Inspection on 09/01/07 for Southfield House Care Home

This inspection was carried out on 9th January 2007.

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

The inspector 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southfield House Care Home 03/02/06

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 9th January 2007 08:45 Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 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.V326853.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 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.V326853.R01.S.doc Version 5.2 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) info@prime-life.co.ukwww.prime-life.co.uk 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.V326853.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2006 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. The fees charged by the home were not available at this time. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was unannounced and took place on 09th January 2007. The inspector was in the home for approximately six and a half hours. The evidence for this report was gathered through a variety of different ways including a pre-inspection questionnaire that was sent to the management of the home before the site visit and questionnaires sent out to the staff and other professionals that are involved in providing care to the service users. What the service does well: What has improved since the last inspection? The care staff now all receive regular supervision. This means that the manager and service users can be sure that the staff have the knowledge and skills to look after the service users. One of the bathrooms in the home now includes a shower. This means that the service users can choose how they wish to maintain their personal hygiene. The floor covering in the lounge has been changed. This is now much easier to clear and improves the appearance of the room. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 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.V326853.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service users are given the opportunity to visit the home before they make a decision to move there and there needs are assessed to make sure that they can be met at the home. EVIDENCE: The Service users are provided with an opportunity to visit the home to see if they think that it will be suitable to their needs. A service user that was recently admitted to the home confirmed to the inspector that he had been asked to visit the home before he moved there and that it was ‘my decision’ to choose to move in to the home. Most of the other service users had lived in the home for a considerable length of time, but those spoken to by the inspector all agreed that they had made decisions to move to and remain at the home. The inspector observed the care files for two of the service users living at the home. Both of these included a full assessment of the service users needs before they were admitted in to the home. The assessments were a combination of the home’s pre-admission information and care management or health service assessments of the service users’ needs. The assessments covered all of the aspects of the service users social and healthcare needs. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 9 A recent episode of abusive behaviour by one of the service users directed towards themselves led to the staff and management of the home holding meetings with the service user, their social worker and psychiatrist to determine the most appropriate placement for the service users due to the effect of the placement on themselves and the effect that their actions were having on the other service users. The home has the capacity to meet the needs of the service users. This evidence was supported through the inspectors contact with three of the service users social workers who all stated that they, or their colleagues had previously placed service users at Southfield and would continue to do so as the staff there had a very good understanding of the needs of service users with mental health problems. This was also supported through the staff training programme including NVQ’s, all of the required mandatory training and specialist training in relation to the individual mental health needs of the service users. The care files for the service users that were observed by the inspector included their care management placement contract with the home and this identified any third party payments that were due to be paid by the service user or their representative. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that although the staff are aware of all of the service users’ needs these are not necessarily identified through appropriate care plans. EVIDENCE: The inspector observed the care files for two of the service users living at the home. Both of these included the care plans completed by their placing agencies detailing the care that must be provided to the service users at the home. One of the files had a full care plan that had been developed for the service user by the manager and care staff working with them in the home. This detailed all of their individual health and social care needs and identified the support that they required to meet these needs. The other file was for a service user that had been admitted to the home approximately one month before the inspection. A care plan to provide for their needs had not been completed by the home. When the staff were asked by the inspector how they knew what the needs were, and how they should support the service users Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 11 they all stated that they had read the original assessments of the service user and followed the care management plan that detailed the care that should be provided at Southfield House. Where appropriate the service users’ care programme approach information was also included. Direct observations during the site visit supported the evidence that the service users are provided with choice throughout their daily lives at the home. This included what