Inspection on 11/07/05 for Southlands

This inspection was carried out on 11th July 2005.

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

Southlands 16/06/09

Southlands 12/06/07

Southlands 10/10/05

Southlands 23/09/04

Southlands 08/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Southlands 7 Linkfield Lane Redhill Surrey RH1 6JF Lead Inspector Mavis Clahar Unannounced 11 July 2005 @ 9:00am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Southlands Address 7 Linkfield Lane Redhill Surrey RH1 6JF 01737 769146 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Ravind Sohun Mrs Angela Sohun CRH - Care Home 15 Category(ies) of DE(E) - Dementia over 65 (7) registration, with number MD - Mental Disordeer (1) of places OP - Old Age (14) Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 - Within the category/categories: 14 within the category (OP), Older people, 7 of whom may be within category DE(E) Dementia over 65, and 1 person within the category MD Mental Disorder. 2 - The age/age range of the persons to be accommodated will be over 65 years of age. One person 62 - 65 years of age. Date of last inspection 26 November 2004 Brief Description of the Service: Southlands is a care home offering 15 beds in 11 single rooms and 2 twin rooms situated over three floors. There is a large dining room and a separate large sitting room.A lift provides access to all three floors.The service is situated in a residential street close to Redhill town centre and all amenities, including shops, post office, theatre, cinema and transport links to London and the southeast. Transport is provided by the service.The house is a detached property set in it’s own grounds with a garden area to the back which is set to lawn with flowerbeds. There is a seating area on the patio close to the house Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection to be undertaken in the Commission for Social care Inspection year April 2005 to March 2006. This joint inspection with the Pharmacist was unannounced and was carried out on the 11th July 2005. The inspector arrived at 09.00am just as the service users were finishing their breakfast. The inspector spent the first part of the inspection talking with service users, followed by discussion with the Responsible Individual, checking the shared parts of the home and looking at care plans and reports The care plans were found to contain a good level of information about the service users based upon a sound assessment of their health and social needs. The home plans to provide additional places with en-suite facilities, and enlarge the current living and dining rooms. Work on this extension will be commenced in September 2005. The second part of the inspection was spent touring the home and gardens and specially the newly installed kitchen. Many of the service users spoken to were not able to fully understand the role of the inspector and stated they were very happy in their home and that the inspector was not needed. Those who were more able to understand were open in their responses. One service user said “It is boring here with nothing to do I am used to running my own home, I wish I could do more in the home”. When the inspector asked what she would like to do she replied, “cooking and dusting”. This was discussed with the manager of the home who said she would discuss the request of this service user with her care manager. The CSCI pharmacist report is included in this report. 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 H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 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: 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 H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 8 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 standard(s) 3 The home was found to be working well in relation to the standard assessed. EVIDENCE: Random review of service users files demonstrated that good pre admission assessments were carried out prior to admission of service users into this home. On admission a full assessment involving the service user and their relatives or the care manager if appropriate is carried out. Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7 9 The health, personal and social care needs are met with evidence of good care planning and delivery A review of medication handling was undertaken by a CSCI pharmacist inspector who found that the home had significantly improved their procedures for administrating and recording medication. EVIDENCE: From this assessment a comprehensive care plan is drawn up to guide care workers in the delivery of care to the service user. The care plans are signed by the service users or care manager as appropriate. The daily worksheets demonstrate that the care set out in the care plans are being met. Service users spoken to on the day of inspection told the inspector they are satisfied with the overall care they receive at the home. Medication stocks and records were sampled and showed that service users were receiving their medication as intended by their doctors. Two service users were prescribed night sedative medication to be given “as needed” with no clear guidelines as to what constituted needed. One service user, who goes to work, takes their lunchtime medication with them. No risk assessment was in place to support this service user with their medication needs. Records were kept of which carer gave him the medication and of whether he took the medicine. Clear records were kept of all medication received into the home, Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 10 administered to service users and returned to the pharmacy for disposal and all medication was stored securely for the protection of service users. Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12 Links with the community are good and support and enrich service users social and spiritual needs. EVIDENCE: The home employs two part time activity coordinators who plan weekly activities in which service users can choose whether or not to participate. Service users said activities have improved and one service user spoken to said she is capable of walking into Redhill to do her personal shopping. On the day of inspection she walked into town to buy lollies for the other service users. She further said she attends church every Sunday and she walks to and from Church, although others take the taxi, which is provided. One service user said she particularly enjoys the art and craft sessions whilst another said he prefer the music and movement sessions. They all agreed the aromatherapy session was their favourite. Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 18 Care workers demonstrated they had the necessary knowledge to deal effectively with prevention of abuse of vulnerable adults. Service users said they knew how to complain if they were not happy with a situation. EVIDENCE: The homes adult protection procedure is in line with Surrey multi agency procedures for the protection of service users. The manager of the home and some senior staff has attended the surrey course. This information has been cascaded down to all other staff. It was observed from reviewing care workers file and the home’s training record that care workers are trained and are regularly updated in Moving and handling, First aid, food hygiene, Health and safety, dealing with challenging behaviours and dementia. Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19 Planned improvements to the home are in process. The home continues to provide a satisfactory standard of accommodation suitable to the assessed needs of the service users. EVIDENCE: Evidence gathered during the inspection confirmed that the home meets the standard assessed. The inspector reviewed the planned programme of development to the home. Various parts of the home has been improved within this plan and the kitchen is in the process of major refitting. Plans are in progress to provide additional bedrooms with en-suite facilities. Shared spaces will also be improved. The inspector was issued with an action plan giving details of how the work will be completed and contingencies that are planned to ensure the effect of the work on service users are minimised. Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The assessed health and social and spiritual needs of the service users are met with evidence of good documentation of actions taken by care workers. EVIDENCE: The staff rota demonstrated a good skills mix of staff over the twenty-four hour period. From observation and discussion with staff and care workers there seemed to be enough care workers on duty to meet the assessed needs of the service users. Random review of care workers files revealed some staff has completed their NVQL2. The inspector was informed one care worker has started NVQL3 and the care worker in discussion about her role and responsibilities in the home supported this. Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Secure facilities are provided for the safe keeping of money on behalf of the service users. EVIDENCE: Social services and or relatives deal with service users major finance. However, the home keeps service users pocket money in a safe place in individual wallets. Receipts are obtained for all transactions and these are handed to the relatives or social services, when new pocket money is due. The home’s policy is not to become involved with service users money. Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x 3 x x x Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 17 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13 Requirement Timescale for action 8.8.05 2. 9 13 A documented risk assessment must be in place for any service user who hold and administers any of their own medication. 8.8.05 The registered person must produce a clear careplan for each service user who is prescribed medication to be given as needed, to provide detailed instructions to staff as to when to give the medication. This will ensure that medication is administered in a clear and consistent way for the benefit of service users. Timescale of 26th November was not met. 3. Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 18 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 15 9 Good Practice Recommendations It is reccommended that the menu be upgraded to include more summer dishes in the hot weather. It is recommended as good practice that when it is necessary to handwrite on a medication administration record chart in the home that the member of staff writing the chart signs and dates the chart and that a second carer checks the entry for accuracy and then initials the chart. In addition the entry should include a reference to where this information was sourced, such as the prescribers name. It is strongly recommended that all entries in the Controlled Drugs register are signed and not initialled, as a signature is less readily forged. 3. 9 Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 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 © 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 Southlands H58 H09 S13791 Southlands V229174 110705 Stage 4.doc Version 1.40 Page 20 - 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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