Inspection on 07/12/05 for Southlands

This inspection was carried out on 7th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Southlands 10/05/07

Southlands 09/05/06

Southlands 11/07/05

Southlands 10/03/05

Similar services:

Hillside

Applegarth

122 Scorer Street

St Marys Nursing Home

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOMES FOR OLDER PEOPLE Southlands 21 Main Street Off Greenside Close Long Eaton Nottingham NG10 1GU Lead Inspector Jenny Thornton Unannounced Inspection 7th December 2005 11:00 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 DS0000035734.V272030.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Southlands Address 21 Main Street Off Greenside Close Long Eaton Nottingham NG10 1GU 01629 580000 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) Derbyshire County Council Yvonne Kristine Fowkes Care Home 23 Category(ies) of Dementia (3), Learning disability (1), Mental registration, with number disorder, excluding learning disability or of places dementia (3), Physical disability (2), Sensory impairment (3) Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2005 Brief Description of the Service: Southlands care home is a detached house in a residential area of Long Eaton, within walking distance of the town centre. The home provides social and personal care for 23 people aged 65 years and over. The home also provides 3 day care places. The facilities are on 2 floors. All accommodation is in single rooms; bedrooms do not have en suite facilities. Access to the first floor is by stairs and a passenger lift. The home has two large lounge and dining areas, a quiet room/library, and a lounge where residents can smoke. Residents have access to well set out garden areas. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was un-announced and took place over five hours. The inspector spoke to ten residents, one visitor, two members of staff, and the unit and area manager. The inspector looked around parts of the home and examined various records. The home has made good progress towards meeting the requirements and recommendations from the last inspection report dated July 2005. What the service does well: What has improved since the last inspection? Residents care plans have been updated to a high standard to include additional information and all needs. A varied social activities programme was planned over the Christmas period. Individual activity sheets have been provided for staff to record activities residents participate in. An information guide has been provided on social activities available to residents. An adapted kettle has been provided in the resident’s kitchen to enable resident’s to make a hot drink safely. New menus were being introduced and residents had been consulted about the changes. Residents’ clothes have been properly named. Several new lounge chairs have been provided and two settees were on order. The manager had established meetings with the catering and domestic staff to discuss any issues. Records have been put in place to show when staff receive supervision. Staffing cover at the home had increased, additional relief staff had been appointed and staff sickness levels had reduced. Training records have been updated to show all training that staff have attended. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 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. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 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 DS0000035734.V272030.R01.S.doc Version 5.0 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 the following standard(s): 3 The care planning system has been strengthened to show that residents’ needs are fully assessed and met following admission to the home. EVIDENCE: Care plans had been updated to include additional information and assessment relating to individual’s needs and preferences. Care plans were completed to a high standard and clearly set out how individual’s needs were being met including religious and social needs. Residents had been involved in completing their care plan and had signed it. The deputy manager responsible for reviewing resident’s personal care plans had completed a detailed six monthly review of their needs. A copy of the resident’s care plan and six monthly reviews was kept in their room with the service users guide. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 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 the following standard(s): 9 and 10 Residents’ privacy and dignity is clearly respected. Systems in place for the safekeeping and handling of medicines safeguard residents’ welfare. EVIDENCE: Residents said that their privacy and dignity is respected; this was observed during the inspection. Good systems were in place relating to the administration and management of medicines in the home to safeguard residents welfare. The medicine procedures covered ordering, receipt, administration and disposal of medicines, and records were kept to ensure that medicines are appropriately handled. The home did not have a list of ‘homely remedies’ that may be used in the home; the person in charge said that the medicine procedures were being updated. Satisfactory storage facilities were provided to ensure that medicines are kept securely. Medication administration records were clearly printed by the dispensing pharmacist and were duly signed, with the exception of several prescribed creams, which required to be applied daily. The administration records contained a considerable number of gaps where staff Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 10 had not signed to say that a cream had been administered or had completed an appropriate code. Where medication charts had been handwritten the member of staff completing the record had signed it and had recorded the quantity of medicines received, and this had been checked and counter signed by a second member of staff. Senior staff had completed medicines training to safely administer medicines in the home. Staff had access to an up-to date reference book on medicines. All residents had signed a disclaimer agreeing for staff to administer their medication, or that they wished to self-administer certain medicines. The signed disclaimer forms required reviewing as certain forms listed medicines that resident’s no longer self-administered. One resident administered her inhaler and had a lockable storage area to keep her medicines in. Various risk assessments completed did not include the resident’s ability to self-administer her inhaler, part of which is to ensure that medicines are administered appropriately and kept safely. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 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 the following standard(s): 13 and 14 Contact with family and friends is supported ensuring residents maintain links with family and friends. The home enables residents to make decisions and choices about their lives. EVIDENCE: Residents and staff confirmed that contact with family and friends is supported. Relatives and friends can visit at any reasonable time and are made to feel welcome in the home. Several residents regularly went out with their family. Residents said that they had formed good relationships with staff. Discussions with residents and observations showed that residents are helped to exercise choice and control over their lives, where possible. An example was that an adapted kettle has been provided in the resident’s kitchen to enable a resident to make a hot drink safely. Residents said that the daily routines are flexible; several residents preferred to spend time in their room during the day. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 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 the following standard(s): 16 The home has a satisfactory complaints system and residents concerns are listened to and acted upon. EVIDENCE: The home has a clear complaints procedure, which was displayed in the home and included in the service users guide, which residents receive a copy of. Residents said they found staff approachable and felt that their concerns are listened to and acted upon. Complaints are dealt with at an informal stage where possible, which results in the home receiving few formal complaints. Appropriate records were kept of complaints received, although staff had not recorded what action had been taken or the outcome to one complaint received. The manager said that the complaint had been resolved and agreed to update the records. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 The standard of the environment is good providing residents with a comfortable and homely place to live. EVIDENCE: Residents consider that the environment is comfortable and homely and is maintained to a good standard throughout; this was apparent on the inspection. An inspection of areas of the home highlighted no issues relating to the environment. The manager confirmed that further bedrooms were due to be redecorated. Several new lounge chairs have been provided and two settees were on order. Arrangements were in place to ensure that the home is well maintained, although the outside areas required repainting and some maintenance. This has been highlighted on the previous three inspection reports. The home was clean and generally free from odours. One bedroom checked contained an odour and the carpet had been shampooed that morning. Staff reported that domestic cover was provided most days. At the time of the Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 14 inspection domestic cover was limited as one of the domestic staff was off sick and a member of staff had recently left. The manager said that the home was due to advertise this vacancy. Care staff washed residents clothes in-between caring for residents. Residents said that their clothes were generally well laundered and duly returned. The manager’s said that work had been carried out to ensure that resident’s clothes are clearly named and returned. The manager said that the clinical waste bins had been replaced, and that the home planned to provide foot operated bins. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 28. Standard 29 was partially assessed. The staffing cover has improved over recent months, which has enabled the senior staff to develop areas of responsibility within the home. The staffing levels do not fully take into account the needs of residents and staff, although the home had recruited a person to assist with the laundry duties, which will enable care staff to spend more time with residents. EVIDENCE: Staff said that the home continues to provide good training opportunities and that they had attended various training in the last year. The training records had been updated to provide evidence of training attended. Two of the deputy managers had commenced N.V.Q. Level 4 in management qualification to further develop their skills. The manager confirmed that 7 out of 13 of the regular care staff had achieved N.V.Q Level 2 or 3 qualification in care to ensure they are skilled to do their job, and a further two staff were undertaking the training. The home has a committed staff team and provides a good mix of staff able to meet residents’ needs. Staffing cover at the home had increased over recent months; additional relief staff had been appointed and staff sickness levels had reduced. Staff vacancies had been filled with the exception of a part time cook and domestic. The staffing hours generally complied with the hours stated in the home’s statement of purpose and allocated by the Local Authority. Staff and residents considered that although residents needs were generally met, the staffing hours provided were not always sufficient. Care staff expressed concerns that they did not always have time to spend with residents, and carry Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 16 out all their duties. Several residents commented that they sometimes had to wait a considerable time for staff to attend to their needs, and felt rushed by staff. The managers confirmed that some additional funding had been provided, which has enabled the home to appoint a member of staff to carry out some of the laundry duties at the home, which will relieve care staff of some of the duties. The member of staff was due to take up shortly. Staff welcomed this position. Staff personnel files were kept at the Local Authority’s area office and these contained the majority of recruitment checks and documents. Staff files will be reviewed at the next inspection. The manager confirmed that she was involved in the recruitment of staff and received a copy of staff’s criminal record disclosure certificate. The Local Authority had agreed that managers receive copies of references for all new staff, although the personnel department had yet to issue copies to the home. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 38 The home is run in an open and positive way, which staff and residents benefit from. The manager is supported well by the deputy managers in providing clear leadership and areas of responsibility in the home. Arrangements are in place to safeguard staff and resident’s safety and welfare. EVIDENCE: Staff and residents considered that the atmosphere at the home is relaxed and friendly and staff enjoyed their work. Staff spoken with found the manager approachable, and said that she involved them in decisions about the home. Staff considered that the morale was good. Senior staff have certain areas of responsibility in the home, which worked well. The manager had set out a clear development plan for the home, which staff were aware of. The home had made good progress towards meeting this, and the manager had identified further areas for improvement for the forthcoming year. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 18 Copies of Regulation 26 visits were available in the home; these were very brief and did not record the actual date or time of the visit or details of the person completing the visit. Discussions with staff and observations on inspection showed that safe working practices were followed. Records showed that the required maintenance checks were carried out. The deputy manager said that the fire alarm system had recently been serviced; the report had not yet been sent to the home. Discussions with staff and records showed that staff had or were due attend further mandatory training. The manager had compiled a chart to assist in planning further training, which showed at a glance what training staff had attended. The deputy manager confirmed that staff had not attended recent training on infection control. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 4 X X X X X 3 Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 20 Yes 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 OP9 Regulation 13 Requirement Timescale for action Staff must duly sign or complete the relevant code on the 31/01/06 medication administration records for all prescribed creams and ointments that require to be applied daily. The exterior of the home must be kept in a good state of repair. (Previous timescale 30/09/05 not met) 31/05/06 2. OP19 19 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 OP9 Good Practice Recommendations A list of ‘homely remedies’ which may be used in the home should be approved with the residents’ G.P’s and pharmacist. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 21 2. OP9 Signed disclaimer forms relating to residents medicines should be kept updated. Resident’s ability to self-administer their medication should be subject to a written risk assessment, part of which is to ensure that medicines are kept safely. 3. 4. 5. 6. OP26 OP27 OP33 OP38 All clinical and non-clinical waste bins should be foot operated. The Local Authority should review the staffing hours on days to further meet staff and residents needs. The person completing Regulation 26 reports should date and sign the record. Staff should receive further training on infection control. Southlands DS0000035734.V272030.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 DS0000035734.V272030.R01.S.doc Version 5.0 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!