Inspection on 24/01/06 for Southlands Court, Bridgerule

This inspection was carried out on 24th January 2006.

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 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 Court, Bridgerule 27/11/08

Southlands Court, Bridgerule 11/01/07

Southlands Court, Bridgerule 21/06/05

Southlands Court, Bridgerule 16/12/04

Southlands Court, Bridgerule 17/05/04

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Didsbury Court Rest Home

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Southlands Court, Bridgerule Bridgerule Holsworthy Devon EX22 7EW Lead Inspector Andy Towse Unannounced Inspection 2:50 24 January 2006 th 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 Court, Bridgerule DS0000022130.V264769.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 Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Southlands Court, Bridgerule Address Bridgerule Holsworthy Devon EX22 7EW 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) 01288 381631 Mrs Celia Jane Goaman Mr Victor Lawrence Goaman Mrs Jennifer Hingston Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (25), Old age, not falling within any other category (25) Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager to attain NVQ Level 4 in Care and Management by September 2005 21st June 2005 Date of last inspection 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 frequently. Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over a period of five hours. Information contained in this report was obtained from discussion with the registered manager, staff and residents and from inspection of documents, including care plans, and policies. This was the inspector’s first visit to Southlands. The majority of core standards were inspected during the previous inspection of 21st. June 2005. The home is well maintained and has a friendly and welcoming atmosphere. What the service does well: What has improved since the last inspection? The registered manager has put into practice some of the recommendations made from a fire safety risk assessment, such as installing electronically controlled door closures and improving the standard of the recording of fire safety issues. Fire safety training is included in the induction programme of new staff. The recruitment procedure has been made more robust and staff files examined contained the appropriate information. Resident’s care plans are available to them and are kept I their rooms. The registered manager has introduced an ongoing quality assurance and quality monitoring system which includes questionnaires for relatives as well as residents. The registered manager has introduced care plans and is introducing a key worker system to assist in implementing them. Southlands Court, Bridgerule DS0000022130.V264769.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 Court, Bridgerule DS0000022130.V264769.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 Court, Bridgerule DS0000022130.V264769.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, 5 Prospective residents only move into the home when their needs have been assessed and the home knows that they can meet these needs. EVIDENCE: The inspector looked at the file of one resident who had been admitted during the previous year and also the information obtained for a person who was in the process of being admitted to the home. The file of the current resident contained a nursing referral from the hospital and a care plan compiled by social services staff. This showed that the home had relevant details regarding this resident’s needs, from which the registered person could determine whether the home would be a suitable placement. The registered manager said that in addition to this information she had visited the resident in hospital prior to admission to the home and the files contained van assessment compiled at the home of the day of admission. In order to determine whether the prospective resident can be suitably accommodated at Southlands the registered manager has visited this person in Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 9 hospital and, in order to determine whether the physical environment of Southlands is suitable, the prospective resident has also visited Southlands. Standard 6 was not inspected as part of this inspection as Southlands does not offer intermediate care. Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 Resident’s health, personal and social care needs are set out in an individual plan of care, however to ensure the effectiveness of the plans further staff training is required. EVIDENCE: Information regarding three residents was inspected. All files contained Care Plans. These were discussed with the Registered Manager and briefly with care staff. Care Plans did contain identified needs of individual residents. The Registered Manager informed the inspector that previously the home did not operate care plans and instead used a system of daily reporting. The Registered Manager is instituting a key worker system. This is still in its infancy, although some residents were aware of who their key worker was. The Care Plans are formulated so as to identify differing needs of residents, into categories such as psychological, physical etc, however staff are still uncertain regarding how to compile these appropriately. Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 11 Care Plans are kept in resident’s bedrooms. Some residents were aware of their care plans and, in the Quality Assurance questionnaire submitted to the relatives of residents there is reference to the plans being available in resident’s bedrooms. This demonstrates the intention of involving residents in their care plans and promoting their access to them. The Registered manager is aware that further training is required to improve the formulation of Care Plans and develop further the key worker concept. Entries in residents’ records showed that the above issues were not affecting the delivery of care to residents, who spoke highly of staff members. Residents receive routine eye checks and there is regular contact with general practitioners and district nurses. Southlands has a written medication administration policy. In order to make it more easily understood, and thereby safer to use, it includes a reference to medical terminology. There is a facility for the appropriate storage of controlled drugs. The administration of controlled drugs was correctly recorded. Prescribed drugs were seen to be stored securely. To ensure the safety of residents, staff who administer medication have received training from a local college. The home encourages residents to remain as independent as they are able. Residents who are able are allowed to self medicate. Such residents sign a disclaimer which acknowledges their responsibilities, including that of ensuring that their medication is locked up securely. Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None These Standards were all inspected during the previous inspection. EVIDENCE: Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 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 the following standard(s): 16 The home has a complaints procedure which requires minor amending to ensure that it meets the requirements of the National Minimum Standards. EVIDENCE: Southlands has a written complaints policy. In order that all residents, their relatives and any other visitors to the home are aware of it, a copy is displayed on the home’s main notice board. The policy offers those who wish aright to complain and also contains timescales within which the home will respond. In order that it complies completely with the National Minimum Standards the policy will need amending to include the right of a complainant to refer the complaint to the C.S.C.I at any stage in the complaint process. As stated in the previous inspection, the home has a copy of the ‘No Secrets’ training video and in addition copies of the Social services ‘Protection of Vulnerable Adults’ handbook. Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 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 the following standard(s): 19, 22, 23, 26 Residents live in a pleasant, clean and well maintained environment. EVIDENCE: Southlands is situated in a rural area. Originally part of a farm, it has been converted into imaginative and spacious accommodation. Externally the grounds are well maintained and include an enclosed, easily accessible courtyard, which allows confused residents access to a pleasant, but safe, outside recreational area. Most bedrooms were seen to be spacious and incorporating ensuite facilities. The home is situated on two levels which can be accessed via a chairlift. At the time of the inspection none of the bedrooms was in shared occupancy. Shared occupancy would only be arranged if this was the expressed wish of the residents concerned. A tour of the premises showed that the home has good standards of hygiene and cleanliness. Southlands Court, Bridgerule DS0000022130.V264769.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): 28, 29, 30 Residents are now protected by a more robust recruitment procedure. Staff competence and ability to meet the needs of residents is enhanced by a rolling programme of training. EVIDENCE: At the time of the last inspection it was found that the home’s recruitment procedure was not robust enough to protect residents. At this inspection the files of two newly recruited staff were inspected. These were found to contain the necessary police checks and references to ensure that these staff were suitable to work with vulnerable adults. Staff at the home participate in a rolling programme of training. This includes training in mandatory subjects such as Moving and Handling which ensures that staff have the appropriate skills to ensure the safety of residents. Staff also receive training in First Aid, Basic Food Hygiene and Fire Safety. Southlands has an Induction Programme for all newly recruited staff. The Registered Manager is encouraging staff members to attend NVQ training. From information supplied by the Registered Manager, at the time of the inspection about 33 of care staff had NVQ level 2 and when those currently studying for this qualification have completed the course, the home should have attained the 50 qualifying level expected under the National Minimum Standards. Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 16 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): 33, 35 An effective quality assurance and quality monitoring system ensures that the views of residents are incorporated into the running of the home. EVIDENCE: Southlands operates an effective quality assurance and quality monitoring system. This includes questionnaires written specifically for either residents or their relatives which are forwarded to both residents and their relatives in order to obtain their views and opinions. Suggestions received from residents and their relatives, in response to the questionnaires were seen to be acted upon. Most of the responses from both residents and their relatives were seen to be positive, including reference to staff being, ‘extremely friendly’ and ‘couldn’t be kinder.’ The previous report highlighted issues relating to fire safety and staff training relating to this. A risk assessment for the home had been compiled in June Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 17 2005 with recommendations made. Since those assessments were made the home was seen to have carried out some of the recommendations such as the installation of automated door closures linked to the fire alarm system. The registered manager has, in accordance with the fire officer’s recommendations included aspects of fire safety in the induction programme for new staff. A successful drill, including evacuation of part of the premises was also carried out and the registered manager has also had further discussion with the fire officer regarding fire safety. In most instances residents or their families took responsibility for personal finances. Where this was not the case there was appropriate recording of expenditure complemented by receipts with monies kept securely. Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 18 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 x 3 X X 3 3 X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X x Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 2 Refer to Standard OP7 OP16 Good Practice Recommendations Although residents have care plans, in order for an effective delivery of service staff require further training in how to compile these. The registered person ensures that written information is provided to all service users for referring a complaint to the CSCI at any stage should the complainant wish to do so. Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Exeter 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. Extracts may not be used or reproduced without the express permission of CSCI Southlands Court, Bridgerule DS0000022130.V264769.R01.S.doc Version 5.0 Page 21 - 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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