Inspection on 07/08/07 for Southfields House EPH

This inspection was carried out on 7th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Southfields House EPH 30/10/06

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 Ms Rajshree Mistry Key Unannounced Inspection 09:30 6th August 2007 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.V340629.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.V340629.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 pterry@northamptonshire.gov.uk www.northamptonshire.gov.uk Northamptonshire County Council 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) 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.V340629.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. 30th October 2006 Date of last inspection Brief Description of the Service: Northamptonshire County Council owns Southfields House. Southfields House provides accommodation for up to forty-six older people over the age of 65 years. Southfields House is focussing on providing care for residents with dementia conditions and associated disability. Southfields House is situated in a residential area, close to local shops and accessible by public transport. The premises offer all ground floor living areas with single bedrooms. There are six self-contained units each with their own lounge/dining areas, kitchenettes, bathrooms and toilet facilities. There are seating areas by the main entrance and in the conservatory area providing people with additional 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 fees charged are £331.60 per week, received after the site visit although people may wish to obtain more up to date information from Southfields House. Additional costs for individual expenditure such as personal toiletries, newspapers, magazines, and private chiropody and contribute towards trips. Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, which included viewing the last Inspection Report, reviewing and gathering of evidence from the Annual Quality Assurance Assessment (AQAA) – the Provider’s self assessment, and reviewing the service history of significant events since the last inspection. Surveys were sent from the Commission for Social Care Inspection to residents, their relatives and health care professionals, who were identified in the AQAA. The unannounced site visit commenced on the 6th August 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the residents. The method of inspection was ‘case tracking’. This involved identifying residents with varying levels of care needs and looking at how these are being met by the staff at Southfields House. Three residents were selected and discussions were held with them. Discussions were held and observations were made of other residents and visitors who were not part of the ‘case tracking’ process. The method of case tracking included the review of residents’ individual care records, discussions with staff with various responsibilities within the home and reviewing the records, training records and the minutes of team meetings. The CSCI sent out fifteen surveys to residents, of which 60 were returned. All the responses were positive about the care provided at Southfields House and the home environment. The CSCI sent out fifteen surveys to relatives of residents at Southfields House, of which 20 were returned. Twenty surveys sent out to Health Care Professionals such General Practitioners, District Nurse Team and Care Management Team, of which 15 were returned. Comments incorporated within Service Users Surveys and direct comments included: “I like it here very much, I have no complaints and would say something of there was something wrong” “I know where I prefer to sit and they notice if the sun is too bright . . . do make me comfortable . . . .” Comments incorporated within Relatives/Main Carers Surveys included: “Making the residents feel wanted and safe and living their life as normal as possible” Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 6 “Definitely needs a regular activities organiser working at least part-time to stimulate the residents with dementia also to keep other residents active. I known how important this is . . . . . .” “Always respond very well when my mother is ill” “Many of the residents suffer from dementia at some level and they always are treated with great kindness. Even if the staff don’t know I’m watching!” “My father has been at Southfields House for over 2 years and I feel that the level of care for him and the other ‘housemates’ that I see when I visit is excellent!” “The recent ‘No Smoking’ rule has caused considerable stress to both staff and patients. I feel that in the long term a more satisfactory smoking area needs to be defined”. “Cannot see the need for immediate improvement but there is always room to strive for improvement wherever you are”. “It is kept very clean and the team are very friendly” Comments incorporated within General Practitioners: District Nurses, Health and Social Care Professionals Surveys included: “ . . . . . GP colleagues at the practice have been there / seen . . . . recently and I am no aware of any problems”. “Meets individual needs; offers choice; encourage independence; listen and act upon requests and concerns of residents; adapt care plans appropriately and keep good records”. “The staff are very caring and I am impressed by the overall standard of care and what’s in the home” What the service does well: Southfields House is a well-managed care home that provides individual care, promotes choice of daily life in a homely environment. Southfields House is well maintained, fresh and clean. There is a relaxed atmosphere in the home, residents move around freely with support if required and without restrictions. People visiting the home are welcomed and information about the home is easily available or displayed, including the recent inspection reports and the home’s newsletter. The assessment process of individuals is good to have peoples care needs are met. Residents and/or their family are involved in the assessment process and Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 7 contribute to having a lifestyle that suits them. Residents and/or their relatives are consulted about shaping the service provided. Southfields House has staff experienced in working with people with dementia. Staff are deployed to ensure all residents needs are