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Inspection on 21/06/05 for Southlands Court, Bridgerule

Also see our care home review for Southlands Court, Bridgerule for more information

This inspection was carried out on 21st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents praised the staff at the home and the care provided by them. A common phrase used by the residents was `staff are exceptionally nice` and `they are all so caring`. One resident said `we are thoroughly spoilt`. The home provides excellent meals, which are very well appreciated by all the residents. The home provides high quality accommodation and furnishings in a rural area, which provides tranquillity and peace. Staff morale is very high and staff take a pride in the care they provide.

What has improved since the last inspection?

Some of the training needs and issues identified have been addressed, with more training planned. Three requirements, not assessed on this occasion, have been carried forward from the previous inspection. These will be monitored on the next visit to the home.

CARE HOMES FOR OLDER PEOPLE Southlands Court Bridgerule Holsworthy Devon EX22 7EW Lead Inspector Vickie Stewart Unannounced 21st June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Southlands Court Address Bridgerule, Holsworthy, Devon Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01288 381631 Mrs Celia Jane Goaman Mrs Jennifer Hingston Care Home 25 Category(ies) of MD(E) Mental disability over 65 [25] registration, with number DE(E) Dementia over 65 [25] of places OP Old age [25] Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: The Registered Manager to attain NVQ Level 4 in Care and Management by September 2005 Date of last inspection 16/12/2004 Brief Description of the Service: Southlands Court is a care home providing accommodation and personal care for up to 25 male and female older people, some of whom may have dementia. The home is situated on the outskirts of Bridgerule, North Devon. The building is a converted farmhouse on 2 floors. The majority of the private and communal living accommodation is sited on the ground floor. A stairlift gives access to the 1st floor. All bedrooms are single and have ensuite facilities. The grounds, including a large pond in a centre courtyard area, are well maintained. The home backs on to farmland and has glorious open views of the surrounding countryside. The owners of the home live a short distance from the home and visit the home freqeuently. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was arranged as part of the normal programme of inspection for the year 2005/6. It took place over 5 hours. This was the inspector’s first visit to Southlands Court and the majority of the time at the home was spent talking with residents and staff. The inspector also spent time with the manager, had a tour of the premises and looked at records including staff files, training records, fire records and care plans. The home had a warm, peaceful and welcoming atmosphere. The home was full with 25 residents on the day of inspection. The inspector met with all of them, but spoke at length with 15 of the residents either in communal areas or private rooms, alone or in a group. The inspector also spoke at length with 6 members of staff. What the service does well: What has improved since the last inspection? Some of the training needs and issues identified have been addressed, with more training planned. Three requirements, not assessed on this occasion, have been carried forward from the previous inspection. These will be monitored on the next visit to the home. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 6 What they could do better: All of the residents were asked how the home could improve the care provided. Without exception, all said there was nothing that could be improved. Following discussion with the manager, the following requirements/recommendations for improvement were identified: • Ensure that the home has a more robust employment procedure. Employment records do not hold all the information required to ensure the protection of residents. Staff must not work unsupervised until the appropriate pre employment information is obtained and considered satisfactory. All staff must undertake the appropriate fire training by a suitable professional. All fire safety equipment checks must be carried out as required by the fire authority. All substances which are hazards to safety must be kept securely in the home. Recognised training on the Protection of Vulnerable Adults should be introduced into the home. • • • • • Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not inspected on this occasion. EVIDENCE: Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 10 Resident’s benefit from staff that respect their privacy and dignity. EVIDENCE: The inspector observed that the residents were treated with privacy and dignity. Residents confirmed that staff knock on doors before entering and speak to them in their preferred name. Residents were very complimentary and positive about the staff in the home. Comments included ‘there are times when I feel I don’t want company, I’ll go down if I want – if I don’t want to I can stay here’, ‘the home is organised unobtrusively and very well run’ and ‘staff leave you alone but if you want them, they are there’. The home has no shared rooms. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and choices. The home is in the process of improving the types of activities on offer. Residents are given choice and control in their day-to-day lives. EVIDENCE: The home has a 3-week plan of meals. All of the residents spoken with praised the high standard of the food served. Comments included ‘food is excellent’, ‘there are two brilliant cooks’, ‘we can choose whatever we want’ and ‘marvellous food’. All private rooms are personalised and individual with items of a personal and sentimental value. Residents confirmed that they exercise much choice and control over their lives. Comments included ‘I can’t pick a hole in it’, ‘I feel safe and well cared for’, ‘it’s very free’ and ‘I choose what I want to do’. The inspector observed a conversation with one resident and the manager which involved the resident choosing whether or not she wanted to change rooms in the home. Social activities are organised in the home and the home has its own minibus. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 11 Staff confirmed that a new activities organiser is co-ordinating and developing the activities in the home. On the day of inspection, some residents were having their finger nails painted, which they enjoyed. Residents were happy with the activities programme. Comments included ‘there’s always something to do’. The inspector observed residents taking advantage of sitting in several different communal or private areas of the home. Residents confirmed that relatives are welcomed into the home and can visit privately in their own rooms if they wish. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 12 Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Staff have limited knowledge and understanding of Adult Protection issues, which could potentially put residents at risk of harm or abuse. EVIDENCE: Staff have not undertaken any formal training on the prevention of abuse. Some staff had seen the ‘No Secrets’ video but felt that it was ‘no use’ and would welcome further training on the subject. All staff confirmed that they would raise any concerns they had with the manager or deputy manager, but were unsure what to do in the event of their absence. Residents confirmed that they were well cared for and comments included ‘I’m very happy living here’, ‘they look after me well’, and ‘staff are all dedicated and caring people’. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24 The standard of the environment is very good, providing residents with an attractive, comfortable home to live in. EVIDENCE: The home is decorated and furnished to an exceptionally high standard. The home is welcoming, bright and comfortable. It is very clean and well maintained inside and out. There is level access to a centre courtyard area, which has a large pond in it. This provides a relaxing, safe and quiet area for residents to sit in. One resident said ‘it is extraordinarily well run and spotlessly clean’. Resident’s private rooms are all individual sizes and types and all contain personalised items. All rooms have full ensuite WC/bathing facilities with the exception of one respite room. Communal areas in the home are inviting and relaxing. Residents confirmed they liked spending time together with their friends. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 15 Assisted bathing facilities are provided. A stairlift gives access to the 1st floor where a further 8 private rooms are provided. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 Residents needs are met by the number and skill mix of staff. Staff have a good understanding of resident’s needs, evident from the positive relationships between residents and staff. The procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to people living in the home. EVIDENCE: Staff morale is high in the home. The majority of staff have worked at the home for some time and live local to the immediate area. The home provides the adequate numbers of staff to meet all the needs of the current residents. Dedicated domestic staff are employed. Residents confirmed they were given all the help they needed and that they did not feel rushed or hurried in any way. They were very complimentary of the staff and comments included ‘they are all so caring’, ‘it’s like being at home, just with extra help’ and ‘the staff are wonderful’. Two staff files were looked at. These indicated that the home had not undertaken all the necessary recruitment checks to ensure the protection of residents. One member of staff on induction had not yet received verification of the necessary Criminal Records Bureau check or suitable written references. This member of staff confirmed she was working unsupervised on occasions whilst carrying out the personal care needs of residents. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,38 The manager has a clear development plan for the home which she communicates to staff and residents. The home reviews aspects of performance through self review and consultation with residents, relatives and staff. Residents benefit from an open, inclusive atmosphere. Some practices in the home do not promote and safeguard the health, safety and welfare of the people using the service and could put residents at risk. EVIDENCE: The registered manager has now been in post approximately 7 months. She has previous experience of senior care/management roles in homes for older people. Since her recruitment, she has identified several areas in the home which need improvement and is working through a structured development plan. She has recently commenced the Registered Manager’s Award. The Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 18 manager leads a happy staff team and staff told the inspector that the management of the home had improved since her appointment. Staff confirmed that regular staff meetings are held and the home had posters displayed advertising the forthcoming resident’s meeting on 23rd June. A recent quality assurance survey for residents/relatives had been undertaken. The manager has recently introduced formal staff supervision. Staff confirmed that they found this a very useful and informative experience and gave the opportunity to discuss training and developmental needs. The home has an inclusive and positive atmosphere and residents spoke highly of the owner. Comments included ‘there is a good relationship with the owner and this rubs off on staff and comes back to us’. Some of the fire doors in the home were wedged open. Inspection of records indicated that regular testing of emergency lights and fire extinguishers had not been carried out. Some staff had recently undergone the appropriate fire training but some staff in the home have not received any fire training. Recent records indicated that fire alarm testing had taken place regularly. Cleaning fluids and other substances hazardous to health were found unsecured in the home. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 2 2 3 x x STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 3 3 3 x x 3 x 1 Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 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 29 Regulation 19 (1) (4) Schedule 2 Requirement Timescale for action 21.6.05 2. 29 18 (2) 3. 38 17 (2) Schedule 4 (14) 23(4) a-e 4. 7 15 (2) The registered person shall not employ a person to work at the care home unless all the information required under Schedule 2 has been obtained. - With regard to ensuring that all staff have the appropriate pre employment checks undertaken and held on file. The registered person shall 21.6.05 ensure that persons working at the care home are appropriately supervised. - With regard to ensuring that all staff are supervised when delivering personal care if the necessary pre employment documentation has not yet been received. The registered person shall take 21.6.05 adequate precautions against the risk of fire, including the provision of suitable fire equipment. - With regard to ensuring that all staff receive the appropriate fire training, all tests of fire equipment is carried out as per regulations and fire doors are not wedged open. The registered person shall make 31.5.05 Version 1.20 Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Page 21 5. 9 13 (2) 6. 24 24 (1,2,3) the service users plan available to the service user; keep the service users plan under review; where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his, revise the service users plan; and notify the service user of any such revision. - With regard to the care planning process, which needs to be overhauled to meet this requirement. The registered person shall make 20.1.05 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines into the care home. - With regard to all with a variable dose. The actual dose administered must be recorded. The Pharmacist inspector wrote to the home on 21.12.04 about this. The registered person shall 31.5.05 establish and maintain a system for reviewing at appropriate intervals; and improving the quality of nursing where nursing is provided at the care home. The registered person shall supply to the Commission a report in respect of any review conducted by him for the purposes of paragraph (1) and make a copy of the report available to service users and they system referred to in paragraph 1 shall provide for consulttion with service users and their representatives. - With regard to the fact that the home did not have a formal Quality Assurance System. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 22 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 18 Good Practice Recommendations It is recommended that all staff receive recognised training on the Protection of Vulnerable Adults. Southlands Court D54-D06 22130 SouthlandsCourt 216992 140605 Stage 4.doc Version 1.20 Page 23 Commission for Social Care Inspection Exeter Office, Suites 1 & 7 Renslade House Bonhay Road Exeter, EX4 3AY 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. 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