assessment. There had been no new admissions in to the home since the last inspection. The written records in the home, discussions with service users and interviews with staff confirmed that the home has the capacity to meet the needs of the service users. Staff training records also provided evidence that the staff Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 9 undertake regular training to ensure that they can meet the needs of the service users. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 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 standard(s) 6,7,8 and 9 The home provides the service users with choice throughout their daily routines and activities. The service users stated that this makes them feel ‘part of the home’. Choice is also available in deciding how individual care needs are delivered to service users. EVIDENCE: The inspector looked at the care plans for three service users and they had all be evaluated on a minimum of a monthly basis. This ensured that the service users needs were up to date and were being met by the home. The care plans evidenced where clear service users had made choices, and they had agreed to the care plan being provided. The care plans identify any needs in relation to religion, race, or culture. Where appropriate risk assessments were associated to individual care plans. These allowed the service users to develop personally and take some risks, but minimise the risks to the service users themselves or other people that they Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 11 came in to contact with. The risk assessments had also been evaluated on a minimum of a monthly basis. To identify any changing needs and risks presented by service users. Discussions with service users supported that they are asked for their opinions in relation to the development of the services and act ivies at the home. Records of service user meetings supported that they are consulted in relation to future activities, day trips, menus at the home, BBQ’s and contentment with their individual care plans. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 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 standard(s) 11,12,13,14,15 and 17 The home provides the service users with the opportunity to develop their personal skills and encourages them to integrate with the local community and to maintain contact with their family and friends. EVIDENCE: Standards 11 and 15 were exceeded. The social activities for the service users at the home are well planned and recorded. Service users stated to the inspector that they were supported very well to access activities in the home and out in the community. Service users said that they have very good contact with their families and this was supported through the written information in individual service users case file records. Service users also confirmed that the staff assist to transport them to see their families. The records for two service users identified that currently they are involved in voluntary work, one in a supermarket stacking shelves, and the other works in a church hall service hot and cold drinks and refreshments. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 13 A seven-day holiday is now made available to the service users at the home and this is paid for through their usual contract agreement. However whilst on a recent holiday at Great Yarmouth the service users were expected to pay for their own meals as these were not provided by the home. The home now has access to a mini bus belonging to the company on two days per month. These days are used for day trips for the service users. The destination of the trips is discussed in residents meetings, and these records were observed by the inspector. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 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 standard(s) 18,19 20 and 21 The personal and healthcare needs of the service users are appropriately met by the home, or with the support of external healthcare professionals. The home does not provide nursing care. EVIDENCE: Service users spoken to by the inspector, and their individual care plans identified how they prefer to be addressed and said that the staff always refer to them in an appropriate manner. Care plans observed identified that the service users are supported to develop and maintain their physical and healthcare needs. The medication in the home is provided through a local chemist and the majority of this is in a NOMAD monitored dosage system. All medication in the home was recorded and stored appropriately. The staff that are involved in administering medication to the service users had all received accredited medication training provided through a local adult education college. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 15 The home does not provide nursing care, however the nursing care needs of individual service users are met through healthcare professionals that are based in the community. The home records any contact that the service users have with healthcare professionals and the outcome of the contact. The records also include identification of deteriorating health, and regular contact then made with healthcare services. Service users confirmed to the inspector that when healthcare professionals visit them they are always seen in private unless they ask a member of staff to support them. Individual care plans identified the service users last wishes in the event of their deaths, or identified why this information had not been made available for example the effect that this may have on individuals mental health particularly when they have a fear of death. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 16 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 standard(s) 22 and 23 The home has processes for the service users to air their views. This includes the regular service user meetings, and care plan reviews. The policies and procedures in relation to abuse could place service users at risk. EVIDENCE: There have been no complaints formally recorded at the home since the last inspection. The homes complaints procedure needs to be updated to include reference to the change of office for the local Commission for Social Care Inspection The staff at the home receive training in relation to the protection of vulnerable adults that is provided through the local authority. The homes policies and procedures for the protection of vulnerable adults are insufficient to ensure the safety of the service users. The policies state ‘if the vulnerable adult does not wish to report the incident to the police, you should document what they have actually said and inform your line manager, and or their social worker.’ In all cases suspected abuse must be reported to the appropriate authorities. Interviews by the management of the home could undermine any evidence in relation to the abuse and nullify its effect in a later court case. They should not interview the complainant or accused until being given the clearance to do so through the appropriate authorities. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 17 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 standard(s) 24,26,27,29 and 30 The general environment is in need of attention. Some bedrooms have recently been redecorated but this has been carried out to poor standards. EVIDENCE: A tour of the premises by the inspector identified that the environment is in need of redecoration. Several service users asked the inspector to look around their rooms. These had all been personalised to the individual’s tastes and preferences. Some of the bedrooms had recently been decorated. The service users stated that they were happy with the redecoration of their rooms but direct observations evidenced the poor quality of the decoration that had been carried out. This included a strip light over a sink in one bedroom being heavily covered in dry paint. This was not just a smudge but clear full brush widths across the light. The two bathrooms in the home are in urgent need of replacement. The current bathrooms are dated and in poor terms of repair. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 18 No service users in the home require any specialist equipment to support them with their mobility. A tour of the premises by the inspector found it to be free of any bad smells and made it a pleasant environment for the service users to live in. However there was no evidence in the home that the staff undertake any infection control training. Toilets and bathrooms are well spaced around the home. The toilet wall in the laundry area needs repairing as it has a home in it. This was identified in earlier inspection reports and has not been acted on. The washing machine in the home is domestic in character and is programmable to disinfection and sluicing standards. Service users care plans where appropriate support them to maintain their own washing and ironing as part of their personal development. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33 and 36 The staff working at the home have the necessary skills and competencies to meet the needs of the service users. EVIDENCE: The training records for the staff, interviews with staff, and discussions with service users all supported the evidence that the staff in the home have the skills to work with, and meet the needs of the service users. The staff have a strong commitment to their NVQ training and the home should meet its commitment of 50 of the homes staff to have achieved NVQ2 or equivalent by 31st December 2005. The records for staff supervision were not available to the inspector as only the manager had access to them and she wasn’t available. Staff that were interviewed by the inspector stated that they do receive at least the minimum of six formal recorded supervision periods per year, and their supervision covers the care plans that they are involved in, the staffs personal development and the philosophy of care in the home. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,40,41,42 and 43 The management approach to the home is open and inclusive. The service users feel comfortable approaching both the internal and external management of the home. EVIDENCE: The manager was not available at the inspection but the inspector was informed that she has completed the Registered Managers Award and is currently working towards NVQ4 in care and this should be completed by December 31st 2005. Service users spoken to by the inspector and interviews with the staff evidenced that the management of the home is open, and encourages the staff and service users to air their views in the development of the services and activities that are available in the home. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 21 This was supported through the observation of the written records of service user, and staff team meetings. The inspector did not observe all of the homes policies and procedures however there was a problem with the protection of vulnerable adults policy and procedure as identified earlier in this report. The external management of the home have improved their recording of regulation 26 visits to the home. A copy of the report is left with the home but a copy is not forwarded to the local office of the Commission for Social Care Inspection. There were several health and safety concerns in the home. An immediate requirement was issued in relation to the home obtaining a certificate for its electrical systems to ensure that they are safe. An immediate requirement was also issued at the time of the inspection to ensure that all of the radiators are fitted with low temperature surfaces to protect the service users from the risk of their skin contacting a hot surface; this also included protecting pipe work that carries hot water. The toilet wall in the laundry has a hole in it that requires repairing. The home has a company business and financial plan that identifies the home as an effective business. Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 3 2 x x 2 Standard No 11 12 13 14 15 16 17 4 3 3 2 4 x 3 Standard No 31 32 33 34 35 36 Score x 3 2 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Southfield House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 2 1 3 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 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 14 Regulation 12 Requirement The registered person must ensure that the service users are provided with three meals per day at least one of must be hot, and this includes holiday periods as part of the basic contract price. The registered person must update the homes policies and procedures for the protection of vulnerable adults to ensure the safety of the service users. The registered person must ensure that all radiators, and hot water pipes are protected with low temperature surfaces the 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. The registered person must improve the bathroom facilities available at the home The registered person must ensure that staff working in the home recieve infection control 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Timescale for action 30/09/05 2. 23 12 30/10/05 3. 24, and 42 16 Immediate 4. 24 16 30/09/05 5. 6. 27 30 16 19 30/11/05 30/12/05 Southfield House Version 1.40 Page 24 training. 7. 33 19 The registered person must ensure that a minimum of 50 of the care staff have achieved NVQ 2 or equivalent. The registered person must ensure that the manager of the home has completed NVQ 4 in care. The registered person must ensure home has a current certificate evidencing the safety of the electrical system. The original timescale of 22/07/04 has not been met. 31/12/05 8. 37 9 31/12/05 9. 43 16 Immediate 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 41 Good Practice Recommendations The registered person must ensure that regulation 26 visits are carried out at the home and a copy of the record of the visit is submitted to the local office of the CSCI Southfield House 20050825 Southfield House UI J54 v246180 s2817 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Unit 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. 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