met timely and have clear roles and responsibilities. Staff demonstrated a good awareness of the people they care for, from addressing them by the preferred names, knowing individual daily routines to supporting people to maintain their own independence as far as possible. What has improved since the last inspection? What they could do better: This was a positive site visit overall, of Southfields House, indicating the care provided and the home environment has improved. The Registered Manager demonstrated strong commitment to improving the quality of life for people living at Southfields House and having trained staff with clear responsibility. The areas of concerns raised directly with the Registered Manager were responded to and provided additional evidence and information to show the actions to be taken to address them. These included decoration of the ceiling near the public payphone and the refurbishment of the smoking lounge. Whilst Southfields House continues to improve the quality of life for people using the service, there are good practice issues, which should be considered • • • Ensure service user guide is available in other formats; The appropriate use of relief staff with skills to meet the needs of the people in the home, especially new residents. Identifying a person to organise and arrange activities of interest for residents, when the Activity Organiser post ends. DS0000034882.V340629.R01.S.doc Version 5.2 Page 8 Southfields House EPH 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. Southfields House EPH DS0000034882.V340629.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.V340629.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Standard 6 is not applicable. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are provided with clear and up to date information about the service; are involved in the assessment process that ensures their care needs are met. EVIDENCE: The information received from the Registered Manager before the site visit stated that prospective residents receive the information about the service, known as the ‘Statement of Purpose’ that gives information about the type of care and support people can receive and the standard of staffing and management of the service. All residents are given a copy of the ‘service user guide’ and available in large print but not available in other formats. A resident on a trial stay, visited the home with family before agreeing to move to Southfields House, confirmed this. Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 11 The records of three residents residing at the home, all were found to contain a comprehensive assessment undertaken by the Care Management Team. The assessment of needs identified the residents care needs, history; such as medication, mobility, special diets and meals, communication needs, mental wellbeing cognitive impairment. Other information was gathered about the resident’s social, religious and cultural needs to ensure residents experience a safe lifestyle without restrictions. The admission process is good and involves the prospective resident and/or their relative or advocate. The senior was observed sharing with the Registered Manager the assessment carried out on two prospective residents. Decision to admit the prospective resident was made through discussion of the assessment and needs of each prospective resident, balanced against the home being able to meet their needs with consideration to the residents already living in the home. Some residents and visiting relatives said they were involved in the moving in process. Some residents said they had been living at the home for a number of years and were very happy. Whilst the majority of the resident surveys indicated they wanted to move to the home and had received enough information to decide the move, 36 of responses said this was not the case. This was discussed with the Registered Manager after the site visit said family members would have been informed, involved in the assessment, and moving in process on their behalf. The records of three residents were viewed, and all were found to contain an the assessment of care needs carried out by the Care Management Team, and a contract of stay with the terms and conditions of the stay. Comments received from Health and Social Care Professionals included: “Initially client was a little unsettled but time and information has been provided to client to assist him with settling into new environment” Southfields House is not registered to provide intermediate care. Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are well cared for having their individual health and daily care needs met with improving system for managing medication. EVIDENCE: The care plans and records of three residents read were well written and were presented to a good standard and have significantly improved, to guide staff providing the care. The care is provided is person centred focus and care plans are written to guide staff to provide the level of care and support needed. The care plans show what the residents can do safely for themselves and where they need encouragement to remain as independence as possible. Residents’ individual lifestyle, preferences and choices are known to enable the staff to support them. The residents’ preference of daily living was recorded and any known impact of cognitive impairment due to their disability or dementia was well documented. Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 13 Specific health care support provided by the General Practitioner and District Nurse was included in the care plan. The District Nurse was seen visiting a resident, whilst another resident was waiting for the General Practitioner to visit. The records showed residents having access to the General Practitioner and District Nurse, when required. Residents said their care and health needs were met timely and in a manner that suited them. A visiting relative acting on behalf of a resident said the family has been consulted and informed of changes that affects the residents’ wellbeing. Where residents were able to express themselves, they were aware of their care plans and said they were asked of their opinion and preferences. Throughout site visit, the majority of staff were seen speaking with residents in a sensitive manner, addressing them by their preferred names whilst promoting of their privacy and dignity. A resident was seen returning from the smoking lounge guided by the care staff. Residents were seen moving around the home freely. Other residents were observed being assisted to the toilet or their bedrooms when asked and staff seen using transfer equipment safely. Comments received from the survey and directly from the residents showed residents’ privacy and dignity was respected, and encouraged to maintain as much independence as possible. The medication trolley is kept locked and stored in the medication room. The system for storing, administering and recording controlled medication is good. Residents were seen receiving their medication at lunchtime, administered by the trained senior staff. The medication records checked against the medication were correct at the time. Where residents take their own medication, the system in place is good and indicated residents receive medication on time. The recent medication error reported to the Commission and a comment received in the residents surveys, where ‘medication is given with only 2 hours between doses’. The Registered 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 General Practitioners had been advised of any errors and their advice sought. The Registered Manager confirmed he would look into the comment received in the survey and raise with the senior staff. The Registered Manager was able to demonstrate monitoring system of managing medication and confirmed senior staff have been re-trained to give medication. A senior staff has the responsibility of ordering, receiving and returning medication to reduce errors and omissions. The Registered Manger said meeting is taking place with an alternative pharmacy provider to improve contribute to improving the medication system. The management system for medication will be reviewed again at the next inspection. Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 14 Comment received from the residents, relatives/main carers’ surveys included: “Recently, we took mum out with the family for lunch and my daughter commented how well Nan looked; she smelt nice; gently perfumed and very well presented”; “Many of the residents suffer from dementia at some level and they always are treated with great kindness. Even if the staff don’t know I’m watching!”; “Care and compassion”; Comments received from Health and Social Care Professionals included: “Regularly care plans adapted and risk assessments” “Key workers ensures individual needs are met” “The staff are very caring and I am impressed by the overall standard of care and what’s in the home” Surveys responses were received from 25 of the General Practitioners’ Health Centre. The responses indicated that the staff at the home communicate clearly, works in partnership and have a clear understanding of the residents needs; residents seen in private; specialist advise is sought promptly and shown in the care plan to benefit the resident, not had any complaints and generally satisfied with the overall care provided to the residents. Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents continue to make choices about daily living, offered a variety of meals and social activities of interest to suit. EVIDENCE: Residents benefit from a flexibly run home, which enables them to make choices as to their daily lives. Care plans have been improved and are centred on the individual residents preference of lifestyle. Information included in the plans guide staff to provide care in the preferred manner, and are supported to continue their interests, contact with family including observance of religious or spiritual practice. The daily records showed residents received visitors and participated in activities. The Temporary Activity Organiser at Southfields House arranges activities on a daily basis, but the post is due to end. During the site visit the Activity Organiser was seen talking with residents individually or in small groups, and later seen doing arts and crafts with a few residents in one of the Unit. Some residents receive daily newspapers and were seen reading the paper, watching Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 16 television or talking with other residents and staff. Residents care plans showed their interests and daily records reflected how they spent the day. A visiting relative said they were aware meetings held in the home for the residents and felt the social events benefited the residents. Residents said they are asked about their views on activities and the minutes of the ‘Residents’ Meeting displayed showed this. Staff were observed supporting residents with their daily routines. Staff said they have specific responsibilities in relation to residents they key to meet the residents’ needs such as assisting resident with bathing or showering. Residents said they enjoyed the meals and always offered a choice. They felt that staff knew their likes and dislikes and spoke of being offered alternatives if they did not fancy the main menu choices. Relatives said they had not received any complaints about the meals and had no concerns about residents loosing weight. The records showed that staff monitor residents’ appetites and weight and are quick to note any problems. Meals are prepared in the main kitchen and taken in hot trolleys to the individual units. Observations showed lunch was the main meal of the day. Meals were served individually at the dining table by staff. Meals were not rushed and residents appeared to enjoy their meals, whilst gentle music played in the background. Survey responses from the residents indicated that staff do listen and act on what they say and staff treat them well. Other comments include: “Watching the comings and goings of the day”, “She’s made a few friends in the unit she lives in and have their own lives”. Comments received from Health and Social Care Professionals included: “Private room – cultural requests always considered” “Individual care plans attempt to allow choices for client but main lunchtime meal is normally provided within a set time period, this however does not cause any problems to residents”. “ . . . . is keen to make contact with family. Senior staff at the home are actively trying to identify addresses and help resident write to family members” Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Residents when asked were confident that should they have any concerns, to whom they should speak with. Residents were aware of how to make complaints and the written complaints procedure, and how to contact Advocacy Services. The complaints procedure is displayed in the reception area and in each unit. Information received from the Registered Manager before the site visit stated Southfields House received 19 complaints, of which the majority were to some extent founded. Records showed the concerns were investigated and resolved to the satisfaction of the complainant to benefit the resident. The Commission for Social Care Inspection has not received any expressions of concern about Southfields House. The Registered Manager informs the Commission on timely basis incidents that affect wellbeing of residents and demonstrate the actions taken to reduce or prevent avoidable re-occurrences. Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 18 Southfields House has had a number of safeguarding adults incidents and investigations are being progressed by the Care Management Team. The Registered Manager demonstrated the actions taken which was consistent with the local multi-agency procedure that protected the resident. Staff demonstrated a good understanding of their responsibility and procedures to follow in relation to safeguarding adults and was confident to whistle blow on poor or bad care practices. Staff files examined contained evidence to show that staff have received training in safe guarding adults, part of the local authority induction training and attaining a National Vocational Qualification (NVQ) in Care. Relief staff receive training in safe guarding adults as part of their induction training. Survey responses from the residents indicated that they know how to make a complaint and know who to speak with if they were unhappy. Other comments received in the residents’ survey and the relatives / main carers included: “I like it here very much, I have no complaints and would say something of there was something wrong” “I am happy with the care my mother received and have no cause for concern”. Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are provided with a warm, safe, clean, comfortable and wellmaintained environment suitable for their needs. EVIDENCE: Residents spoke positively about the home environment. The communal lounges and dining rooms in each of the units were bright and airy with lots of natural sunlight. All the living areas were decorated and created a homely feel. Residents were seen sitting in the lounge within their Unit whilst other residents chose to meet their friends in the other Units. Residents were using a designated smoking lounge. Residents can sit out in the garden areas, which has been landscaped and designed. Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 20 The information received from the Registered Manager before the site visit was consistent with the improvements seen during the site visit. Southfields House have had improvements made to the environment: 5 out of 6 Units have been re-decorated; purchase of vacuum cleaners; carpet shampoo machine; new blinds; mirrors; clocks; decoration of the conservatory; new lighting and new furniture. The Registered Manager should consider the re-decoration of Unit 3, not part of the recent refurbishment programme. During the site visit the ceiling near the public pay phone was identified needing attention. Residents spoken with using the smoking lounge felt the smoking lounge needed to be decorated to be more homely. The Registered Manager confirmed after the site visit that the ceiling area identified needed re-decoration and also confirmed the programme of re-decoration of the smoking lounge was due to start in September 2007. This addresses the comments received from the residents and relative’s surveys about having suitable provision for a smoking area. Residents were observed moving around the home, without restrictions. The Inspector was invited by residents to see their bedrooms and said they were offered keys to their bedrooms. Two bedrooms viewed were decorated and furnished to a good standard, with lockable storage and personalised. A resident said they were happy with their bedroom, which was spacious, close to the toilet and bathroom and equipped with bath hoists and grab rails. The information received confirmed Southfields House has a policy in place for preventing infection and managing infection control. Information received from the Registered Manager before the site visit stated 40 of the staff had completed infection control training. The Registered Manager confirmed staff training is being addressed with the staff-training department. Staff were observed wearing protective clothing when assisting residents with their personal care needs or handling food. Staff said that they had received training in infection control, demonstrated a good understanding and practice in health, safety, hygiene and infection control, which was consistent with the staff training records. There is a team of domestic staff responsible for the cleanliness of the home and the laundry. The monthly visits carried out by a representative of the local authority looks at the home environment and reported areas of concerns and safety are addressed. Survey responses from the residents indicated that home is fresh and clean and was consistent the view of the visiting relative. Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are protected by robust recruitment processes although should consider the staff skills to meet residents care and social needs and interests. EVIDENCE: Southfields House employs sufficient staff to meet the needs of residents and use relief staff to provide additional staff cover. All the Units have at least one member of staff working, whilst two staff work in the unit where residents require the help of two staff. The staff rota was reflective of the staff on duty including the senior staff. The Registered said increased staffing levels has benefited residents having accidents and incidents. Relief staff are to cover staff shortages or additional cover. The Activity Organiser is responsible for organising activities of interest for residents, but the position is ending. The recruitment and selection procedure in place is robust and is supported by a Human Resource Team in accordance with the local authority equal opportunity policy and guidance. The files of five staff were checked including a senior and relief staff, and all files contained thorough pre-employment checks including Criminal Record Bureau disclosure and protection of vulnerable adult check, a completed application form and two written references. Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 22 The information submitted to CSCI by the Registered Manager before the site visit, detailed the training provided and planned for staff, which included medication training, moving and handling, food hygiene and first aid. The Registered Manager confirmed over 90 of the staff had attained National Vocational Qualification (NVQ) in Care, level 2 or above with a further 18 of staff undertaking NVQ 2 and above. Staff were aware of their roles and responsibilities, where to find the home’s procedures and who to report any concerns to. Staff said they had received dementia training and demonstrated knowledge and skills used to support people with dementia. Staff said that they have handover meetings at the change of shift and staff meetings on a regular basis. The minutes of the meetings available and demonstrated staff are informed. Residents said they felt that the staff understood their needs. Staff were seen responding to residents promptly and assisting residents walking with the residents and generally having a good rapport with the residents, encouraging the resident to do as much as possible, safely. However, observation of a member of staff and a new resident appeared to be unsupportive. The Inspector spoke with the staff about supporting the new resident, who replied, “She’s new and just needs to settle down”. This was shared with the Registered Manager, who said what he would do to ensure new residents are supported and staff are confident. The Registered Manager said consideration would be made to offer further training and making sure staff have the right skills and confidence to support the residents in the unit. Comments received from Relatives/Main Carers surveys included: “I feel when agency staff is on shift sometimes, there is not the attention we expect for the residents e.g. afternoon teas missed, although this doesn’t happen very often” “My father has been at Southfields House for over 2 years and I feel that the level of care for him and the other ‘housemates’ that I see when I visit is excellent!” Comments received from Health and Social Care Professionals surveys included: “Always have senior staff on duty or contact numbers for advice if required” Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well managed home, being involved to shape and improve the service, whilst their health; safety and welfare are promoted. EVIDENCE: The Registered Manager has a number of years’ experience working and managing a residential care home. The information received from the Registered Manager before the site visit stated she has attained the Registered Managers Awards and the National Vocational Qualification, level 4. The Registered Manager has demonstrated he is actively managing the home, dealing with safeguarding investigations with the respective professionals and Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 24 the care management team, whilst looking after the best interests and wellbeing of the residents. Staff confirmed that the Registered Manager is approachable and offers guidance, support and leadership. Records demonstrated that staff are provided with regular formal supervision sessions and staff meetings. A representative of the management team of the Local Authority, who is external to Southfields House, visits the home on a monthly basis, representing the Responsible Individual. The reports generated from each visit, demonstrated checks are carried out monthly, detailed the evidence, the findings and the actions required to address any issues. Residents and their relatives were happy with the running of the home and said they were able to discuss with them, any issues about the provision of care individually. Residents meetings are held regularly and the minutes of the meetings are displayed on the notice board. A relative said they have received ‘Southfields House Newsletter’, occasionally and felt they were informed of developments at the home. A number of ‘thank you’ cards, letters and commendations were on site, complimenting Southfields House, the staff and the care provided. Residents said they manage their finances themselves or with support from their family or Solicitors. Where small amount of money is held on behalf of the resident, a record of the financial reconciliation is in place, which demonstrated procedures are in place for handling residents’ finances. Residents and staff records viewed were kept in good order, comprehensive, up to date, stored securely and was available for the purpose of the site visit. Staff were aware of where information, incident and accident record, policies, and procedures are kept. The accident/incidents records viewed were consistent with those received by the Commission. The Registered Manager has analysed the number of events and demonstrated measures taken to reduce these, by increasing staffing levels at specific times of the day. Staff said they receive supervision, attend staff meetings and supported by records. The information received from the Registered Manager before the site visit indicated equipment such as hoist, lift fire detection and emergency equipment, is maintained. Southfields House has a planned programme of maintenance. Risk assessments are in place for the home, residents and an emergency plan. Southfields House EPH DS0000034882.V340629.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 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP27 Good Practice Recommendations It is recommended that the service user guide should be made available in other formats, suitable for existing and prospective residents and/or their families. It is recommended that consideration be given to: • The skills, experience and competency of staff to support new residents in specific units; • Identifying a person to be responsible for organising activities and social events. Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Southfields House EPH DS0000034882.V340629.R01.S.doc Version 5.2 Page 28 - 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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