they wanted to eat and where they wanted to eat it. The service users were also given the opportunity to take part in activities in the community and in the home with the staff. One service user stated to the inspector ‘It is the best home that I have ever lived in, it is like home and we are able to do what we want to do as long as it is safe’. Regular service user meetings are also held at the home to determine how they see the services that are provided to them and to gain their views and perspectives of how the services could be improved in the future. The service users’ financial records held in the home showed that they are supported to maintain their own personal finances with appropriate support where it is identified. The service users’ care plans were supported with risk assessments. These were a combination of the risk plans developed by the home and care programme approach risk contingency plans. The service user that did not have any care plans provided by the home was at a high risk of self-abuse and there were no risk assessments highlighting these issues that had been developed by the home. Risks to service user from staff could have been increased through a member of staff being employed at the home before any Criminal Record Bureau clearances had been received. All information recorded at the home in relation to the care of individual service users were stored in accordance with the Data Protection Act 1998. Service users spoken to by the inspector stated that when they needed to speak in private or see doctors or other professionals these visit and meetings were always kept confidential. The inspector’s observations during the site visit supported the other evidence that information relating to individual service users maintained confidentiality. This included closing doors when speaking privately to service users and not discussing personal issues in public areas of the home. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service users living at Southfield House have the opportunity to develop and maintain their personal lifestyles, however there were some concerns in relation to the future planning of service users’ annual holidays. EVIDENCE: The inspector’s observation of individual service users’ care plans showed that they are supported to develop their social, emotional, communication and independent living skills, the latter of which were also supported through occupational therapy assessments. One service user said to the inspector, ‘I go out and do some voluntary work, I am more independent than I have ever been, but I don’t think that I could live on my own, or anywhere else but Southfield House’. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 13 Other records and discussions with service users supported that they attend activities in the community for adult education and training. One of the service users said to the inspector that they attend a local day centre for people with mental health problems and that they attend a workshop there, where he makes items for himself and other service users out of wood. Other service users also informed the inspector that they go to a local cafe in the community on a regular basis and also get involved in activities there. The home is located close to the middle of the town and the service users told the inspector that they are made welcome wherever they go. A service user informed the inspector that they can go out wherever they want ‘as long as we let the staff know where we are going and when we will be back. He also said that he knew that this was to ‘make sure that I will be safe’. The home does not employ a cook. All of the meals eaten at the home are prepared by the care staff who are at times supported by individual service users as part of their personal development plans. All individuals including the service users that access the kitchen had completed food hygiene and safety training. Records from service user meetings showed that the service users have the opportunity to discuss the menus for the following weeks. The service users that were spoken to by the inspector all stated that they enjoyed the meals provided for them at the home. One service user added ‘it would be nice to have a small kitchen where we could make hot drinks for ourselves and maybe some toast or sandwiches’. Service users are offered an annual holiday from the home. This year and in previous years the service has provided a set fee of £500 towards the holiday. The staff stated that they had been informed that this funding will not be available any longer. The registered person must make sure that the service users are provided with the opportunity of a seven-day annual holiday as part of the basic contract price. In the summer the majority of the service users went to Great Yarmouth for a week. There were also a wide range of days trips that were made available to the service users. These included trips to Cleethorpes, York (National Railway Museum), Leeds and the Nottingham Museum of life. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that all of the service users personal and healthcare needs are met at the home. EVIDENCE: Although one of the service users living at the home did not have a care plan identifying how their needs should be met, other documentation supported that appropriate care was being offered to them in relation to their personal and healthcare needs. This included a record of their registration with a local GP and regular contact with the care manager that placed them at the home. The service users confirmed to the inspector that when healthcare professionals see them, they are always seen in private unless they ask one of the staff to support them with the appointment and commented that their privacy, dignity respect and independence is respected at all times in the home. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 15 All of the staff that administer prescribed medication to the service users had received appropriate medication training. The staff were observed administering medication to the service users. All appropriate legislation and good working practice guidelines were followed. The records were all up to date and had been accurately recorded. There were no controlled drugs in the home at the time of the inspection. The care files that were observed by the inspector included the identified last wishes of the service users in the event of their deaths. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s policies and procedures have the potential to protect service users from abuse at the home and there is a clear complaints procedure open to them, however failure to adhere to recruitment procedures can compromise this. EVIDENCE: There had been no recorded complaints at the home since the last inspection. However the home has a complaints procedure that the service users all said that they were aware of if they needed to use it. One complaint had been received directly by the Commission. The complaint was anonymous and concerned the poor treatment and breach of confidentiality in relation to a service user (un-named) when they were in the doctor’s surgery. The complaint was re-directed to the doctor’s surgery, however even after four further telephone conversations with the manager of the practice there has been no formal response to the complaint. Staff confirmed to the inspector that they receive training for the protection of vulnerable adults to ensure that they are kept safe. The training is provided through a variety of resources including NVVQ, the local authority and in house training. However the safety of the service users could have been compromised as the management of the home had employed a new care worker who had access to Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 17 the service users and their records before any safety vetting had been carried out in relation to them. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the environment provided for the service users is very basic and there are some areas that need to be improved. Some of these areas are outstanding requirements. EVIDENCE: Southfield House is situated close to the centre of the town and is easily accessed. Parking is restricted to the road in front of the home. The member of staff deputising in the absence of the manager stated that there are plans to redevelop the home in the near future, this would include additional bedrooms, and communal areas for the service users and there was also a possibility that a new car park could be included in the grounds of the home. The radiators in the home are not provided with protective covers to make sure that service users are not harmed if they come in to contact with them. A risk assessment supports the decision to leave the radiators unprotected Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 19 however this was very basic and did not recognise the individual risks presented to individual service users. The week before the site visit the company had completed an audit of the environment to determine what maintenance and repair would be carried out over the next twelve months. However this information was not available at the time of the site visit. Since the last inspection of the bathrooms has been updated and now the service users have the choice of a shower unit. One service user stated that ‘it’s better now because I can have a shower at any time’. This room had a block of soap left in it. The staff stated that there had been a soap dispenser in the room prior to the room being updated and during the development it had not been replaced. Therefore infection control was at risk in this bathroom. The kitchen of the home is kept very clean. The floor in the kitchen was replaced approximately one year ago. The covering is discoloured and the staff stated that it is very difficult to try and keep clean. A member of staff said that they thought that the kitchen was one of the areas identified in the home’s audit that required replacement. The toilet in the laundry area needs to be replaced. The bowl is very discoloured and the staff state that it will not clean. The remainder of the bathrooms were old and needed to be updated. There was no evidence provided that identified that this would be undertaken at the same time, or shortly after the further building development of the home. The floor area in the service user lounge had been replaced due to the damage caused through dropped cigarettes. The carpet had been replaced with a cleanable floor that would not be easily damaged through spilled hot drinks and dropped cigarettes. The service users’ bedrooms are individualised with their personal pictures, ornaments and small items of furniture. The inspector spoke to six of the service users and all of them were happy with their personal accommodation. One service user stated to the inspector ‘I’m very happy here, my room is very good.’ .Service users’ care plans identified if they had any mobility needs and the support that they service users required with them. The home does not employ any domestic staff. All of the domestic chores are undertaken by the care staff and where it is identified in the service users individual care plans for personal development needs the service users also undertake some tasks that include keeping their own rooms clean and tidy. The home only has a very small staff group. Due to the need to carry out the domestic chores this often leaves the staff with very little time to develop regular activities for the service users. Although several of the home’s toilets are very old and discoloured the majority of the home was free of any Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 20 offensive odours. The only odour present was in the toilet area of the home’s laundry. