Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 22/02/07 for Southlands Residential Home

Also see our care home review for Southlands Residential Home for more information

This inspection was carried out on 22nd February 2007.

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.

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

The home is very homely and welcoming, it is well decorated and very clean. A resident said, "its lovely and clean," "they take care of my clothes nicely." The managers and staff know the residents well and spend time making sure they are cared for the way they need to be. A relative said, "the care is really good they have extended her life." Good meals are provided that the residents said that they liked and enjoyed. Many of the staff have a National Vocational Qualifications (NVQ) in care. The residents have good access to health care. A doctor said, "Southlands provide very caring, competent, personalised care to all their residents."

What has improved since the last inspection?

Some areas of the home have been decorated and some windows replaced. All staff have the necessary checks before they start working at the home to ensure residents are kept safe. Residents wheelchairs have footplates on them unless there is a good reason for them not to be fitted and this is written down.

What the care home could do better:

The information that tells people about the home and how to complain could be made more interesting and be easier to understand by using photographs and symbols. Information about what residents like/dislike, their interests before moving to the home and memorable dates and events in their life`s should be gathered and this information used when writing the care plans, (the information that staff need to be able to care for residents the way they want and need to be cared for.) The resident`s files that hold the information that show staff the care people need could be better organised. Dementia awareness training and training in end of life care needs to be provided for the staff working at the home. The home should ask what relatives and other people think about the home and what could be made better so they can make plans for the future.

