Inspection on 23/01/07 for Southlawns

This inspection was carried out on 23rd January 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.

Other inspections for this house

Southlawns 26/02/09

Southlawns 12/01/06

Southlawns 01/09/05

Southlawns 26/01/05

Southlawns 20/08/04

Southlawns 26/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Southlawns Highfield Road Street Somerset BA16 0JJ Lead Inspector Ms Sue Hale Unannounced Inspection 23rd January 2007 09:30 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 Southlawns DS0000016004.V324936.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. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlawns Address Highfield Road Street Somerset BA16 0JJ 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) 01458 443635 01458 448860 Somerset Care Limited Mrs Vera Margaret Fellows Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Southlawns is a care home providing up to 40 places for older people. It is owned by Somerset Care Ltd, a Somerset based company with 25 care homes and a domiciliary care service. The home is based in a residential area in Street, close to the High Street where there are shops and other amenities. The home is in two floors and the first floor is accessible by a through-floor lift. All bedrooms are single, with either en-suite facilities or with wash hand basins. The home has undergone extensive upgrade over the last two years, considerably improving the whole physical environment. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first key inspection of Southlawns residential home using the Inspecting for Better Lives methodology introduced by the Commission for Social Care Inspection in 2006. The inspection methodology enables the Inspector to make a judgment on the service delivery based on the quality of the outcomes for residents. The inspector looked at selected resident and staff files and other documents including policies and procedures relevant to the running of the home. The Inspector undertook a tour of all the communal and domestic areas and viewed some residents’ private rooms. Surveys were sent out to some residents, some relatives/representatives and medical, health and social care professionals who visit the home. The responses and comments received are incorporated into this report. The current fees are between £361 and £430. What the service does well: The home produces a statement of purpose and service user guide that is clearly written and gives detailed information about the home to enable prospective residents to make an informed decision about residency. Both documents make clear the home can and does accommodate all members of the community and is sensitive to individuals’ differences, life experiences and culture. Clear information about the terms and conditions of residency at the home is given to each resident and includes general information about the facilities available and what residents can expect to be provided. All residents receive a full comprehensive needs assessment before admission to make sure that the home is able to meet their health, social and care needs before they move in. All residents have individual care plans and risk assessments, which details all their care needs and provides clear and detailed guidance for staff on how to meet such needs. Residents have access to health, social and medical professionals as necessary both within the home and in the community. Three surveys were returned by GPs all of whom were satisfied with the standard provided by the home and their relationship with medical professionals. Residents right to privacy and dignity is respected and an integral part of the homes culture. The home has an activities coordinator who creates meaningful activities and experiences in line with residents’ preferences and abilities. Residents are Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 6 actively encouraged to keep in contact with family and friends and visitors are made welcome to the home. The practice of the home is to encourage residents to have as much control over their lives as they are able. One resident surveyed said that they were ‘very happy’. The majority of relatives surveyed said that the home always or usually met individuals’ differing needs. Residents are very satisfied with the standard of food served at the home and mealtimes are considered social occasions to be enjoyed. Residents said that the food ‘was lovely’ and ‘very good’. Residents and others associated with the home state that they are extremely satisfied with the service provision, feel very safe and well supported by the manager and the staff team. Policies and procedures to protect the residents are in place and staff aware of the right way to manage any such issues. Southlawns offers a well maintained, warm and welcoming environment for residents and encourages them to have as much control as possible over their surroundings. Relatives and friends are welcomed into the home. The majority of relatives surveyed were very positive about the service offered by the home and comments included ‘excellent’ and ‘provides a good standard of care’. Infection control procedures are in place to protect residents and staff. Appropriate laundry facilities are provided and residents satisfied with the service they receive. Appropriate recruitment and selection procedures were in place to safeguard and protect residents. All staff has access to appropriate training and support to enable them to provide a good standard of care for residents and currently there are 59 of staff who are qualified to NVQ level 2 or above. The management of the home is very effective and provides a positive culture for staff and residents. Health and safety policies and procedures were in place to safeguard residents and staff. What has improved since the last inspection? What they could do better: Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 7 The adult abuse policy should be reviewed and updated to reflect current good practice and locally agreed procedures. The whistle blowing policy should make clear employees rights to contact Public Concern at Work and include its telephone number. Consideration should be given to redecorating the kitchen to reduce the risk presented by flaking paint. 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. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 8 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 Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 9 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): 1,2,3. Standard six is not applicable to the service Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide gives clear information about the aims and objectives and philosophy of the home. Clear information about the terms and conditions of residency is given to each resident. Good planning and careful consideration is in place before residents move into to the home. EVIDENCE: The home produces a service user guide that tells prospective residents and their relatives/representatives about the facilities and services available at the home. It is clearly written and includes colour photographs so that readers can Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 10 see what the home looks like. It is currently being revised to include details of staff qualifications and reference to where the latest CSCI inspection report can be obtained or viewed within the home. The home also produces a statement of purpose that is clearly written and includes all the information required in the national minimum standards. Both documents can be made available in accessible formats according to individual needs. Each resident is provided with a statement of terms and conditions about residency at the home. This is clearly written in plain English and gives the residents a very clear understanding of what they can expect. It also includes general information about the facilities available at Southlawns. The home accepts respite and ‘step down’ placements as well as permanent admissions. Southlawns also has a ‘block contract’ with the Primary Care Trust for fifteen of its beds. Day care provision is provided for an average of six – seven persons per day. The manager and the deputy undertake pre admission assessments and careful consideration is given to the needs assessment for each prospective resident before agreeing they can move into the home. Prospective residents and their relatives/representatives always have the opportunity to visit and spend time in the home before making a decision about residency. Many of the residents spoken to told the inspector that they had spent time in the home as a day care client or had visited for respite care before moving in permanently. All admissions are on a four-week trial basis and then reviewed before the placement is confirmed as permanent. Where the assessment has been undertaken through care management arrangements the manager and deputy make sure that they receive a summary of the assessment and a copy of the care plan. The manager and the deputy showed a good awareness of the importance of seeing residents as individuals and were respectful of residents’ cultural backgrounds and needs. Residents who wanted to share a room would be supported to do so and their right to privacy respected. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 11 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. Care planning and risk assessments are detailed to individuals needs and ensure that all residents receive a good standard of care. Residents have access to health and medical professionals whenever necessary. Medication practices are well organised and protects residents health and well being. Residents right to privacy, dignity and to be seen as an individual is a key principle of the homes culture. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 12 EVIDENCE: The inspector looked at several residents’ personal files. The care plan is used as working tool and is understood by all staff. It is written in clear language and details specific care needed by individual residents. Each care plan includes a comprehensive risk assessment covering falls, nutrition, moving and handling and other issues according to individual need. There was clear evidence that care plans were reviewed and updated regularly and the residents and their relatives/representatives were involved in decision-making. There was evidence on one file checked, that the intensive support and care provided by the home since admission had led to a significant improvement in the individuals’ health and well being. One social care professional commented that at all times ‘Southlawns have demonstrated a good awareness and understanding (of individuals problems) and intervened appropriately’. Regular meetings are held between Mrs Fellows, the deputy and medical and health professionals. Staff actively promote the residents right of access to the health or remedial services they need, both within the home and in the community. Regular appointments are seen as important and other systems in place to make sure residents are reminded and appointments are not missed. Staff keep a regular check on health aids, making sure they are working effectively and that each resident has the necessary aid to improve their quality of life. Residents are encouraged to be independent and responsible for their own personal hygiene where possible. Residents at risk of developing pressure sores are referred to the district nursing service and equipment such as cushions and mattresses are provided. The need to respect residents’ privacy and dignity when delivering health and personal care is a principle of the homes aims and objectives. Staff are made aware through induction and foundation training of the need to respect residents right to privacy and dignity. Residents spoken to confirmed that staff knock on the doors of their private room before entering and that they are always treated with courtesy and respect by staff. The home strongly promotes independence and those residents assessed as being able are encouraged to and facilitated to keep, and take their own medication. Medication is managed by Mrs Fellows, the deputy and senior staff who have all undertaken relevant training. Medicines are stored appropriately and securely and are managed in line with the organisations policies and procedures. The community pharmacist visits regularly and undertakes their own audit. Residents said that the home was friendly. There are several lounges and private outdoor spaces at the home for residents to use. There is an enclosed Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 13 phone booth for residents to make calls in peace and privacy. Residents are also able to have a telephone line fitted within their private room at their own expense. There is a treatment room offering privacy when a community health care professional visits for a resident’s individual consultation. Records were seen that showed that residents had ready access to opticians, dentists, audiology and podiatry. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 14 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 excellent. This judgement has been made using available evidence including a visit to this service. The home has an activities coordinator who creates meaningful activities and experiences in line with residents’ preferences and abilities. Residents are actively encouraged to keep in contact with family and friends and visitors are made welcome to the home. The practice of the home is to encourage residents to have as much control over their lives as they are able. Residents are very satisfied with the standard of food served at the home and mealtimes are considered social occasions to be enjoyed. EVIDENCE: There is a part-time activities coordinator employed at home and forthcoming events are displayed on a notice board in the dining room. The activity programme for February included quizzes, reminiscence, music and Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 15 movement, bingo, coffee morning, a Valentines event and a celebration of the Chinese New Year. On the day of the inspection the dining room was still decorated from the Chinese New Year celebrations and all the residents spoken to told the inspector that they really enjoyed the Chinese food tasting and finding out their ‘Chinese horoscope signs’. Residents who are independent are supported to go out locally with risk assessments in place based on individual needs. . Key worker care staff also have 1:1 allocated time to spend with their residents in order to do in-house activities or time for a chat. There is a small shop at the home so that residents are able to have some control and buy things they need to themselves. Residents told the inspector that they had enjoyed trips out to Burnham on Sea and to other local attractions. The routines of the home are as flexible as possible to reflect the needs, preferences and choices of people living there and residents spoken to confirmed that this was everyday practice. Care plans seen reflected the staff culture of supporting and encouraging residents to be as independent as possible and retain existing life skills. All the residents spoken to told the Inspector that their visitors are always made welcome and were able to come to the home at times to suit them. Residents are able to see their visitors in their own rooms or in one of the several communal lounges. The menu at the home follows the organisations corporate policy and has been drawn up in conjunction with a dietician. A menu giving details of the choices available for all meals on that day was on each dining room table. Tables were well laid with tablecloths, napkins, condiments and individual teapots. The Inspector observed breakfast and the atmosphere in the dining room was relaxed and unhurried with staff assistants available as necessary. All the residents spoken to were very positive about the quality and variety of food served at the home. One resident had a birthday on the day of the inspection and the cook had made and iced a birthday cake. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 16 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 others associated with the home state that they are extremely satisfied with the service provision, feel very safe and well supported by the manager and the staff team. Policies and procedures regarding protection of residents are in place and need minor updating to reflect current good practice. EVIDENCE: Neither the home nor the Commission for Social Care Inspection has received any complaints since the last inspection. The home has a corporate complaints policy that is readily available to residents, visitors to the home and staff. The home also keeps records of any compliments received from residents or relatives/representatives and several of these had been received since the last inspection all of which were very complimentary about the service provided by the home and included ‘thanks for all care and kindness shown’ of a former resident and also a thank you’ for taking such a wonderful care of me’ from current resident who have been given a card and present on their birthday. All residents spoken to were clear that they could raise any concerns or issues with Mrs Fellows or any senior member of staff. All relatives surveyed were clear that they could raise any concerns or complaints with the manager. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 17 The home has a policy and procedure on the protection of vulnerable adults and this is available to all staff. The information on action to be taken by the manager should a serious allegation be received needs to reflect the advice given in Safeguarding Vulnerable Adults Adult Protection in Somerset Multi Agency Policy and Practice Guidance. However, all staff spoken to on the day the inspection was aware of the correct local procedure to follow. Appropriate recruitment checks are undertaken of new staff to ensure the protection of people living at the home. The home has up-to-date policies giving staff advice on how to manage physical and verbal aggression by residents. The homes policies make it clear to staff that they cannot accept gifts from residents and cannot assist with or benefit from residents wills. The home has a whistle blowing policy. However, the emphasis is clearly on reporting concerns within the organisation and it does not mention employees right to contact Public Concern at Work. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 18 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, 24, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Southlawns offers a well-maintained, clean and tidy environment for people live there. All residents are encouraged to personalise their rooms to reflect their individual preferences and tastes. Appropriate laundry facilities are provided and infection control procedures in place to protect residents and staff. EVIDENCE: The home was clean, comfortable, tidy and warm on the day of inspection and there were no unpleasant odours. The home was well maintained and meets the needs of all residents including those with disabilities. All bedrooms are for Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 19 single occupancy and rooms are routinely decorated when a room vacancy occurs. Residents are able to bring in small items of furniture within the space constraints of their room and are able to redecorate to their own choice if they wish to. All residents’ private rooms seen by the inspector had been personalised and reflected individuals tastes and preferences. One relative surveyed said that they were satisfied with the ‘overall cleanliness’. Some areas of the home have been redecorated since the last inspection. The grounds of the home are kept tidy, safe and are accessible to residents. However, the kitchen needs redecoration as some walls have flaking paint in some areas that could potentially cause a hazard. Some hallway carpets are worn from wear and tear and would benefit from replacement. There are robust infection control measures in place at the home. Visitors are requested to use alcohol gel on their hands that is provided in the foyer when entering and leaving the home. There are liquid soap, paper hand towels and flip top bins provided in bathrooms, toilets and bedrooms where personal care is provided. Staff wear gloves and aprons when attending to personal care tasks. The laundry is equipped sufficiently to manage cross infection and infection control in the home. There are two sluices with bedpan washers for managing commode hygiene. Staff receive statutory training in the Control of Substances Hazardous to Health (COSHH). The standard of domestic cleanliness on the day of the announced inspection was good. The home is warm with radiators protected to prevent burning injuries. Hot water is controlled at source to prevent scalding injuries to residents in bathrooms and the home has a maintenance contract to monitor the risk of Legionella. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 20 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 staff are employed to meet the needs of residents, Residents have confidence in the staff that care for them. Recruitment and selection procedures ensure the protection of residents. Management recognises the benefits of a skilled, trained workforce and encourages staff to obtain relevant qualifications. The majority of care staff is qualified to NVQ level 2 or above. EVIDENCE: There is a staffing structure of management, administrator, care supervisors, care staff, care support and ancillary workers. Copies of four weeks staffing rosters were supplied as part of the pre-inspection questionnaire. The home was fully staffed on the day of the inspection. There are two vacant care assistant posts that have been advertised. The staff rosters take into account day care provision at the home in addition to permanent resident numbers. The manager has some flexibility in the staffing budget to increase both day and night staff according to individuals needs for a short period of time. However, whilst the majority of relatives surveyed were confident that there was sufficient staff two commented that ‘more staff’ were needed. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 21 Residents spoken to said that ‘staff were busy, but come if you need them’ and that staff were ‘very good, always helpful’. Although one resident surveyed said that ‘some staff are more helpful than others’. A social care professional surveyed described the staff as ‘caring and professional’. Information provided by the home showed that 59 of staff is qualified to NVQ level 2 or above which means that they have the skills and experience to provide a good standard of care. Supervisory staff go on to complete level 3. Kitchen staff and other ancillary workers are also supported to achieve NVQ awards in their job disciplines. There are NVQ care assessors as part of the staff team. There are manual handling trainers on the staff team and supervisory staff are given specific role training such as for health and safety or infection control to enable them to advise staff or complete health and safety or infection control risk assessments for the home. The home has an annual staff training plan, covering both statutory and staff training suited to the clinical needs of residents. New staff work ‘shadow’ shifts with experienced staff until they are confident in carrying out their work. The staff files of three new workers were checked and they contained all the documentation required in the national minimum standards including, two references, proof of identity, and evidence that POVA first and CRB checks had been carried out. The organisations application form had recently been revised to comply with new age discrimination legislation. A job description is sent out with application forms and all staff are given terms and conditions of employment at the end of their probationary period. Induction is linked to Skills for Care common induction standards and all new staff was currently doing induction training. Employees were not given individual copies of the General Social Care Council code of conduct. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 22 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, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is skilled and effective and promotes a positive culture within the home for staff and residents. Quality assurance systems are in place to ensure the quality of service is audited. Financial polices and procedures are in place to safeguard residents monies. Health and safety is taken seriously and safeguards staff and residents. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home has a full-time manager and deputy manager, both of whom have worked together for sufficient time to establish managerial specific responsibilities for the home. The deputy manager is currently undertaking the registered managers award and the manager, Mrs Fellows is skilled, experienced and suitably qualified. The managers often work alongside care staff for shift cover and this can be either day or night duty. This allows managers to have hands on knowledge of resident’s needs and staffing pressures, if any. Regular staff meetings are held with all staff encouraged and supported to attend. Minutes are kept and these showed that a range of relevant topics are discussed and staff involved in the day to routines of the home. All staff spoken to were very positive about the level of support and encouragement they received from Mrs Fellows and the deputy manager. Staff confirmed an open door management style that encouraged people to feel valued and work together to provide a high standard of service to residents. Seven surveys were returned by staff, which confirmed that they receive appropriate training and support from the management team. The home undertakes regular quality assurance checks in line with Somerset Cares policies and procedures. Residents and relatives are surveyed and the results collated and audited to review the quality of the service provided. Mrs Fellows and the deputy manager have recently undertaken an audit of medication practice and care plans to make sure that policies and procedures are followed and that staff follow good practice. The home has a residents finance policy and procedure and the inspector checked the personal allowance records of residents that were being case tracked and all were found to be correct. Information provided by the home showed that equipment was well maintained and regularly serviced to ensure that the health and safety of residents and staff was maintained. A fire risk assessment had been updated in 2006 and was detailed and specific to the home. Records were kept in the kitchen to show that fridge and freezer temperatures were regularly checked. A cleaning schedule was in place and the kitchen clean and tidy on the day of the inspection. All mandatory training is undertaken and updated in April with moving and handling training taking place within the home. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 24 All accidents were recorded by staff and audited and evaluated by Mrs Fellows and the deputy manager. The inspector crosschecked accident and care planning records and all were found to be correct. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 25 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 3 3 X X N/A 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 X X 3 Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 26 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 OP18 OP18 Good Practice Recommendations The adult abuse policy should be reviewed and updated to reflect current good practice and locally agreed procedures. The whistle blowing policy should make clear employees rights to contact Public Concern at Work and include its telephone number. Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Southlawns DS0000016004.V324936.R01.S.doc Version 5.2 Page 28 - 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. 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