Inspection on 12/06/07 for Southlands

This inspection was carried out on 12th June 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

Southlands 16/06/09

Southlands 10/10/05

Southlands 11/07/05

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 Southlands 7 Linkfield Lane Redhill Surrey RH1 1JF Lead Inspector Kenneth Dunn Unannounced Inspection 12th June 2007 09:00 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.V338378.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. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlands Address Southlands 7 Linkfield Lane Redhill Surrey RH1 1JF 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) southlandsresthome@hotmail.com Mr Ravind Sohun Mrs Angela Sohun Mrs Angela Sohun Care Home 19 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number disorder, excluding learning disability or of places dementia (7), Old age, not falling within any other category (19) Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age/Age range will be 60 years and over. Date of last inspection 10th October 2005 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 people how use the service (The residents). The weekly fees range from £350- £450 per week. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes site visit as part of the key inspection process by the Commission for Social Care Inspection (CSCI). The visit was carried out by Mr K. Dunn, regulation inspector and included a full tour of the premises, informal interviews with staff and the people who use the service (The residents). The inspection process included a review of documents, policies, procedures and any other relevant records. The visit commenced at 09:00hrs and finished at 13:00hrs. The inspector would like to thank the registered manager, the staff, residents, and others for their contribution. What the service does well: What has improved since the last inspection? There has been significant improvement in the day-to-day management of the home and the documentation and recording of the service users care plans and risk assessments. The home has met the requirements made by the CSCI to improve practice at the home with some policies and procedures revised and updated to reflect changing legislation and good practice. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Southlands DS0000013791.V338378.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1, 3 & 6 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose supplies only a basic outline of the home and the services it provides to the residents. The arrangements for assessing needs are good ensuring prospective residents needs are assessed and assured that they will be met. EVIDENCE: The service has a statement of purpose and a service users guide available, which outlines the basic service offered at Southlands, however the information provided does not accurately reflect the home or the care provided and requires to be expanded. In discussions with the manager it was agreed that both documents must be fully reviewed and updated in order to supply the reader with a clear and accurate picture of the home, the management structure and staffing prior to a new resident moving in. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 9 A representative of the service stated that potential residents are only admitted to the home on the basis of an full assessment of their needs has been completed. A review of records confirmed the home had a policy on admission and a care needs assessment which covered personal care, health needs and social support. The assessments viewed by the inspector during the visit were clear and offered a high level of information about the individual residents, to enable the manager and the staff to design a package of care for that person. The manager confirmed the home does not offer intermediate care and this standard was not assessed. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning is good setting out the personal care, health needs and social support required by the residents. The arrangements for health care are good ensuring the residents have access to a full range of healthcare services. Medication practice at the home has improved but is still in need of updating and consistent supervision by senior staff members. The arrangements for upholding the resident’s privacy and dignity are good. EVIDENCE: The manager stated the home had individual care plans, which included risk assessments in the areas of mobility and prevention of falls. A review of records confirmed care plans were based on best practice, regularly reviewed, dated and signed by staff and where ever possible by the residents themselves. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 11 A senior care worker explained that this was essential to reflect the changing needs of the individual residents at the home. The home had arrangements for meeting the health care needs of the residents with input from a wide range of health care professionals as required. A review of records confirmed service users were registered with a local GP (General Practitioner) and had access to chiropody, dental and optical services. The senior care staff stated the home had a policy on medications and a service level agreement with a local chemist to supply medications to the home. A review of records confirmed medication record sheets were dated and signed by staff and a record of medications received by and disposed of was kept to prevent mishandling of medications. However a review of the homes controlled drugs register highlighted areas where records did not accurately reflect the homes policies and procedures. The register contained an entry, which indicated that a quantity of medication was still on site when it had actually been returned to the dispensing chemist some considerable time before and was documented in the homes returns book. The manager stated the home had a policy on privacy and dignity and staff have training in privacy, independence, rights and respect reflected in the staff induction programme. Observations confirmed staff addressed the residents by their preferred names and knocked on doors before entering bedrooms and bathrooms. The residents have access to a range of independent advocates and councillors and their contact details were seen to be within easy access of the residents and displayed on their notice board. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities at the home satisfy the social, recreational, religious and leisure needs of the residents. The arrangements for community contact are good promoting family links. Policies and procedures are good enabling the residents to exercise choice over their lives with assistance as needed. Meals at the home are good and offer variety, choice and healthy eating options. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 13 EVIDENCE: Residents are supported to access a range of recreational and social activities, which meet their needs and preferences. The social needs, hobbies and interests of individuals are recorded in their care plan. The inspector noted the home had arrangements for meeting the religious needs of the residents. The home has visit from a local minister who offers the residents Holy Communion if they wish or to offer a friendly face to chat to. A review of menu plans confirmed meals offered variety, choice and healthy eating options. The home uses a flipchart menu, which shows the daily menu and the alternatives if the residents do not like the main choice. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 17 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies and procedures for making a complaint are restrictive and if followed require the complainer to write to the management of the home or the CSCI stating the issue they have. The arrangements for safeguarding adults need strengthening to safeguard the welfare of service users. EVIDENCE: The manager stated that the home has not received any complaints since the previous site visit by the CSCI and review of the complaints log substantiated this. The residents that spoke to the inspector felt that they could easily make a complaint if they felt there was a need to and they were all confident that they would be listened to if they did complain. A review of the policies and procedures does not allow free and easy dialogue between anyone wishing to make a complaint and the home. The residents or their representatives are expected to make formal complaints in writing to the manager or directly to the CSCI. This policy makes it difficult for people with any communication difficulties to make an effective complaint. However the manager stated that in reality the residents and their representatives are welcome to make a complaint in any form they wish they were not restricted and can make a complaint to anyone in any way they find convenient. