Inspection on 16/01/08 for Southlands

This inspection was carried out on 16th January 2008.

CSCI found this care home to be providing an Good service.

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 13/03/07

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 Unannounced Inspection 16th January 2008 09:30 Southlands DS0000000059.V357062.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.V357062.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.V357062.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 01642 700583 sally701.kerrison@btinternet.com 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.V357062.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th March 2007 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. Fees are £355 per week Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was a key unannounced inspection and was completed by an inspector in one inspection day. As a key inspection, all of the key standards were examined. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. A number of records were looked at including assessments of people who use the service and plans of care, staff recruitment records, complaints and maintenance records along with the annual quality assurance assessment. Two people who use the service, a member of staff and one of the proprietors, were engaged in discussion about living at Southlands. The proprietor had completed an Annual Quality Assurance Assessment prior to the inspection. The AQAA is the services self-assessment of how they think they are meeting the National Minimum Standards. This information is received prior to the inspection and it is then used as part of the inspection process. On the day of the visit the home did not have a registered manager and one of the proprietors, who was running the home provided the information and documentation required. The Commission for Social Care Inspection sent a number of surveys to the home for people who use the service to complete. Three were completed and returned. Comments received can be read within the report. This was a positive inspection; people were open and friendly and welcomed discussion about the home. What the service does well: Southlands provide a comfortable homely environment for the people who use the service. It is very clean, well maintained and recent improvements ensure every person has their own individual space. People who use the service receive a good standard of care. From discussion with people who use the service, a member of staff and the proprietor it was apparent that they are involved in various activities and hobbies depending on their particular likes and dislikes. One person who uses the service said he worked one day a week and was learning how to make Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 6 pagodas. He also attends a Day Centre with other people from the home where they can play cards, dominoes, and bingo, attend art classes and do craft work. Other people who use the service attend college undertaking courses in computing and cookery. One person had completed a course in Manual Handling and was pleased to show his certificate. The people who use the service also socialise in the community, visiting family and friends, going for a drink at a local pub. What has improved since the last inspection? What they could do better: However whilst it is apparent from reading documentation, speaking to staff and people who use the service that staffs are meeting needs and wishes it would be beneficial if training in aspects of Mental Health was available. The care planning documentation could be further developed to include a ‘plan of action’ where a need is identified. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 8 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.V357062.R01.S.doc Version 5.2 Page 9 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 People who use the service experience excellent quality outcomes in this area. Each persons care needs are assessed prior to the move to the home, and periodically thereafter. This will help ensure that each person’s needs are met at the home and inappropriate admissions avoided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An assessment of the needs and wishes of people who may wish to use the service is carried out before admission to the home. Since the previous inspection the assessment documentation has been reviewed and developed further. Included is information regarding, personal details, a description, mental health history, medical history, the activities of daily living including plans and fears for the future, family and friends. The files of two people who use the service were examined and this information was contained in both of them. Further assessments are carried out regularly and in most cases the person who uses the service is involved and signs to show their agreement. If a person who uses the service does not wish to take part this is documented in their care plan. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 10 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 People who use the service experience good quality outcomes in this area. People who use the service are supported to take risks within a risk management framework. This helps to ensure they remain safe and that their independence is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous inspection, new care plan documentation had been introduced. There is information written for each area of daily living, which forms a comprehensive and detailed picture of the person who uses the service. However the documentation could be further developed to include a ‘plan of action’ where a need is identified. One person interviewed knew about their care plan and said he was involved in the reviews of the plan with their key worker and signed to agree. The key worker also writes a monthly summary. Information for the plan is gathered from the person who uses the service, relatives where possible, social worker and health professionals. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 11 Each person has individual risk assessments in their plan depending on their needs and activities that they carry out. The risk assessment documentation had been improved upon, was detailed and included scoring to denote a high, medium or low risk. They are either reviewed annually or as the situation changes. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 12 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 People who use the service experience excellent quality outcomes in this area. Links with the community are very good and enrich people’s opportunities. The meals are good, offering both choice and variety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From discussion with people who use the service, a member of staff and the proprietor it was apparent that they are involved in various activities and hobbies depending on their particular likes and dislikes. One person who uses the service said he worked one day a week and was learning how to make pagodas. He also attends a Day Centre with other people from the home and they play cards, dominoes, and bingo, attend art classes and do craft work. Other people who use the service attend college undertaking courses in computing and cookery One person had completed a course in Manual Handling and was pleased to show his certificate. The people who use the service also socialise in the community, visiting family and friends, going for a drink at a local pub. A comment from a survey was’ I like to watch television Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 13 and look through books’. Relatives and friends are also welcome to visit at any time. Since the previous inspection the menus had been changed and now offered more choice. People who use the service have been involved in the changes, which were discussed and agreed prior to the changes. Meals are chosen a day in advance. There are more alternatives available along with any special diets. When a person who uses the service has a birthday, they get to choose the tea and type of birthday cake. The other people in the home can either have the same meal or choose from the menu. One person had recently chosen a mixed grill for her birthday and another was going to have a buffet tea. A comment from a survey was ‘I like to listen to music, I enjoy my meals’. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 14 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 People who use the service experience good quality outcomes in this area. People who use the service 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 people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From discussion with a person who uses the service and observation from staff interaction with others it was apparent that support is given in the way it is needed and required. A comment from a survey was ‘I have always been happy here, the staff are nice people and listen to me’. This was also confirmed from information in the care plans. Staffs are always available for the people to chat to and give support and they know them very well. Each person who uses the service have their own General Practitioner and are also seen by their Psychiatrist three monthly. At the time of the inspection there were no people who self medicate. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 15 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 People who use the service experience good quality outcomes in this area. The home has a complaints system, which people can use if they are unhappy, have a grievance or dispute. Staffs have received training in adult protection to safeguard the people who use the service from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a copy of the complaints procedure is on display in the home for people who use the service and it is also in every person’s room. One person said he had never had to complain but would talk to any member of staff if he had a problem. Comments from a survey were’ I am happy with my life, I have nothing to complain about’. There had not been any complaints made since the previous inspection. Examination of the staff training files showed that all staff had received training in Adult Protection. A member of staff interviewed was able to describe the procedure to follow in the case of suspected abuse. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 16 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 People who use the service experience good quality outcomes in this area The environment is attractive homely and comfortable for the people who live there. All areas were safe, well maintained and extremely clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home was carried out with the proprietor and one of the people who use the service. Since the previous inspection refurbishment had been carried out to make all single accommodation for the people who use the service. Each person had chosen their own colour scheme for their room and the lay out of the furniture. There had also been some changes to the use of communal space. The lounge to the front of the home is now for people who wish to smoke and more lounge furniture and a television has been added to the dining area for an alternative place to sit. There is also a computer, which two of the people enjoy using. In the kitchen, there are new cupboards, worktops and a cooker. There is a new shower room/ toilet on the first floor. The proprietor said re tiling work is going to be carried out in the shower room on the ground floor and bathroom on the first floor. The hall and stairs have been re carpeted and painted. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 17 People spoken to during the inspection said they were very pleased with the changes in the home. The home was very clean without any odours. A comment from a survey was’ the home is always clean, neat and tidy. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 18 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, 24 &35 People who use the service experience good quality outcomes in this area Staffs have a clear understanding of their roles. Recruitment policies and procedures are robust. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has recruitment policies and procedures in place. Two staff files examined showed that the home’s policies are being followed and all the required documentation was in place. Training for staff is ongoing. Since the previous inspection training has been delivered in Moving and Handling, Health and Safety, First Aid, Infection Control and Nutrition On the day of the inspection staff were receiving refresher training in the Monitored Dosage System of medication. However whilst it is apparent from reading documentation, speaking to staff and people who use the service that staffs are meeting needs and wishes it would be beneficial if training in aspects of Mental Health was available. At the time of the inspection there were six carers employed. Five had achieved NVQ level 2 or above in care. There were three catering/ domestic staff employed, one had NVQ 2 in care and one NVQ level 3 in catering. The duty rota showed that senior staff covers the home on every shift. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 19 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 People who use the service experience good quality outcomes in this area The home regularly reviews aspects of its performance through a programme of self-review and consultations, which include seeking the views of people who use the service and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection one of the proprietors was managing the home, as there was not a registered manager in place. However the proprietor was in the process of applying to the Commission for Social Care Inspection for a manager to be registered. The staff group had worked at the home for several years and knew the residents well. People who use the service are encouraged to be involved in the running of the home, one person interviewed said he liked to know ‘what was going on’ but was not really interested in the paper work. Meetings for people are every three months and any proposed changes in the home are discussed. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 20 People who use the service are given questionnaires annually to complete, which cover areas such as, the environment, staff attitude, food, complaints, activities and personal bedrooms. An action plan is formulated from the completed questionnaires. From the previous one, a cordless phone had been requested for the home, to enable people to make phone calls in private from their rooms. The proprietors purchased one and it was used regularly. Staff records showed that training in health and safety is received, and a member of staff interviewed confirmed this. The home has health and safety policies and procedures in place. Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 21 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 4 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 3 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 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 X 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 3 X X 3 X Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 22 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. Refer to Standard Good Practice Recommendations Southlands DS0000000059.V357062.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Fourth Floor St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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. 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