Inspection on 30/10/06 for Southfields House EPH

This inspection was carried out on 30th October 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Southfields House EPH 07/08/07

Southfields House EPH 22/11/05

Southfields House EPH 23/05/05

Southfields House EPH 19/07/04

Southfields House EPH 27/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Southfields House EPH Farmhill Road Southfields Northampton Northants NN3 5DS Lead Inspector Mrs Pat Harte Unannounced Inspection 30th October 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southfields House EPH Address Farmhill Road Southfields Northampton Northants NN3 5DS 01604 499381 01604 790719 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.northamptonshire.gov.uk Northamptonshire County Council Mr Phil (Ian Philip) Terry Care Home 46 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (46), Old age, not falling within any other of places category (9), Physical disability over 65 years of age (5) Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. No person falling within the DE (E) category can be admitted where there are already 46 people of DE (E) category already in the home No person falling within the DE category can be admitted where there are already 2 people of DE category already in the home No person admitted within the DE category will be below the age of 60 Total number of service users in the home must not exceed 46 To be able to accommodate up to five people within the DE (E) category who have additional needs within the PD (E) category To be able to accommodate nine named service users who have needs within the OP category To be able to accommodate one named service user who has needs within the LD (E) category To be able to accommodate one named service user who has needs within the MD (E) category. 22nd November 2005 Date of last inspection Brief Description of the Service: Southfields House is owned by Northants County Council. The Manager is Mr. P. Terry. The Home provides permanent personal care for up to forty-six older people over the age of 65 years, including two places for people with dementia between 60 and 65 years. The aim is to provide care for residents with dementia conditions and the home is also able to provide for up to five people who have an additional physical disability. Currently the home has additional conditions allowing the continuing care of two named residents, one of who has a learning disability and another who has a mental disorder. The home is situated in a suburb on the outskirts of Northampton close to local shops and accessible by public transport. The premises offer all ground floor accommodation and all residents are provided with single bedrooms. There are six self-contained units each with their own lounge/dining areas, kitchenettes and bathroom and toilet facilities. In addition there are seating areas by the main entrance and in the conservatory area providing Residents with additional Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 5 communal space. Residents have access to garden areas and the home has surrounding security fencing with access through electronically operated gates. The Northamptonshire County Council carries through a financial assessment of all residents to determine their contributions towards the cost of their care. The maximum, fee charged is £325 per week; the manager is not privy to individual charges. Extra charges are made for the following: - Newspapers, toiletries, transport such as taxis and theme nights, charges are variable but at cost only. Charges are also made for external services such as hairdressing, from £6.50 to £25 and chiropody at £24 per visit. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for Service Users and their views of the service provided. Inspection planning took one day and consisted of a review of the last inspection report and requirements, the home’s service history including notifications and events, the pre-inspection questionnaire completed by the manager and comment received. Eight, thirteen relatives and five Doctors responded to our survey offering their opinions on the service. The primary method of inspection used was ‘case tracking’ which involved selecting three Residents and tracking the care they receive through review of their records, talking with them and the care staff. In addition four staff and six residents were spoken with to gain their opinions on the service. Discussions were held with the manager. Selected areas of the premises and a selection of records were viewed. The Inspection was unannounced and took place over a period of approximately six hours. What the service does well: Southfields House continues to have a dedicated and a stable staff group who demonstrated their commitment to the well being of their residents. Residents spoke very highly of the staff group commenting that they were very caring and helpful and relationships were very good. All residents are visited prior to their admission and staff carry out thorough assessments to identify needs and ensure that they can be met. Staff demonstrated that they involved all their residents in the planning of their care, including those residents with dementia. Residents’ commented that staff treated them as individuals and respected their individual wishes and preferences on how the care was to be provided. Health care needs were carefully monitored and residents confirmed they were enabled to see their relevant medical professionals promptly and in private. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 7 Residents and their relatives confirmed that they were aware of the home’s complaints procedure and felt confident to raise any issues or concerns with staff or the manager. The Manager ensures that all concerns are carefully investigated and that action is taken to improve the service where necessary. Thorough systems are in place to ensure that any allegations or suspicions of abuse are reported to the relevant authorities and that action is taken to safeguard the residents. Routines were relaxed and flexible enabling residents to follow the routines that they had had at home. They could get up and go to bed when they wished and they had choice in how and where they wished to spend their time. Observations confirmed that staff took care to protect residents’ dignity and privacy by ensuring personal care tasks were carried out in private. Residents commented that staff took care to ease any embarrassment and make them comfortable when intimate tasks such as bathing were carried out. They said and the review of records showed that they were encouraged to remain as independent as possible and do things for themselves. What has improved since the last inspection? What they could do better: The activity programme should be reviewed in conjunction with staffing levels to ensure that staff are able to provide residents with suitable activities on both a group and one to one basis. The Local Authority must address the outstanding redecoration and refurbishment issues to improve the shabby appearance of the home and raise the standards to an acceptable level. The service is changing to provide care only for residents with dementia needs. As the numbers of residents with dementia increase staff have become more and more pressurised to meet those needs and provide good levels of supervision and monitoring. The Local Authority must now review the staffing levels to ensure sufficient numbers of staff are deployed. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with information to enable them to make informed choice about their placement. The pre-admission assessment is thorough and effective in ensuring that the needs of people admitted to the home can be met. EVIDENCE: Prospective residents are provided with written information on the home and its services and have opportunities to visit the home, where possible, to view their proposed accommodation, meet with existing residents and staff and discuss any worries. Residents felt that this process helped decide on whether the home would be right for them. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 11 The manager or senior staff visit all residents before they are admitted to assess their needs. The manager showed, through discussions, that the needs of each prospective resident were carefully considered and balanced with the needs of people already living in the home to ensure that the needs of any new resident can be met. Two residents’ assessments were viewed and showed a well-rounded approach. Care had been taken to establish their individual preferences on daily routines so that these could be continued after admission, for example the times they usually got up and went to bed. Food likes, dislikes and any special diets were recorded to ensure their preferences were known to staff so that they were provided with food to their tastes. Cultural diets can be provided where necessary. The records showed that care was taken to identify any arrangements needed so that residents could continue to follow their religions. Arrangements can also be made for residents to be supported by independent Advocates to speak on their behalf if necessary. The assessments carefully recorded the physical support that residents would need in their daily lives. The assessments also took account of medical histories to ensure that the right health care arrangements were made. Historical information was gathered from residents, families and relevant professionals to broaden staffs’ understanding of residents who had dementia. This information enabled staff to help residents with their confusion and frustration and to understand the things, people or events that were important to them. Areas of risk that might make residents vulnerable are identified For example or where residents may not be eating sufficiently. Care had also been taken to identify risks to the safety of residents with dementia and to identify the level of monitoring that they would need to protect them, for example from going out alone and running the risk of an accident. Residents felt that when they had arrived at the home the staff were well briefed on their needs. Staff felt that they were provided with a good level of information and guidance on how to provide the care. They showed that they were aware of the emotional support needed to help residents to adjust and settle into the home although this was not recorded on the care plans. Records showed that after approximately a month a review was carried out with new residents and their families to find out if they wished to continue living at the home. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 12 Resident’s records showed that they had been given contracts detailing the terms and conditions of their placement, details of the fees to be charged are provided direct from the County Council following a financial assessment. Residents are given information in the Service Users Guide on services not covered by the fees. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided with good levels of instruction and guidance on how to provide the care. EVIDENCE: Three residents care plans were inspected. Records showed and residents confirmed that they had been involved in the development of their plans and that they were consulted on any changes that were made. Where there were changes the plans were updated and new instructions were given to staff. The care plans gave step-by-step guidance to staff on the areas on the personal support needed. For example routines such as bathing were thoroughly documented, showing residents preferences on timings, giving detailed instructions to staff on the equipment needed and how the task was to be carried through. The plans detailed the areas that the residents could safely undertake for themselves showing they were encouraged to maintain as much control over their lives and be as independence as possible. Reminders were Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 14 incorporated into the plans for staff to routinely monitor skin and nail conditions, this meant that any changes were quickly picked up and referred to the necessary specialist such as Doctors or Chiropodists. Residents confirmed that the need for or their preference for night checks had been discussed and agreed with them. They spoke of being reassured that help was at hand throughout the night and had peace of mind that that staff popped in to check that they were all right. The care plans showed that historical information was gathered from residents, families and friends to help staff understand support and talk with residents who had dementia. Staff showed that they knew the ways in which individual residents could be helped if they were confused, angry or frustrated but this was not always written down in the care plans. This is an area for further development. Observations showed that staff responded warmly and sensitively to their Residents. They spent time with them dealing with their questions or concerns and finding out what they wanted to do or what was worrying them. For example a staff member saw that a resident restless and quickly responded to find out what was worrying him and enabled him to discuss and resolve his fears. Health care records showed that staff were quick to identify any changes and requested Doctors visits. A Doctor commented, when replying to our survey, that the staff called her in appropriately. Residents said they were able to have routine checkups, for example eye or dental checks and that arrangements were made for regular foot care. They confirmed that they were able to see their Doctors or other medical professionals in private. Staff can provide care for Residents who are ill or dying provided so long as the needs of the individual can be met with the assistance and support of the Community Medical Services such as Doctors, Nurses and specialist Nurses. Observations confirmed that staff made constant checks on residents who were poorly, spent time talking with them and ensured that their needs were taken care of. Since the last inspection errors in medication administration have been notified to the Commission. The manager showed that he had investigated all occurrences, had audited and reviewed the systems to make improvements to the administration processes and taken action with the staff concerned. The incident records showed that the relevant Doctors had been advised of any errors and their advice sought. No adverse effects had occurred. The manager showed that he continues to give high priority to monitoring the systems to ensure safe and accurate administration. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 15 The Medication system and records were viewed. Medication was safely stored and records for incoming, administration, including the Controlled Drugs register, and the disposal records were well maintained. Residents confirmed that they were given their medication at the right times. Observations showed that Staff made sure that any personal care tasks are carried out in private protecting residents dignity and privacy. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are enabled to exercise choice in the way they wish to lead their lives. The activity programme is in need of improvement to ensure all residents are provided with stimulation and appropriate activities suitable for their needs. EVIDENCE: Residents stated and observations confirmed that routines were relaxed and flexible. Staff respect the way in which residents wish to lead their lives and enable them to continue with their lifestyle routines. For example they have complete freedom of choice in the times they wish to get up or go to bed and are free to choose where and how they wish to spend their time. The homes activity programme was discussed with the manager as some residents had expressed adverse comments in their questionnaire responses. Activities organised on a group basis include theme nights such as a Caribbean Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 17 evenings and the forthcoming Halloween celebration. Residents were positive in their comments on these events but not all residents are able or wish to take part. Staff on the units have responsibility for organising both group and individual activities suitable for the needs of their residents. No activities were being carried out on the day of inspection and staff commented that they were having difficulty in carrying through programmes due to the high dependency needs of their residents. The aims of the service are changing and it is the intention that the home will only cater for residents who have dementia. This has a direct impact on providing suitable activity programmes for residents who may require one to one support and individually designed programmes to enable them to take advantage of opportunities and live fulfilled lives. The manager showed that he is currently addressing this area. He has employed the services of a volunteer on a twice-weekly basis to provide some activities however this is an area for further development. Consideration needs to be given to staffing levels to ensure they are sufficient to carry through the programmes and also to providing staff with training in activities suitable for people with dementia. Residents said they can receive their visitors at any time and may take them to their rooms if they prefer privacy. Residents said the food at the Home was good and they were offered choices for all meals. They felt that staff knew their likes and dislikes and spoke of being offered alternatives if they did not fancy the main menu choices. The records showed that staff monitor residents’ appetites and weight and are quick to note any problems. Referrals were made to Doctors where the need for food supplements is identified and food and fluid charts are maintained, if necessary, to monitor individual residents intake. Observations showed that the midday meal was served efficiently in three of the units although a staff member in a further unit was experiencing difficulty in settling her residents the residents and as a result the meals were getting cold and had to be reheated. The manager agreed to review this area and make any necessary adjustments to the serving arrangements. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thorough and effective systems are in place to ensure that complaints or concerns are listened to, investigated and acted upon and that Residents are protected from abuse. EVIDENCE: Residents and relatives are given information on how to complain; this information was also displayed in the Home. All residents spoken with stated that they felt able to raise any issues or concerns with staff and had confidence that these would be listened to, looked at and resolved. The manager showed, through the review of the complaints record that he takes any complaint or concern very seriously. No complaints have been raised with the Commission, 27 complaints or concerns have been raised with the Manager since the last inspection. The issues included medication, missing clothes or property, cleanliness of bedrooms, concerns expressed about a residents’ behaviour, security of files, concerns about care provided and staff attitude. The manager demonstrated that all issues had been investigated thoroughly, of the 27 complaints 18 were founded, 5 partially founded and Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 19 investigations into four areas are on going. Records showed that action had been taken to make improvements in all the areas raised. Safe and thorough systems are in place for the Protection of Vulnerable Adults. This means that any allegations or suspicions of abuse are reported to the Authorities and investigations carried out in order to protect the residents. Staff receive training in recognising abuse and discussions with two carers showed that they were fully aware of their reporting duties. Records showed staff took immediate action to notify the relevant authorities including the Commission. Since the last inspection 12 notifications have been made, eight of which concerned aggression outbursts from residents towards other residents. The review of the information showed that the allegations had all been investigated appropriately and action taken to ensure the safety of the residents. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Failure to carry through redecoration and refurbishment work continues to result in the premises being below an acceptable standard. The failure to improve electrical lighting has the potential to compromise the health and safety of residents and staff. EVIDENCE: Residents and relatives have commented on the poor standard of décor in all but one unit of the home and comments were also received on poor lighting in some areas of the home. An action plan was received from the Local Authority in December 2005 addressing requirements made in the November inspection report with regard to the premises. Improvements had been made to about half of the electrical lighting system during 2005 and plans were in place to complete the programme of improvement during the financial year 2006/07. No work has Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 21 been carried out to date and the poor lighting in the remainder of the home has the potential to compromise the health and safety of residents and staff. The action plan also stated that it was the Local Authority’s intention to complete the redecoration and refurbishment of two further units during the same 2006/7 and the remaining units in the year 2007/08. No work has been carried out to date and overall the premises remain shabby and in need of urgent attention. The manager evidenced that he has constantly raised the issues with the Authority who must now give confirmation to the Commission that the work is arranged to bring the premises up to an acceptable standard. Despite the shabby appearance of the home domestic and hygiene maintenance was viewed as good with all areas including toilets and bathrooms kept clean. Residents confirmed that the domestic routines were carefully organised and did not disrupt their individual routines. The furnishings were suitable for their needs and residents are able to personalise their rooms as they wish. Additional equipment such as “hospital beds,” mobility aids, special mattresses and hoists were in place for the comfort and safety of residents and to ensure safe movement and handling practice. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are insufficient to ensure that residents’ needs are met in full and to address the shortfall in the activity provision. EVIDENCE: Residents were generally very positive in their comments about the staff group. They saw them as committed and caring and doing all they could to support them, provide for their needs and ensure their well being. However some negative comments were received from residents, relatives and staff and observations made during the inspection showed that staff are very pressurised to meet resident’s needs in the afternoon and evenings. The current staffing levels are for 8 care staff on duty on the morning shifts and 7 up to 10pm at night. 4 care staff provide night care. 2 carers are deployed at all times during day shifts to the high dependency dementia unit and a single carer is deployed to the other five units. In the mornings there is one floating carer who can give assistance where needed, in the afternoons carers have to leave their units to provide back up to other units. The service is changing with the aim to provide all 42 places to residents with dementia care needs. On the day of inspection the high dependency unit was full with three residents being ill, bed bound and in need of constant attention. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 23 Some residents in other units also exhibited high dependency needs and the need for close monitoring and support. Observations confirmed that staff did their best to monitor and supervise their residents but at times these residents were left unattended due to the need for staff to provide back up and assistance in other units. The Authority must consider the care staffing levels, as the service develops to ensure good levels of supervision and monitoring. There have been 8 protection notifications of aggressive resident-to-resident outbursts in the last year. Whilst these were investigated and resolved there is a high risk potential for more such instances. There have also been a high number of falls for example 34 instances of falls or residents being found on the floor during the month of August 2006 indicating a need for higher levels of supervision and monitoring. In addition it was clear that the activity programme is suffering as a direct consequence of inadequate staffing levels. In addition to the care staff a senior residential care supervisor or night senior is designated to lead all shifts. Domestic, laundry and catering staff are employed ensuring that care staff are not diverted from their care duties. The manager showed that the use of agency staff has been reduced for example 57 shifts were covered by Agency staff in the week 29th August 2005 whilst in September to October 2006 this has been reduced to an average of 1 shift covered and at the time of inspection no Agency staff were employed. This reduction in the use of Agency staff has provided better continuity and consistency of care, which is particularly important for residents who suffer from dementia. Two staff member’s records were viewed and showed that the appropriate Criminal Records Bureau clearances and two references had been obtained prior to staff commencing employment. Induction records linked to the Sector Skills Council guidelines and timescales were in place. Staff training records showed that training and updates are provided in core areas such as fire safety, food hygiene, movement and handling and the Protection of Vulnerable Adults procedures. Specialist training is also provided and most staff have received dementia care training and the person centred care approach. Shortfalls noted were in the areas of equalities and continence management; the manager has agreed to address these areas. Staff spoken to felt that they had good access to training. Approximately 56 of the staff group have attained a National Vocational qualification in care; this is above the expected average of 50 . Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is proactive in ensuring the well being of his residents and encouraging them to be involved in the running of their home. EVIDENCE: The manager showed that he takes his responsibilities very seriously and consults with his residents and relatives on the running of the home. He is accessible to his residents and their relatives on almost a daily basis He regularly seeks their opinions on the service through regular residents meetings, individual consultation and surveys. As part of the pre inspection process the manager supplied an excellent level of information showing that he has a good oversight of the running of the home. He has sound systems in place to monitor practice and an example of this was the information on Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 25 complaints and concerns raised. The information showed he is proactive in investigating any negative comments on the service and taking action to make improvements. Staff confirmed that the manager is accessible to them to provide guidance, support and leadership. Records demonstrated that staff are provided with regular formal supervision sessions and regular staff meetings. The management of residents monies held for safekeeping were discussed. The systems have been operating well until recently when it was found that approximately £60 belonging to three residents and held in the safe was unaccounted for. The matter has been referred to the Police for investigation. The management of health and safety was viewed as good. No hazards were noted during the inspection. The fire safety records showed that the alarm system, fire equipment and the emergency lighting were all checked at the frequency advised by the Fire Officer. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 2 2 3 STAFFING Standard No Score 27 1 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 2 3 X X Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP19 Regulation 23(2)(p) Requirement The Local Authority must submit an action plan confirming the dates arranged to carry out redecoration and refurbishment work to all outstanding units. The Local Authority must submit an action plan confirming the dates arranged for work to be undertaken on the lighting systems. The Local Authority must submit an action plan showing proposals for an increase in staffing levels to address the high levels of dependency and provide residents with suitable activity programmes. Timescale for action 15/12/06 2 OP25 23(2)(d) 15/12/06 3 OP27 18 (1) (a) 15/12/06 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 OP35 Good Practice Recommendations The security of the safekeeping systems should be DS0000034882.V315102.R01.S.doc Version 5.2 Page 28 Southfields House EPH constantly monitored in light of the recent issues. Southfields House EPH DS0000034882.V315102.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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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