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 15 During a discussion with the manager it was felt that the policies for making a complaints was indeed very restrictive and therefore in need of reviewing in order to comply with standard 16 of the National Minimum Standards for Older People. A requirement has been made please refer to page 27 of this report. The home had a policy on protection of vulnerable adults and a copy of the local authority (Surrey County Council) procedures on safeguarding adults. Further evidence confirmed the home had a whistle blowing policy and training is continues for staff in dementia awareness to ensure the emotional needs of the residents are understood and dealt with appropriately. A review of information confirmed no adult protection matters were recorded about the home since the last previous site visit by the CSCI. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 16 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): Standards 19, 20, 21, 23, 24, 25 & 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents live in a relatively well-maintained, clean, comfortable, homely and safe environment. EVIDENCE: The home is spacious, relatively well maintained and safe for the residents to live in. Some areas of the home are very well decorated and furnished to a good standard. The outside area at the rear of the property is well maintained for residents to access. All areas in the home are accessible by a lift. Call bells are provided and regularly tested. The recently built extension has given the home an additional 4 bedrooms with en-suite bathrooms and an extension to the sitting room. The registered providers have invested a considerable time and effort in the improvements to the home however there are areas where changes still need to be made. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 17 One of the principal areas of concern and was discussed with the manager was the newly completed rear of the sitting room. The extension to the sitting room is inappropriately furnished and lacks any real purpose, and appeared to be a no man zone. The lack of window dressings means that the residents privacy is not assured when sitting watching television or engaging in activities in the main sitting room or the extension. Window restrictors were missing from one of the new ground floor windows. The standard of decoration the unoccupied bedrooms was poor as was the assisted bathroom of the first floor and two bedrooms had considerable water stains on the ceiling from the floor above. The inspector discudded these areas with the manager who will submit a detailed timed schedule of works in order to bring the areas to the same high standards otherwise found in the home. During this visit the home was cleaned to a good standard. There were however strong pervading odours in certain areas of the home even after deep cleaning. A requirement has been made in respect of this. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 & 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are good ensuring sufficient numbers of staff on duty to meet the needs of the residents. Training is well funded and the commitment to National Vocational Qualification (NVQ) training is good. Recruitment and vetting practices ensure that the residents are safeguard. EVIDENCE: The manager stated the home had adequate staffing levels that were calculated using an approved formula and the inspector noted the manager had responsibility for planning the home’s duty roster. The home is committed to staff training and development and a review of records confirmed a carer had completed an NVQ Level 3 in Care with a further 4 carers currently undertaking NVQ level 3 training. This is in addition to the 3 carers how had completed their NVQ level 2 in care. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 19 The home had a policy on staff recruitment and the manager confirmed prospective employees are vetted before being employed by the home. The inspector sampled staff recruitment files which contained completed application forms, written references, statement of terms and conditions, training records, CRB (Criminal Record Bureau) disclosure information, a recent photograph of the employee and staff have copies of the GSCC (General Social Care Council) code of practice to safeguard the welfare of service users. The inspector noted staff recruitment files were securely stored to promote confidentiality. However on one of the carer’s files the gaps within the employment history were not fully documented. The agreed to action an audit to remedy this situation on the day of the inspection. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 & 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the day-to-.day management of the home are good. The systems for quality assurance ensure the home is run in the best interest of the residents. Policies and procedures are designed to safeguard the financial interests of the residents. The arrangements for health and safety are good promoting safe working practices. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 21 EVIDENCE: The inspector noted the home had a management structure with clear lines of communication and accountability and during discussions a member of staff stated ‘‘management is good, fine and I have no problems’’. The home had a policy statement on money and valuables and the manager confirmed relatives have responsibility for the resident’s money. The inspector noted the manager did not act as appointee and relatives or alternative representatives safeguarded the financial interests of the residents. The home had a policy on health and safety and staff have training in health and safety, fire safety, food hygiene, infection control and other relevant and appropriate training. Further evidence confirmed the home had a policy on COSHH (Control of Substances Hazardous to Health) with products stored in a locked cupboard to promote safety. A review of the homes records demonstrated that systems and procedures were in place for routine service and maintenance arrangements for the environment. The manager provided evidence to the inspector, which indicated that regular water temperature monitoring takes place. Appropriate food storage and temperature records were maintained. Fire maintenance records and checks were recorded. Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 17 3 18 X 2 3 3 X 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 4, 5 & 6 Schedules 1, 4.1 & .2 Requirement A statement of purpose and a service users guide must be produced which accurately reflects the service and how the home will meet the needs of the residents. The manager must supply a copy of both documents to the CSCI. The resident’s files must be clear and secure. All random items within the files must be correctly located or removed. Further training must be offered to staff involved in recording medication, to ensure that the records reflect the quantities held. The complaint policy must be open and fully accessible to all residents and or their representative. The registered person must ensure that all works required regarding the maintenance, repair, refurbishment or redecoration identified during the site visit by rectified. A timed schedule of works must be provided to the CSCI. DS0000013791.V338378.R01.S.doc Timescale for action 12/07/07 2. OP7 15 12/07/07 3. OP9 13(2) Schedules 3.3(I&k) 22(, 3 & 4) Schedule 4.11 16(1), 23(1 & 2) 12/07/07 4. OP16 12/07/07 5. OP19 12/07/07 Southlands Version 5.2 Page 24 6. 7. OP19 OP26 16(1), 23(1 & 2) 13, 16 & 23 All windows must have restrictor fitted and in operation. Suitable floor coverings must be used in all areas of the home, specifically in bedrooms where the resident has frequent accidents. 30/06/07 12/07/07 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.V338378.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Southlands DS0000013791.V338378.R01.S.doc Version 5.2 Page 26 - 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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