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. This means that the staff have all of the skills and knowledge to meet the needs of the service users, however they had not all received the approved security vetting procedures before they commenced work with the service users. EVIDENCE: The inspector was unable to access the staff personnel records as the manager of the home was not available. However the inspectors observations and interviews with staff supported the evidence that they understand their own roles and those of their colleagues. There are no staff working at the home that are under twenty-one years. Staff spoken to by the inspector confirmed that the staff are provided with all of the mandatory training and specialist training in relation to the needs of service users with mental health needs. Staff also confirmed to the inspector that they attend regular staff meetings. This enables them to be brought up to Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 22 date on any new developments in the field of social care and also provided them with an arena to air their views in the provision of care in the home. The staff working at Southfield House have exceeded their requirements for NVQ training. Approximately 86 of the care staff have completed the NVQ 2 in care. Six of the care staff also hold a current first aid certificate. The homes provides appropriate care staff in relation to the numbers of service users. However due to their other duties including preparing meals, completing the laundry and cleaning the home this leaves very little time for service users to be supported with activities, or for individual one to one time with their key workers. Although the staff personnel files were not available to the inspector, it was identified that a member of staff had recently been employed to work at the home before any safety vetting had been completed though the Criminal Record Bureau. This could have placed the service users at risk of abuse. Although the member of staff had a CRB completed several months earlier they were advised that this was not transferable. Records in the home also supported that the staff now all receive the minimum recommendation of six formal supervision periods per year. Staff interviewed by the inspector confirmed the frequency of their supervision and stated that all areas of practice, the philosophy of care in the home and personal development opportunities were discussed in supervision. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 and 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the management of the home is supportive of the needs of the service users, however the employment procedures in the home could place the service users at risk of abuse. EVIDENCE: The manager was not available on the day of the site visit. However evidence was provide that she has completed the Registered Manager’s Award and the NVQ4 in care. Service users and staff all confirmed to the inspector that the manager is very open and approachable. All of the staff and service users spoken to by the inspector stated that the manager always had time for them. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 24 There are regular service users’ meetings held at the home to allow them to voice their opinions in relation to the delivery of the services provided at Southfield House. The corporate body is responsible for the quality monitoring of the services provided at the home. The last quality audit was completed in December 2006. The corporate body assessed the home as a 4 star service. The information for the audit was gathered through questionnaires sent out to the service users and their relatives. The home’s policies and procedures are brief however they cover all of the areas required of them. The employment policies and procedures were not followed in relation to the member of staff that was employed without a current CRB. All of the records required by regulation had been maintained well and had been accurately recorded. The records of the service users’ daily activities were very comprehensive and thorough. The diary sheets clearly evidenced any patterns of behaviour for individual service users. The majority of the home’s requirements for health and safety of the service users and the staff were met and this included a certificate evidencing the safety of the electrical systems in the home. Previously this information had not been available. A representative from the corporate body visits the home on a monthly basis to complete a regulation 26 visit. A record of these visits can be accessed at the home. Regular accounts are produced for the home so that the manager can determine what is available to develop the services being provided to the service users. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 25 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 4 33 3 34 2 35 3 36 3 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 3 12 3 13 3 14 2 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 4 3 2 3 2 3 Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 Requirement Timescale for action 30/01/07 2. YA23 YA34 YA40 YA42 13.4c,18 and19 3. YA24 16 4. YA27 16 The registered person must make sure that all service users admitted to the home have a care plan detailing how all of their needs must be met in the home. The registered person must 10/01/07 make sure that no staff are employed to work at the home until they have received the appropriate security vetting to uphold the health, safety and protection of the service users. The registered person must 30/03/07 ensure that a maintenance and redecoration plan is put in to effect in to the home, and improve on the current standard of decoration. Original timescale of 30/09/05 and 30/03/06 have not been met. The registered person must 30/06/07 improve the bathroom facilities available at the home. Original timescale of 30/11/05 and 30/04/06 were not met. Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 27 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 YA14 Good Practice Recommendations 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 person should consider replacing the floor covering in the kitchen area of the home. The registered person should make sure that all bathrooms meet control of infection guidelines. 2. 3. 4. YA24 YA24 YA30 Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Southfield House Care Home DS0000002817.V326853.R01.S.doc Version 5.2 Page 29 - 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. 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