CARE HOMES FOR OLDER PEOPLE Southlands Residential Home Withins Lane Breightmet Bolton Lancashire BL2 5DZ Lead Inspector Sue Donovan Unannounced Inspection 22nd February 2007 08:30 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 Residential Home DS0000009304.V308233.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 Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlands Residential Home Address Withins Lane Breightmet Bolton Lancashire BL2 5DZ 01204 528369 01204 528369 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) Mrs S A Winterbottom Mr M A Winters Mrs S A Winterbottom Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd March 2006 Brief Description of the Service: Southlands is a privately owned care home providing residential care for older people. It is situated close to a bus route, at the end of short private access road in the Breightmet area of Bolton. The home is a large, detached building with 27 places on two floors. There are 13 single rooms (3 of which have ensuite facilities) and 7 double rooms. The grounds include a car park and large, enclosed gardens. Mrs Winterbottom has jointly owned, managed and worked at Southlands for 18 years. The current charges are £337 for a shared room, £347 for a single room and £357 for a room with ensuite facilities. Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told the inspection was to take place. The site visit took place over a seven-hour period from 8:30am to 3:30pm. The report was written after looking at the information sent to the Commission for Social Care Inspection (CSCI), including comment cards from relatives, residents and doctors. Time was also spent talking to the residents, their relatives, the deputy managers and the staff and walking around the home. During the inspection, care and medicine records were looked at to make sure resident’s needs were being met. The building was inspected to check if it was clean and well decorated and the inspector sat with residents during their lunchtime meal. Other records were looked at to see how the home and the equipment in the home were kept safe. No complaints had been received by the home or by the CSCI since the last inspection. Residents said, “it’s excellent here, you can’t fault it,” “it’s good care, good food, good company,” and “they go out of their way to please you. Make you feel as comfortable as they can, it’s spotless.” Everyone who returned comment cards said nice things about the home. One relative said, “I am highly satisfied with the home and the care received.” What the service does well: The home is very homely and welcoming, it is well decorated and very clean. A resident said, “its lovely and clean,” “they take care of my clothes nicely.” The managers and staff know the residents well and spend time making sure they are cared for the way they need to be. A relative said, “the care is really good they have extended her life.” Good meals are provided that the residents said that they liked and enjoyed. Many of the staff have a National Vocational Qualifications (NVQ) in care. The residents have good access to health care. A doctor said, “Southlands provide very caring, competent, personalised care to all their residents.” Southlands Residential Home DS0000009304.V308233.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 Residential Home DS0000009304.V308233.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 Residential Home DS0000009304.V308233.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): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Up-to-date information is given to residents and their families to enable them to make a decision as to the suitability of the home. Prospective residents have their needs assessed prior to admission to assure these will be met. EVIDENCE: A statement of purpose/service user guide was available to prospective residents and their representatives to help them to decide if the home and the services it provided could meet their needs. The information covered all the required areas and included the aims and objectives, details about the staff, the environment, admissions procedure and how to complain. A small two page leaflet is also available that introduces the home and shows the comforts that residents can expect when choosing to live at Southlands. As Southlands Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 9 is a family business the information introduces the members of the family who currently work at the home and shows their background and experience. An enquiry regarding vacancies was received during the inspection and the service user guide was posted out to the individual supplying them with the information they had requested. Although the information available is clear it could be produced using pictures/symbols and in large print to make it accessible to as many people as possible. Three residents files were looked at and each contained evidence of the homes assessment for both funded and self-funded residents. Two files also held hospital assessments. This information had been used when writing the residents care plans (the information that staff need to be able to care for residents how they want and need to be cared for.) An admissions procedure is followed and includes visiting the prospective resident in hospital or in their home to assess whether the home can meet their needs. The person and their families are encouraged to spend time visiting the home prior to deciding if they want to move in. A visitor said that her family had looked around a few homes before choosing Southlands saying, “ it’s excellent here, the care is really good they have extended her life.” It was discussed with the deputy manager that more information would be beneficial about resident’s likes/dislikes, interests and hobbies, memorable family and life events and social contacts. One assessment showed that the resident “would like to be kept busy” but the only other information was “likes T.V.” This information could be gathered as part of the admissions process and added to as the home got to know the resident and their families and representatives. This could then be used to make sure that resident’s interests were continued whilst living in the home. One resident said, “ I used to live at another home but I wasn’t happy so I moved here. It’s lovely here,” and another said, “ my daughters looked round a lot before choosing here.” All residents that were spoken with said that they felt they or their families had made a good decision choosing Southlands when they had needed to move into a residential home and one relative said, “ I am highly satisfied with the home and the care received.” Southlands Residential Home DS0000009304.V308233.