CARE HOMES FOR OLDER PEOPLE
Southlands 21 Coombeshead Road Highweek Newton Abbot TQ12 1PY Lead Inspector
Susan Samways Announced 4 May 2005
th 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 D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Southlands Address 21 Coombeshead Road, Highweek, Newton Abbot, Devon, TQ12 1PY 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) 01626 363510 01626 363510 Mark Harris Maureen King 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 D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 28/10/04 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. Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection which took 7.25 hours. All areas of the home were visited and the majority of the residents were spoken to. Two care staff and the cook were also spoken to as were two visitors. What the service does well: What has improved since the last inspection? What they could do better:
The safety of the residents needs to be improved by the fitting of approved devices to hold doors open rather than using door wedges. This will allow residents to exercise their choice as to having their doors open or not without compromising their safety. Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 Page 6 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 D54-D07 S3805 Southlands V215108 040505 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 D54-D07 S3805 Southlands V215108 040505 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) 3 Prospective residents have a comprehensive assessment made which provides all those concerned with sufficient information to make the decision whether Southlands is an appropriate home for them. EVIDENCE: Five residents files were examined. All had detailed assessments covering all aspects of the residents life including likes and dislikes, their preferred name and key information about their past history. Southlands D54-D07 S3805 Southlands V215108 040505 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) 7 8 9 10 Care plans have improved and involve the resident in the writing and reviewing thus ensuring the provision of appropriate care. The medication procedure is good which safeguards the residents. EVIDENCE: Five 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. Daily records had been completed and records of all visits by the G.P. and other visiting professionals. Residents stated that the G.P. is called promptly if they are unwell or a member of staff will take them to the surgery if they prefer. 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. Medication is popped out of the blister pack into a small pot which is given to the resident to take. The pots are colour coded to match the blister packs as an additional safety check. The medicine charts checked had been completed correctly. Residents
Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 Page 10 were observed to be treated with respect and in discussion they confirmed that this was the norm. Staff were seen to knock on residents’ doors and wait to be invited in. Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 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 standard(s) 12 13 14 15 The home enables residents to maintain control over their day to day lives by promoting choice. EVIDENCE: Residents’ likes, dislikes and preferences are recorded in their care plans. Residents talked positively about being able to choose, within reason, how they spend their time, being able to have visitors or go out when they wanted and being able to participate if they wished in any organised activities. They stated that their visitors are always made welcome by the staff. They also spoke enthusiastically 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 and is involved in the sourcing of the ingredients for the meals. Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 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 standard(s) 16 17 18 Residents rights are protected and they are safeguarded from abuse by staff being made aware of adult protection procedures. EVIDENCE: The home has policies and procedures in place regarding the protection of vulnerable adults and training in this is included in the induction programme for all new staff. Residents spoken to 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. No formal complaints had been received during the previous twelve months. The inspection took place the day before the general election and some residents said that they had used a postal vote while others were looking forward to going to the polling station. Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 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 standard(s) 19,20,21,23,24,25,26. The home is attractive and homely providing a clean and hygienic environment but residents’ safety is compromised by the use of door wedges to hold doors open. EVIDENCE: All areas of the home were visited during the inspection. It was found to be clean and well decorated. Residents’ rooms had been personalised with items of their own furniture, photographs and ornaments. Residents said that they liked their rooms and appreciated being able to bring some of their own things with them when they moved in. Most rooms have en-suite facilities. All residents asked said that the home was comfortable and a nice place to live. They particularly liked the decked area outside the sun room which enabled everyone to enjoy the garden. However, residents’ safety is being compromised by the use of door wedges to hold doors open, particularly those of the residents’ rooms. While it is recognised that some residents prefer to have their doors open while they are in their rooms, a safe system for closing them in the event of a fire or other emergency needs to be installed.
Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 Page 14 Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 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 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) 27,28,29,30 Improvements in staff recruitment and training safeguard residents and provide consistent good levels of care. EVIDENCE: The home has an experienced core group of staff and benefits from having bank staff that can be called upon at times of staff shortages. Additional funding has been made available to increase the weekend staffing levels by one. At night there is one member of staff on duty with another doing a sleepin. Examination of the file of a recently appointed member of staff showed that the correct recruitment procedures had been followed. The home now uses the TOPSS induction programme and at the time of the inspection three staff had completed it and three others were part of the way through. Records also showed that four staff have completed NVQ 2 in care, another is about to start and another is waiting to do NVQ 3. Other staff are undertaking distance learning courses in medication and infection control. The home also provides in-house training a recent example of which was managing continence. Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 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 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) 31,33,35,38 The management style is open and receptive to the views of the residents and others involved with the home. EVIDENCE: The manager, who has over 30 years experience in care, many at a senior level, has completed NVQ 4 and the Registered Manager’s Award. The deputy manager is an NVQ assessor and is starting the NVQ 4 and Registered Manager’s Award. All residents asked stated that the manager was very approachable and that they felt that any concerns or suggestions they might have regarding the running of the home would be taken seriously. During the inspection it was observed that the manager took time to listen to the residents and answer any questions they had. 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. There is a
Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 Page 17 comprehensive manual on safe working practices and there are completed risk assessments for all areas. Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 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. 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 3 x 3 x x 3 Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 19 Regulation 13 Requirement The registered provider must ensure that suitable devices are fitted to all doors which need to be held open, especially those to residents rooms, to enable them to be closed rapidly in the event of a fire. Timescale for action 31/10/05 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 Good Practice Recommendations Southlands D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 Page 20 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 D54-D07 S3805 Southlands V215108 040505 Stage 4.doc Version 1.20 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. 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!
