Inspection on 13/03/07 for Southlands

This inspection was carried out on 13th March 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 16/01/08

Southlands 13/01/06

Southlands 26/07/05

Southlands 12/01/05

Southlands 13/05/04

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

CARE HOME ADULTS 18-65 Southlands 56 Southfield Road Middlesbrough TS1 3EU Lead Inspector Val Daly Key Unannounced Inspection 8th March 2007 09:30 Southlands DS0000000059.V332272.R01.S.doc Version 5.2 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 DS0000000059.V332272.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 Adults 18-65. 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 DS0000000059.V332272.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlands Address 56 Southfield Road Middlesbrough TS1 3EU 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) 01642 230562 Mr D Kerrison Mrs S Kerrison Position Vacant Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 Brief Description of the Service: Southlands is a large three storey converted terraced house built around the turn of the 20th century. It is situated in a busy thoroughfare in Middlesbrough and was established as a care home in 1987. The home is registered with the Commission for Social Care Inspection under the Care Standards Act 2000 a as care home for 10 adults with a mental disorder. It is indistinguishable from other homes in the area and is in keeping with other family homes in the street. The home is managed by Mr John Harrison Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and was completed by one inspector over one day. As a key inspection, all of the key standards were examined. A tour of the home took place, residents records were examined, records including accidents, complaints and menus were looked at and three residents, two members of staff and the manager were engaged in discussion about life at Southlands. What the service does well: What has improved since the last inspection? Since the previous inspection several of the bedrooms had been redecorated. Residents had chosen the colours and two, who were in their rooms discussed how pleased they were with them. All rooms had individual, personal items in them, which gave them all a very different look. All areas of the home were comfortable and homely. Staff training is ongoing and three carers had enrolled on a course for NVQ 2. Southlands DS0000000059.V332272.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 DS0000000059.V332272.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident’s care needs are assessed prior to the move to the home, and periodically thereafter. This will help ensure that each resident’s needs are met at the home and inappropriate admissions avoided. EVIDENCE: Three residents files were examined and they both contained a full detailed assessment of needs and wishes. The residents had signed to agree each area of the assessment. Further assessments are carried out on a regular basis. Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to take risks within a risk management framework. This helps to ensure they remain safe and that their independence is promoted. EVIDENCE: Three care plans were examined and there was evidence to show that residents are fully involved in the drawing up of the plans and the reviews. Residents enter into a care planning agreement and then sign the plans and reviews. They also sign and agree to a confidentiality statement which informs who is allowed to read the care plan. Individual parts care plans are reviewed three monthly or when needed and a full review takes place six monthly. The key worker carries out this process with the resident and agrees any changes. Risk assessments are in place for any activity where it is required, trips out, behaviour, personal hygiene and these are agreed by the resident. Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Links with the community are very good and support and enrich resident’s opportunities. The meals are good, offering both choice and variety. EVIDENCE: Each resident has an individual activity plan, activities include, attending a day centre, art class, cinema, church, pubs, clubs, shopping, voluntary work in a charity café, seeing friends and relatives. During the inspection residents were in and out carrying out their own interests, and many were spoken to in between. One resident discussed his holiday abroad and happily showed his holiday photographs. He talked of his family and how he enjoys meeting up with his brother. Another resident had been out for a walk arriving back after lunchtime but staff ensured he was offered a meal. One resident was getting ready to go to work in a charity shop café, which he enjoyed. Residents stated they were very happy and were able to decide how they spent their time with staff being there to support/help if needed. Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 11 Residents enjoy their meals, the main one being served at teatime to suit daytime activities. There are choices for every meal and lots of home baking. Food is discussed at residents meetings and also suggestions asked for on the quality assurance questionnaire. Different dishes are added to the menu at resident’s requests. Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive good support from staff to ensure that their personal, physical and emotional needs are met. The homes procedures for storing and administering medication are robust to safeguard the residents. EVIDENCE: The care plans examined detailed the personal support needed and given. All residents in the home have their own General Practitioner, some attend appointments on their own and others require an escort. A Psychiatrist also sees residents at least annually. Each resident receives support from staff to the level that they choose and require. Policies and procedures are in place for the ordering, receipt, storage, disposal and administration of medication. Examination of medication administration records showed that the procedures were being followed. Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 13 At the time of the inspection there was one resident who managed his own medication. He collects his medication weekly from the chemist in a blister pack. Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints system, which residents can use if they are unhappy, have a grievance or dispute. Staffs have received training in adult protection to safeguard the residents from abuse. EVIDENCE: The home has a complaints procedure and policy in place, which includes information regarding the Local Authority. Each resident has their own copy of the complaints procedure in their room. There had not been any complaints made to the home since the previous inspection. Residents interviewed said that they were happy to talk to staff or the home owner if they had any problems and were confident that they would be dealt with. The home has an adult protection policy and procedure in place and staff interviewed were aware of the procedure. Staffs training files were examined which showed that training in ‘No Secrets’, the protection of vulnerable adults had been completed. Information about adult protection is available to residents. Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is attractive homely and comfortable for the people who live there. All areas were safe, well maintained and extremely clean. EVIDENCE: Since the previous inspection several of the bedrooms had been redecorated. Residents had chosen the colours and two, who were in their rooms discussed how pleased they were with them. All rooms had individual, personal items in them, which gave them all a very different look. All areas of the home were comfortable and homely. Any maintenance required is organised by the providers and carried out straight away. The home is kept extremely clean with no odours. Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear leadership skills demonstrated by the provider and staff have a clear understanding of their roles. Recruitment policies and procedures are robust. EVIDENCE: The home has recruitment policies and procedures in place. Three staff files examined showed that the home’s policies are being followed and all the required documentation was in place. Staff in the home receives regular training. Staff have individual training plans. Since the previous inspection training has been delivered in First Aid, Fire Safety, control and restraint and Adult Protection. Training had also been arranged for later in March and April for updates on Moving and Handling and Food Hygiene. Two members of staff interviewed confirmed they receive regular training. There are six carers in the home, two of which have completed training in NVQ 2 and above, a further three carers had enrolled for NVQ level 2. Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home regularly reviews aspects of it’s performance through a programme of self-review and consultations, which include seeking the views of residents and staff. EVIDENCE: At the time of the inspection the provider, who has previously been a registered manager was overseeing the home. She had been interviewing potential managers and had offered one person the position. An application was in the process of being put forward to the Commission. The resident’s needs and wishes are paramount and residents are encouraged to be involved in the running of the home. Residents interviewed were very happy living in the home, knew and liked the staff and were concerned that a member of staff had been on sick leave for some time. Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 18 Meetings for residents are held every three months and minutes are taken and agreed to and signed by the residents. There are also staff meetings, which are well attended. An annual audit of the home is undertaken and an action plan is formed where required. Residents are given questionnaires to complete, which cover areas such as, the environment, staff attitude, food, complaints, activities and personal bedrooms. Comments from residents include ‘choice of food, if you don’t like it just see the cook and she will make something else, good balanced diet, plenty of fresh fruit’, ‘very satisfied and happy’, ‘our families are offered tea/coffee and biscuits/cakes when they visit’, I would like to thank everybody’, ‘very happy, food beautiful’. Relatives were also sent questionnaires and comments included, ‘atmosphere cosy, friendly and nice’, always made welcome, aware of any issues regarding my family member via the key worker’, ‘atmosphere happy and harmonious, told of any concerns either by letter or phone’, my family member seems to be content with every aspect of the home’. Staff were asked to complete questionnaires, they all thought that the staff work together as a team and were looking forward to e new manager starting in the home. Staff records showed that training in health and safety is received, a member of staff confirmed this. The home has health and safety policies and procedures in place. Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 4 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 4 X X 3 X Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 20 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. 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. Refer to Standard YA35 Good Practice Recommendations 50 of carers should complete NVQ training at level 2 or above. Southlands DS0000000059.V332272.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 DS0000000059.V332272.R01.S.doc Version 5.2 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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