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system in place provides staff with sufficient information for them to meet the resident’s health and personal care needs. However very little information is available showing how residents like to spend their days. The medication system was safe ensuring the residents received their medicines safely and correctly but storage of some medicines could be improved. EVIDENCE: Three care plans were looked at. The plans contained information about how to care for the residents. Completed care plans showed health and personal care needs and recorded the actions needed to meet these needs. There was evidence on all three files that these were being reviewed on a monthly basis. Monthly care plan reviews were carried out but only recorded basic details showing any changing needs of residents. The care plans did not include Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 11 details of residents preferred activities (how they like to spend their days and preferred routines). Activities sheets on the files seen showed that residents had been offered or had joined in some activities over the last twelve months but very few. Care plans recorded the involvement of doctors, district nurses and other health care professionals including visits from the chiropodist and optician. Residents were weighed at least monthly and their weight monitored. Four doctors returned comment cards and all were positive regarding the care provided by the staff at the home. One doctor said, “Southlands provide very caring competent personalised care to all their residents.” Daily records were not held on resident’s files. A daily logbook was kept and this showed any concerns or changes regarding residents, some of this information was then used to update care plans. It is recommended that resident’s files be audited and tidied into sections (assessments/care plans/ daily logs etc) to ensure that information is comprehensive, accessible and current. Residents spoken with considered they received “good care” describing it as “excellent, I can’t fault it,” “very good in all ways” and “they go out of their way to please you. Make you feel as comfortable as they can.” A relative said, “she gets the care she needs,” “they look after the residents very well.” Risk assessments were in place and up-to-date and covered areas such as use of wheelchair, slip, trips and falls, and moving and handling. Risk assessments had been reviewed and altered as necessary. Activities at the home, (see life and social activities section) including a weekly gentle keep fit session, helped some residents to keep active. Residents said that they enjoyed going out into the garden when the weather permitted. A medication policy and procedure was in place. Only staff trained administered medication. Two staff had recently (February 2007) completed training with the primary care training group in the administration of medication and certificates seen confirmed this. Most medication was supplied by the pharmacy in a monitored dosage system. Medication appeared to be given and signed for correctly. Resident’s photographs were attached to record sheets to ensure medication was administered correctly. The home does not currently have a lockable medication fridge. It is recommended that one be purchased for the safe storage of medicines or alternatively medicines currently stored in the kitchen fridge should be moved into a lidded box marked ‘medication’. Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 12 It was noted that the lunchtime medication was administered after residents had finished eating. This is good practice not disturbing residents during their meal. On the day of the inspection site visit observations showed that personal care and hygiene needs were met in a discreet and sensitive way. Staff were observed knocking on doors and explaining to residents where they were taking them when assisting them with personal care or to go back to their rooms. All residents’ rooms have a call system. Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. Some activities are provided for the benefit and enjoyment of residents. Visiting arrangements are good, ensuring links between residents and their families are maintained. Food was well balanced and nutritious but a limited choice was available for residents. EVIDENCE: The home does not employ an activities co-ordinator but does organise some activities for residents to take part in. On Mondays a hairdresser works in the home. A physiotherapist who is a volunteer organises a gentle keep fit session each Thursday. This activity was observed on the day of inspection and twelve ladies took part and seemed to be enjoying being encouraged to stretch and move around within their capabilities. Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 14 Every other week a craft instructor runs a session at the home and staff sometimes organise games on other days of the week. A resident said she sometimes enjoyed a game of dominoes. Many residents said they enjoyed spending time in the extensive gardens, one lady said, “I like to sit out near the apple trees in warm weather.” A few community activities were available and during the last twelve months a boat trip and shopping trip had been organised for some residents. The home also arranges for local community groups to provide entertainment within the home especially leading up to Christmas and evidence of concerts were seen. However one resident did say that she would enjoy more to do during the day and two surveys returned by residents said they ‘usually’ had enough to do during the day. The home should consider how they could extend their activities programme to provide a range of choices for residents who wish to be offered activities. The home had an open visiting policy. A relative said, “I visit whenever I want.” Residents can see their visitors in the lounges or in their rooms. The visitor’s book showed the frequency and the variety of times that visitors had called at the home. The Church of England hold a communion quarterly and each Saturday a service is held. Some residents have visits from their own ministers. The choices made by residents each day varied. Residents are generally free to choose what time they get up, what time they go to bed, what clothes to wear and how to spend their day. Menus inspected were seen to provide a nutritious and varied diet over a fourweek period. Although the menu only showed one option at lunch and dinner, residents said that if they did not like what was on the menu an alternative would be provided. The home should provide a choice at each mealtime for residents to choose between. The home serves the main meal of the day in the evening. Lunch was observed. The dining room was clean, well furnished and set with tablecloths and matching condiments. Staff served the residents giving appropriate assistance to those who needed it. The atmosphere in the dining area was good, the meal was unhurried and staff checked with residents if they had the drink they wanted and that they were happy with everything. Additional portions were offered and accepted by some residents. Both residents and relatives were complimentary about the food provided saying, “we are fed well, the cooks good,” “lovely food, can’t grumble” and “ it’s good care, good food, good company.” Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 15 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives were confident their concerns would be listened to, taken seriously and acted upon. Appropriate systems were in place to protect residents from abuse. EVIDENCE: The home has a complaints procedure and this is included in the Statement of Purpose/Service User Guide. The home would benefit from displaying a userfriendly complaints poster in the entrance to the home for visitors (both family and professionals) to view. Residents and relatives spoken with said that they knew to see one of the managers if they wished to raise a matter of concern. A complaints log was available but no complaints had been documented in the last twelve months. A previous complaint documented showed that the home had investigated it appropriately. It was discussed with the deputy manager the need to document all complaints in order to show that the home is responsive to peoples concerns and uses them to improve the service provided. The CSCI had not received any complaints about the home since the last inspection. The home had received a number of compliment cards and messages showing peoples satisfaction with the care provided at the home. Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 16 A procedure for responding to allegations of abuse was available (including a whistle blowing policy) as was the Bolton inter-agency safeguarding adults policy. Staff spoken with understood the importance of reporting bad practice and said they would report it immediately to the manager. Staff had received training in the protection of vulnerable adults (POVA) as part of their induction and during completion of National Vocational Qualifications. The home has a POVA training video. The manager was reminded that all staff must attend refresher training in the protection of vulnerable adults every two years. Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe, clean, pleasant, hygienic and well-maintained home/building was provided for residents. EVIDENCE: Southlands Residential Home is situated in the Breightmet area of Bolton. The home has extensive well-maintained gardens and ample parking is available for both staff and residents. The home was safe and well maintained with a high standard of cleanliness throughout. A relative said, “ it’s very clean” and a resident said, “they make you feel as comfortable as they can, it’s spotless.” Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 18 The home is on two floors and has a passenger lift for residents use. The ground floor has four small, homely lounges and a large dining area. Toilet areas were situated close to lounge areas and were fitted with grab rails. Baths were fitted with hoists and two level access showers were provided. The home was well decorated and had quality furniture and fittings. The manager continuously improves and maintains the environment and is planning on replacing some window frames, decorating the landing and replacing the carpet during 2007. The entire home was very clean, hygienic and free from unpleasant odours on the day of inspection. Policies and procedures were in place with regard to infection control. Staff were provided with disposable gloves and other personal protective equipment. Liquid soap and paper towels were situated near to hand washing facilities. Staff were observed to be maintaining good hygiene practices. Environmental health had visited 5/5/06 and the action required (re- artexing the pantry ceiling) had been implemented. The laundry area was sited away from food preparation areas and was seen to be clean and orderly. Sufficient and suitable equipment was provided and the laundry was attended to efficiently. It was the night staffs duty to wash all clothing and iron and day staff returned the washing to residents rooms. All residents clothing looked pressed and well cared for. One lady said, “ they take care of my clothes nicely.” Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 19 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. Sufficient numbers of staff are provided to meet the needs of residents. Recruitment and selection policies supported and protected residents. The majority of staff are trained and are competent to do their jobs. EVIDENCE: Inspection of rotas showed that the home currently had on duty five staff in the morning, four staff in the afternoon and evening and two staff on night duty. Carers spoken with felt that there were enough staff to meet the needs of the residents presently living at the home. Observations showed that residents had good trusting relationships with staff. Residents said, “they are lovely,” “they look after you here,” “the girls are smashing.” Staff spoken with said that they enjoyed working at the home. “It’s good working here. It’s well organised,” “ I like helping residents to be comfortable and smart” and “it’s a good staff team.” The home has encouraged staff to undertake National Vocational Qualification (NVQ) training and has provided time, help and support for staff to complete Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 20 the award. 80 of care staff have a minimum of NVQ 2 in care qualification and two domestics have a NVQ 1; cleaning and support services. Both deputy managers have The Registered Managers Award. This is good practice. Inspection of four staff files showed that Criminal Records Bureau (CRB) checks, which the home had applied for, were all in place. Other recruitment procedures were satisfactorily followed, interview notes were kept and two satisfactory references had been obtained. Evidence was seen to show induction was provided when staff started to work at Southlands. The home ensures they are additional to the number of staff on the rota for two weeks. During this time they get to know residents, shadow experienced staff and read the homes guidelines that show the standards that are expected from staff. These included ‘getting a resident up from bed’ ‘ bathing’ and ‘in the event of a person falling.’ New staff also attend Bolton Councils social care induction programme that includes moving and handling, food hygiene, employee responsibilities, safe use of equipment and fire safety. Records showed that some staff had received very little training in the last twelve months. Of the four files looked at one carer had attended two one day courses, Moving and Handling and fire training, and three had attended one days training. It is recommended that a training matrix is developed showing when staff have attended training and when they are due for refresher training. It was discussed with the deputy manager that specific training should be sourced in Dementia Awareness and End of Life Care. These would give staff additional knowledge to be able to meet the needs of some residents currently living at the home. A relative said, “we have no complaints what so ever. The staff are really good. We are kept in contact with, she is in safe hands.” Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 21 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 home has an effective management team. Some quality assurance systems are in place to ensure residents and staff can voice their opinions. The home ensures that resident’s monies are safeguarded and has good systems for ensuring the health and safety of residents. EVIDENCE: The registered manager is a registered nurse who has many years of experience. The two deputy managers have both gained the Registered Managers Award. Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 22 The two requirements made at the last inspection have been met. The home has an open door policy for the residents and their relatives who confirmed that they feel they can speak to the managers about anything. They are holders of the Investors in People Award. This was renewed in November 2006 and the report was very positive about the home. Staff meetings are held quarterly and staff confirmed that they attended meetings on a regular basis and found them useful. There was no evidence of residents meetings and these could be considered. No surveys had been completed in the last twelve months. The deputy manager felt that they got verbal feedback from relatives and had encouraged them to complete the CSCI comment cards (six comment cards had been returned from relatives and four from residents). A survey should be considered to include other stakeholders, district nurses, social workers and other health care professional. The system for safeguarding resident’s money was good. Their relatives generally undertake the management of resident’s finances. Only personal allowances are held for any purchases or to pay for example hairdressing. Money was found to correspond to the log for the residents that were checked. The manager supervises staff on a day-to day basis. Staff said “ the managements good” “I get on well with the managers, if you have a problem you can discuss anything with them,” and “ they are nice, fair. Helpful with work if I need information.” Staff receive around two formal supervisions per year. The manager should increase this to six documented 1-1 sessions in a twelve-month period. Some of this responsibility could be delegated to other senior staff. The home had a health and safety policy. Regular weekly checking and testing of the fire detection system took place. It was noted that although the water temperatures are regulated with thermostatic valves the temperatures are not being tested in between services. All hot water outlets should be tested at least monthly and these recorded to ensure the water is maintained at the correct temperature for residents safety. Portable electrical appliances had been tested on 17th January 2007 but the office equipment had been missed this should be undertaken. The accident record book was seen and was being completed for all minor and more serious injuries. Staff had been reminded to record all accidents in the book at the last staff meeting. Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 23 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 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 3 X 2 X 3 2 X 3 Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 24 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. 1. Standard OP12 Regulation 16 (m)(n) Requirement The home should consult with residents and consider how it can extend its activities so residents have a range of options with regard to recreation available to them. Timescale for action 30/04/07 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 OP1 Good Practice Recommendations The Statement of Purpose/Service user guide could be produced to include photographs, symbols and in large print to ensure that the information provided is accessible to all. The manager should obtain more information about resident’s life’s including likes/dislikes, interests and memorable life events. This information should be used when developing care plans Residents files and care plans should be audited to ensure they are organised, easily accessible to staff and daily logs are kept showing the health, wellbeing and chosen activities on any particular day. DS0000009304.V308233.R01.S.doc Version 5.2 Page 25 2. OP3 3. OP7 Southlands Residential Home 4. OP9 5. 6. OP15 OP16 7. OP30 8. OP30 9. 10. OP33 OP38 The manager should consider purchasing a lockable medication fridge for the safe storage of medicines or alternatively medicines currently stored in the door of the kitchen refrigerator should be stored in a lidded box marked ‘medication’. The menu should provide alternatives for residents to choose between at each mealtime and take into account the known likes of residents. A user-friendly complaints poster using photographs /symbols should be displayed in the entrance that would enable relatives, visitors and professionals to view the procedures as they entered the home. Training should be sourced in dementia awareness and end of life care to ensure staff have the knowledge they need to meet the needs of some residents currently living at the home. A training matrix should be developed showing when staff have attended training and when they are due for refresher training to ensure all staff attend the mandatory training they require. A survey should take place of residents, relatives and other stakeholders to ensure everyone’s views are taken into consideration when planning for the future. All hot water temperatures should be tested monthly to ensure the safety of residents. Southlands Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Residential Home DS0000009304.V308233.R01.S.doc Version 5.2 Page 27 - 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!