CARE HOMES FOR OLDER PEOPLE
Southlands Southlands 7 Linkfield Lane Redhill Surrey RH1 6JF Lead Inspector
Mavis Clahar Announced Inspection 10th October 2005 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 Southlands DS0000013791.V250034.R01.S.doc Version 5.0 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. Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Southlands Address Southlands 7 Linkfield Lane Redhill Surrey RH1 6JF 01737 769146 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 Ravind Sohun Mrs Angela Sohun Mrs Angela Sohun Care Home 15 Category(ies) of Dementia - over 65 years of age (7), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (14) Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Within the category/categories: 14 (fourteen) within category (OP), 7 (seven) of whom may be within category DE(E) and 1 (one) person within the category MD. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE 1 PERSON 62 – 65 YEARS 11th July 2005 2. Date of last inspection Brief Description of the Service: Southlands Rest Home is a care home offering 15 beds in 11 single rooms and two twin rooms situated over three floors, with a large dining and separate living room situated on the ground floor. A passenger lift provides access to all three floors. The home is situated in a residential street close to Redhill town centre and all amenities including shops, post office, theatre cinema and good transport links to London and the southeast. The house is a large detached property, set in its own grounds with a garden area to the back, which is set to lawn with flowerbeds. The front of the home is paved and provides off street parking for staff and visitors. The home provides transport for the service users. Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was announced and was carried out on the 10th October 2005 and lasted five hours and forty minutes. The inspection was well advertised and CSCI received a number of completed pre inspection questionnaires from a wide variety of individuals including the General Practitioners, the care managers, the district nurses, relatives and friends of the service users. The answers and more importantly the comments made on the home were very encouraging and supported the documented evidence that the home provides a good service to the service users. The first part of the inspection was spent greeting the service users and informing them the inspector would like to spend time with each one after they had had their midday meal. This was followed by discussion with the owners about the home in general and the arrangements that are in place to ensure the safety of service users during the additional building, which is currently taking place. This was followed by random review of service users care plans and risk assessment, and complete review of the last two new admissions to the home since the last inspection. These admissions were in line with the guidance within the National Minimum Standards for Older People. The second part of the inspection was spent with individual service users. Some were not able to give coherent answers, but those who were able gave glowing reports of the home and how comfortable they were. One visitor was present during the inspection and when questioned on the suitability of the home for her relative replied “I am very happy with the care my relative receives; my relative has been at this home for a long time and is settled here”. One service user informed the inspector “I particularly enjoys the bible studies as in my youth I have been a missionary out in Africa”. The third and final part of the inspection was spent touring the home and grounds and looking at the new addition being built. This was followed by feedback to the owners on the findings of the inspection. What the service does well:
The service operates the key worker system, which is reflected in the service users assessments of health and social needs. The service users care plans were informative and risk assessments were carried out as required dated and signed by appropriate personnel.
Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 6 Care workers were observed to be working well with the service users, being friendly but respectful. The home provides a taxi service on Sundays for those service users who wish to attend church. The Vicar from the local C/E church visits once per month to give Holy Communion to service users unable to attend church. A volunteer worker holds Bible reading sessions on Sundays. What has improved since the last inspection? What they could do better:
The home has really demonstrated that they are trying very hard to act on advice given to enhance the lives of the service users and they are commended for this. However, more effort needs to be made in instructing and insisting that care workers sign the control drug record sheet with their signature and not their initial or Christian names. Also care workers need to be supervised at least six times per year in line with the guidelines as contained in the National Minimum Standards for Older People.
Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 7 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. Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 8 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 Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 9 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): 36 Standard 6 was not assessed. It does not apply to this home. EVIDENCE: Standard 3 was not assessed on this inspection. For information on Standard 3, please refer to the report of 11th July 205 Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 10 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): 8 9 10 The health care needs of the service users are met with evidence of good planning and delivery, and that their privacy is upheld. Review of the medication documentation revealed that care workers have tried to conform to the requirements within the homes policy on administering controlled medication, with the occasional lapsed in signing the record book. EVIDENCE: Random samples of service users files to include the most recent admission to the home were reviewed. All files demonstrated good health care needs assessments from which the care plans were drawn. Both the assessments and care plans are signed by service users/relatives or social services care managers. Daily care needs notes demonstrated that care is being given according to the requirements of the service user as laid out in the care plan. Review of the medication records in the home demonstrated that one service user is risked assessed as capable of self administering their mid-day medication whilst out at work. The homes guidelines on self-administration of medicines was completed and adhered to by the care workers. There is a vast improvement in the documentation of controlled drugs, but there are still occasions where two members of staff are occasionally confusing their
Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 11 signatures with their Christian names, in signing their signature in the control drug book. A requirement has been issued on this standard. The pre inspection questionnaires sent back by service users, visitors and relatives and care managers to CSCI were very revealing in that they were unanimous in their appreciation of the care given to the service users in this home. The inspector spoke with all of the service users and those who were able to answer, said they were treated very well and their privacy were maintained. One visitor was at the home during the inspection and she told the inspector she was very satisfied with the care her relative was receiving. Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 12 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): 13 14 15. The home continues to meet each of the assessed standards. EVIDENCE: On the day of inspection the inspector noted that service users were out and about as they wished. Some service users are able to go out to the local town on their own, whilst some went with members of staff. The inspector was informed that the Vicar had visited that morning to give Holy Communion, and had left a note for the inspector with his comments on the home and to say he was sorry to have missed the inspector. The manager informed the inspector that service users had choice over their lives in this home. The inspector spoke with a number of service users who were able to support the manager’s statement. One service user informed the inspector that the Bible studies group is particularly interesting for him as this helps to reaffirm his fate. In his younger days both he and his wife were missionaries. The home has invested in a new style flipchart menu, which shows the planned menu with alternative choices for the week and on a daily basis. The content of the menu has changed to reflect more variety, salads and light dishes if the service users want to make a different choice to the main meal. The inspector
Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 13 did not sample the food, but service users asked, said the food is very good and that they get plenty of it. On the day of inspection, the lunch served, looked appealing and appetising. Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 14 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 Relatives and service users are assured that the management would take their complaints seriously. EVIDENCE: Evidence gathered from the pre inspection questionnaire, from speaking with service users and one relative on the day of inspection, along with the record of no complaints held by the home, reassured the inspector that service users concerns are taken seriously, and dealt with immediately to reduce the number of complaints the home receives. On the day of inspection no complaints were documented in the complaints record book, and the manager informed the inspector that no complaints were received by the home since the last inspection. Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 15 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): 26 The building of the extension has commenced, but this has not affected the standard of accommodation of the current service users. EVIDENCE: No usable space has been lost as a result of the extension being built. The home has been made safe for service users during this period of building. The patio furniture has been moved to the front left side of the home for the duration of the building programme, and the side entrance to the home is kept locked and the keys left in a reachable safe place. On the day of inspection the builders were not working, so the inspector was not able to ascertain if any dust from the building work was seeping into the home. However, it was noted that doors and windows to the building works were locked. Generally, the home was clean and tidy and free from any odours. Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 16 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): 28 29 30 Staff morale is high, and they work positively with service users to improve their whole quality of life. EVIDENCE: The home places high importance on training carers to support the service users. Review of staff files and the home’s training record demonstrated that the service users are being cared for by staff trained to do the work they are asked to do. On the day of inspection three carers had completed NVQL2, and one carer has recently commenced NVQ L2. One care has completed NVQ L3, and two carers are currently undergoing NVQ L3. The carers spoken to on the day of inspection were all enthusiastic about their roles within the home. From the random sample of care workers file reviewed and from speaking with care workers and the manager it was evident the home follows their employment policy and procedure, which incorporates the equal opportunity policy of the home. Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 17 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 33 36 38 The home has met all the standards fully except standard 36 which is partially met. EVIDENCE: A registered manager who holds the City and Guilds Certificate in Advanced Management for care runs the home. She continues to be of good character and discharges her duties and responsibilities fully. Documentation reviewed and service users and relative spoken to all agree that the service users are consulted about the running of the home. Currently, the carers are being formally supervised once per month. Following discussion with the manager and responsible individual, it was agreed to increase this to twice per month, thus fulfilling the requirements of standard 36, a requirement was issued on this standard.
Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 18 The home continues to promote and protect the health and safety of the service users. The builders have submitted risk assessments relating to the safety of the service users during the building of the extension. The inspector noted various notices posted over the home reminding carers and service users of their responsibilities during this extension-building phase. The home has conducted their own risk assessment for all staff and visitors to the home during this building period. Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 19 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 x X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 3 Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 20 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. 1 Standard OP9 Regulation 13 Requirement All entries in the Controlled Drugs register are signed by signature and not use Christian names in this space. Increase the number of times carers are supervised to twelve times per year. Timescale for action 10/10/05 2 OP36 18 30/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Southlands DS0000013791.V250034.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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