Inspection on 16/11/06 for Southlands, Highweek

This inspection was carried out on 16th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Southlands, Highweek 17/01/06

Southlands, Highweek 04/05/05

Southlands, Highweek 28/10/04

Southlands, Highweek 10/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Southlands, Highweek 21 Coombeshead Road Highweek Newton Abbot Devon TQ12 1PY Lead Inspector Susan Samways Unannounced Inspection 16th November 2006 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, Highweek DS0000003805.V310618.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 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, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlands, Highweek Address 21 Coombeshead Road Highweek Newton Abbot Devon TQ12 1PY 01626 363510 F/P 01626 363510 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) Mark Harris Mrs Carol Dyke Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability over 65 years of age of places (25) Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 25 Service Users within the Old Age category may reside at the home. 25 Service Users within the Physical Disability (over 65 years of age) category may reside at the home. 17/01/06 Date of last inspection Brief Description of the Service: Southlands is a registered care home for up to 25 people over the age of 65. It is a large, detached, Victorian property which is set back off the road. It is a short drive from the main town centre and is on a bus route. Southlands is set in extensive grounds and the sun room opens on to an attractive decked area. The property has been extended and has a lift to the first floor. Fees range from £280 to £465 per week. Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which lasted for eight hours. At the start of the inspection a senior carer was on duty, the operations manager was out doing some shopping for a resident but soon returned and the registered manager was off duty but came in during the inspection as she was concerned about a resident. This was the first inspection since the appointment of the new manager. Time was spent in discussion with the registered manager and the operations manager and in examining documents and records. Two residents were spoken to on their own and several others in passing. Five residents had completed Service User surveys prior to the inspection. Three staff filled in survey forms, four relatives and a visiting professional completed comment cards. A pre-inspection questionnaire had been completed and returned to the Commission for Social Care Inspection. What the service does well: Residents are enthusiastic about living at Southlands. Many of the residents are from the immediate area and are pleased that they have been able to remain in the local community and maintain their social contacts. They described the home as wonderful with staff who look after them very well. They said that they are given help with the things they are not able to do and encouraged to do everything else themselves and maintain the independence they have. They appreciate the freedom to choose how and where they spend their time. They also said that the meals are good with a choice being offered and different diets catered for. They said that they have confidence that any concerns they might have would be dealt with promptly. Relatives said that they are always made welcome when visiting and that they are kept well informed about the well-being of the resident they visit. Regular staff supervision is established and staff said they feel well supported. There is also a good training programme for staff. They were observed to interact well with the residents and the manager was seen to be approachable by staff and residents. A very good standard of care was observed to be given to those who were poorly, a resident who had had an accident and a resident who was coming to the end of their life. The registered manager and the operations manager have a good working relationship, which ensures the smooth running of the home. The home is clean and hygienic and is regularly maintained and redecorated. Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 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, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have a comprehensive assessment made and are invited to visit the home in order to provide all those concerned with sufficient information to make the decision whether Southlands is an appropriate home for them. EVIDENCE: The files for three residents, including one recently admitted, were examined. All were found to have detailed assessments covering all aspects of daily living. Their preferences, including the name by which they wished to be addressed Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 9 and their religion where applicable, had been recorded as well as key information about their medical and family history. One of the residents interviewed said that their family had found the home for them. They had been impressed by the welcome they had had and the way that their questions were readily answered. The resident said that they trusted their families judgement and had been very pleased with the choice they had made. The registered manager stated that whenever practicable prospective residents are encouraged to visit the home and/or have a short stay on a trial basis before making a final decision. Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents, and when appropriate their relatives, are involved in planning and reviewing their care. The medication procedure safeguards residents. Staff treat residents with respect and are caring and supportive when residents are coming to the end of their lives. EVIDENCE: Three care plans were examined. They covered all aspects of care and had been signed by either the resident or their relative. They had been reviewed and signed and dated by the person carrying out the review. One had been Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 11 reviewed more frequently than the others due to the deteriorating health of the resident. Daily records had been completed for each resident as had records of all visits by the G.P. and other visiting professionals. The two residents interviewed said that their care was discussed with them by the registered manager and the senior staff. Both said that the care was very good. A visiting health care professional had completed a comment card stating that the staff of the home were co-operative, that they understand the needs of the residents and that they have confidence that their advice would be followed. A district nurse spoken to was complimentary about the care given and said that manager and staff were clear about the limitations of the care they were able to give and when to ask for professional advice and support. During the inspection a resident had a fall. The situation was dealt with calmly by the registered manager and a senior member of staff. The paramedics were called to ensure that no serious injuries had been sustained as, due to the resident’s physical condition, it was difficult for the staff to ascertain. Reassurance was given to the residents who had witnessed the accident by other staff on duty. Following this incident the issue of falls was discussed with the registered manager. She stated that all residents have mobility assessments. Those with a history of falls or assessed as being at risk are encouraged to wear hip protectors and the advice of a physiotherapist is sought. Evidence of this was found in residents’ files. At the time of the inspection only one resident was responsible for their own medication. This is kept in a locked cupboard in the resident’s room and a risk assessment is completed at least annually to ensure that this remains a safe practice. All other medication is kept in a locked cupboard in a locked room. A monitored dosage system is used with the blister packs for each round being transported around the home in a small medicine trolley. The medicine charts checked had been completed correctly. Sadly, during the inspection, the condition of one resident rapidly deteriorated. A family member was with the resident and staff endeavoured to contact others. The registered manager rang the GP to inform him and he arrived at the home very quickly. Soon after this the resident died. The registered manager and the staff were observed to give the family member support and comfort until other family arrived. They were able to spend as much time as they wanted with their relative. Wherever possible the care plans include details of the care residents wish to have when coming to the end of their lives and funeral arrangements. Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home enables residents to maintain control over their day-to-day lives by promoting choice. Residents are benefiting from an increased range of activities including physical activities. EVIDENCE: The residents spoken to talked enthusiastically about life at Southlands. They said that staff took trouble to find out their likes and dislikes and that they had the freedom to choose how and where they spent their time. Since the last inspection more activities have been organised. Armchair exercises take place on a regular basis and videos of films, particularly musicals are shown on a Saturday. Some residents have started playing cards and a choir visits to entertain the residents and to spend time chatting with them. Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 13 Religious services are also held for those who wish to participate. A Church of England communion service is held every three weeks, the Methodist church visits every six weeks and an ex-member of staff has a prayer and hymn meeting in the home each Sunday. Residents spoken to said that they can have visitors at any reasonable time and that the staff of the home always make them welcome. This was confirmed by the relatives who completed comment cards. Relatives also said that they can see their family member in private and that the home keep them informed about their well-being. Residents are supported by members of their family or their solicitors to manage their financial affairs. The home has a third party advocate to help residents and their families to sort out financial planning if they wish. Records, including receipts, are kept of personal spending money. These are available for inspection by those concerned at any time. The residents spoke positively about the standard of the meals stating that if they didn’t like the choices on offer an alternative was provided. The cook is familiar with the residents’ dietary requirements and preferences. Lunch was observed during the inspection. The meal was well balanced and nicely presented with variations being served according to the residents’ preferences e.g. poached fish instead of fried fish. Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ rights are protected and they are safeguarded from abuse by staff being made aware of adult protection procedures. EVIDENCE: Residents spoken to and those that had completed surveys were clear about what to do should they be unhappy with any aspect of their care or the running of the home. The registered manager stated that many potential problems are sorted out during normal contact with the residents during the day and this was confirmed by residents spoken to. No formal complaints had been received during the previous twelve months and no complaints about Southlands have been received by the Commission for Social Care Inspection. All residents are registered to vote, some have a postal vote while others prefer to go to the polling station. The home has policies and procedures in place regarding the protection of vulnerable adults and training in this is included in the induction programme Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 15 for all new staff. It also forms part of the NVQ level 2 in care. All staff contacted, including ancillary staff, said that they were aware of adult protection procedures. It would, however, be advisable for refresher sessions to be arranged as no training for established staff has been held in the last twelve months. Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is attractive, homely and appropriately equipped providing a clean, hygienic and safe environment. EVIDENCE: The residents spoken to said that they liked their rooms which they described as lovely. They had been able to bring some of their own furniture to the home and had personalised their rooms. They also appreciated the varied communal space which includes a large lounge/diner, which opens onto a decked area overlooking the garden, and a smaller quiet lounge. The Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 17 registered manager said that rooms are redecorated as they become vacant or there is a vacant room to temporarily accommodate a resident while their room is done. The home was found to be clean and hygienic and the residents commented that this was always the case. Staff have had training in infection control but would probably benefit from a refresher session. The registered manager stated that the dependency levels of the residents is increasing. As a result more specialist equipment is being used. One resident requires the use of a hoist for all transfers and three others need one from time to time. The district nurses support the home in caring for more dependent and poorly residents by providing hospital beds and pressure relieving mattresses and cushions. Seven of the residents are also dependent on wheelchairs to move distances around the home. Fortunately the home has sufficient space to accommodate this. Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff recruitment procedures and staff training safeguard residents. EVIDENCE: This was an unannounced inspection and on arrival sufficient staff were found to be on duty. The rotas seen showed that this was the norm and residents and relatives also said that there are always sufficient staff on duty. At night there is one member of staff awake and another sleeping in. Cooks and domestic staff are also employed so care staff can concentrate on directly caring for the residents. Staff files examined showed that an adequate recruitment procedure had been followed including taking up references, checking identities and carrying out police checks. This was confirmed by the staff who returned questionnaires. A range of training is arranged for staff during the course of a year. All new staff follow an induction training programme. Four staff have NVQ level 2 in Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 19 Care and two other staff are undertaking it. Other training in the last twelve months has included fire safety, medication, basic food hygiene, manual handling, dementia and hip protection. Refresher training, particularly at present in adult protection and infection control, needs to be included in the training programme to ensure that staff are kept up to date. Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management style is open and receptive to the views of the residents and others involved with the home. EVIDENCE: Since the last inspection there has been a change of manager. The new manager was previously the deputy which pleased the residents as they liked her and they did not have to get used to someone new. She has been registered with the Commission for Social Care Inspection and has recently Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 21 completed the Registered Managers Award. The residents spoken to said that she was doing a good job, that she was approachable and sorted out any difficulties they might have promptly. Staff said that they felt well supported. During the inspection it was observed that the residents and the staff approached her with confidence and were relaxed in her company. All the residents contacted said that the manager and staff listened to them and that they felt able to ask questions and make suggestions. There is a good system in place to ensure effective communication. The manager and operations manager have monthly meetings to monitor the homes performance and how it can be improved. Records that the home is required to keep were seen to be in order. Formal staff supervision is in place. New staff have supervision at the end of their first week, their first month and after three months. All staff have supervision at least every two months. One of the senior staff has started to take on some of the supervision. There is a comprehensive manual on safe working practices and there are completed risk assessments for all areas. Fire safety checks are carried out at the required intervals and recorded. Other safety checks such as the servicing of the gas heating system, the lift and hoists had all been carried out in June 2006. Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 22 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 3 8 3 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 3 Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP30 Good Practice Recommendations The registered provider should ensure that refresher training in mandatory topics is included in the training programme. Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Southlands, Highweek DS0000003805.V310618.R01.S.doc Version 5.2 Page 25 - 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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