Inspection on 18/08/08 for Southlea Residential Care Home

This inspection was carried out on 18th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southlea Residential Care Home 18/07/07

Southlea Residential Care Home 13/09/06

Southlea Residential Care Home 12/10/05

Southlea Residential Care Home 06/05/05

Southlea Residential Care Home 04/11/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Southlea Residential Care Home 23a Cross Lane Radcliffe Manchester M26 2QZ Lead Inspector Lucy Burgess Unannounced Inspection 18 August 2008 09:30 th Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 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 Southlea Residential Care Home DS0000061330.V368947.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 Adults 18-65. 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. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlea Residential Care Home Address 23a Cross Lane Radcliffe Manchester M26 2QZ 0161 280 9841 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) southleacarehome@supanet.com Southlea Limited Manager post vacant Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should at all times employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection 18th July 2007 Date of last inspection Brief Description of the Service: Southlea is a privately owned care home registered to provide care and support for up to 5 people with mental health needs. The fee charged by the service is £355.11 per week. The home is a large Victorian property situated on a main road in the Radcliffe area of Bury. It is close to several amenities and has good transport links. The metro-link is close by and Bury is a 5-minute bus/tram ride away. Accommodation is provided in single rooms with en-suite facilities. The home provides practical and emotional support 24 hours a day from staff with training in, and knowledge of, mental health needs. Staff work closely with other professionals to ensure that the needs of service users are met and reviewed. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a key inspection, which included a site visit and took place over one day for a period of 5½ hours. The service did not know that the inspector was going to visit. As part of the inspection process the provider was asked to complete a selfassessment survey information document (Annual Quality Assurance Assessment). This was sent to the home before the inspection and had been completed by the provider and returned to us prior to the site visit. Information provided was limited and could be expanded upon to demonstrate the future plans of the service and how they intend to achieve this. During the visit we spent time looking at care records as well as information about the staff and health and safety. Other information was gathered from the feedback surveys we sent out. We received completed surveys from people at the home, 2 relatives and 2 staff. Staff were also spoken with during the visit. Comments made have been added to the report. Discussion and feedback was held with the manager during the visit. Because of our findings we have asked for an improvement plan from the organisation to tell us what they are going to do to improve the service. What the service does well: Southlea is a small home providing comfortable, homely accommodation for those living there. Some of the people have lived at the home for a number of years and continue to be very settled. We spent time talking with the manager and staff. It was clear that they have a good awareness of the needs of people and the support they require. Comments were received from people at the home and their relatives. The two relatives who provided feedback were overall satisfied with the support provided. One person described the service as ‘giving a personal family style of support’. The other said, ‘I feel the home is run to a high standard’ and ‘ would probably be very difficult to better’. Both felt that the staff have the skills to support peoples needs and that they were kept informed of any issues. A person living at the home also expressed; ‘the home allows me to live my life as I would wish, with support and guidance’. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 6 Staff confirmed that they were provided with relevant training, felt supported in their role and that they occasionally met with the manager. One staff member spoken with felt the new manager had sorted out certain things quickly. What has improved since the last inspection? What they could do better: The home has been without a registered manager for some considerable time. This must be addressed without further delay. A comprehensive assessment must be carried out on all new people referred to the home so that they are sure that people coming to live at the home can be supported in a way, which fully meets their needs. Care plans need to include detailed information about the person, their needs, goals and wishes so that staff support them in a way they choose. Individual risk assessments need to be completed in areas of potential risk to ensure that people are safe and not placed at risk of harm. Medication records need to be improved ensuring information is accurate and practice followed by staff is safe. All staff should receive training in relation to the local authorities safeguarding adults training so that they are clear of the procedure to follow should an allegation be made. Confirmation of the recent POVA referral made by the provider should be forwarded to us. A robust system must be in place when recruiting new staff so that people are not placed at risk. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 7 Arrangements must be made ensuring all staff receive regular training, including induction and supervision so that they have the knowledge and skills needed to carry out their role, as well as ensuring their continued personal and professional development. A copy of the staff training matrix and plan should be forwarded to us. The manager must ensure that any incident, which occur that may affect the well being of people at the home are reported to us in line with regulation 37 along with the action taken. An annual business plan should be developed showing how they intend to develop the service whilst considering the views of those living at the home. A copy of the report should be distributed to people using the service as well as other stakeholders including the CSCI. Arrangements should be made for a fire drill and periodic checks to all water outlets ensuring people are safe. 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. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Without clear and detailed assessment information there is no assurance that the placement is suitable and needs will be met. EVIDENCE: Two people have moved into the home since we last visited in July 2007. On the first file this person had previously lived at the home. Information was seen with regards to the manager and owner visiting their home to carry out an assessment to establish their support needs. The pre assessment document had been completed and showed what skills and abilities the person has as well as areas they would need support with. With regards to their mental health needs, nothing had been recorded other than their diagnosis. There was no information with regards to behaviours displayed, possible triggers, strategies used to support the person or their current mental health status. In relation to the second person the staff on duty informed us that this person had spent the last 12 months in hospital and had a history of non-compliance with medication. Information had been provided from the funding authority with regards to an up to date Care Programme Plan (CPA). An assessment document had also been completed by the home. This contained similar Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 10 information to the first file examined however again there was no information with regard to the person’s diagnosis, why they had been detained in hospital, behavioural issues or areas of potential risk. The home is registered to provide care and support for people with a formal mental health diagnosis. Therefore assessment information should focus on their specific needs. Without such information there is no assurance that the placement is suitable and their needs will be met. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the support needs of people should provide clear details and direction for staff so that people are supported safely and their needs are fully met. EVIDENCE: Care files were also looked for the two new people. Information was orderly and included personal information, assessment, care plan, risk assessment, diary notes, professional appointment, CPA review minutes, personal care charts, meal records and weight records. We were advised that one person had been admitted to the home following discharge from hospital. They had a clear mental health diagnosis and from observation displayed specific behaviours related to this. On examination of the person file however there were no details about this. The plan stated the person’s mental health diagnosis but nothing further. Information should detail the behaviour displayed, possible triggers and interventions. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 12 This person at times can become quite agitated with verbal outbursts. Staff stated that they would encourage the person to spend time away from other people and suggest they have some privacy in their own room. During one incident a staff member had recorded on file that this person ‘had been sent to their room’. This language is neither appropriate nor dignified. Staff should consider how information is recorded. It was also discussed if this was a suitable form of intervention as the person may be in some distress and need an opportunity to spend time with staff. Information recorded on the OT assessment stated that the person would benefit from 1-2-1 support from staff. The manager stated that she had approached the local authority regarding accessing additional funding so that this could be offered as at present only single staffing is provided throughout the day and therefore restricts any opportunity for this. This person had been refusing all medication and at times would refuse meals. This was a pattern in relation to their mental health. Again little information was recorded within the plan. Weight records showed that the person had lost weight however the nutritional assessment had not been completed. We were also advised that the person had recently had two further admissions to hospital, their mental health was being monitored by a number of health professionals and support services had been put in place. The manager advised us that they had been discharged, as there was no medical intervention required and that input was now in relation to managing behaviours. Again this information along with management strategies was not recorded on file. On the second file again the persons diagnosis was stated however there was no information about what behaviours are displayed, possible triggers or interventions from staff. This person however was settled and was very active and able to follow their own activities in and away from the home with no support from staff. As previously identified, the home is small and therefore people receive informal day-to-day contact with staff. This allows the opinions of both parties to be easily aired. From general discussions and observations it was clear that people continue to enjoy the company of staff. Interactions with staff were seen to be open and friendly. It was also apparent that staff have a very good insight into the needs and behaviours of people however this needs to be recorded on file so that it can be shared with other relevant people. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Routines remain flexible. Social and leisure activities are made available enabling people to lead as full and active lifestyle as they choose. EVIDENCE: People living at the home continue to follow routines of their choosing. People are able to rise and retire when they wish. Those people living at the home are also encouraged in making decisions about their daily routines whether in or away from the home. People were seen to come and go as they choose At present no one is accessing any formal college courses or employment. Activities are generally informal and include things both in and away from the home. Some of the activities include watching TV, crosswords, local shopping centres, attending a gym, bus rides, social clubs, walks and helping staff with tasks within the home such as washing up, preparing meals, cleaning etc. A Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 14 person living at the home also expressed; ‘the home allows me to live my life as I would wish, with support and guidance’. Some people also spend time visiting their family and friends. One person continues to visit his relatives several times a week, another person visits their family over the weekend every fortnight. Visitors are also welcome at the home. A third person spent time with their friend on a daily basis. People continue to receive their mail unopened, however support would be provided from staff should this be needed or a response is required. Staff also confirmed that people have a front door key and keys for their rooms, however it is at their discretion whether they are used. With regards to meals this too is relaxed. People are able to make their own choice on a daily basis. Meals are taken at various times depending on people’s plans. Those able to prepare there own breakfast are encouraged to do so, with lunch and evening meals being prepared by staff with some assistance from people. Records are made of all meals served along with regular weight checks ensuring people are well. Records in relation to Safer Food Better Business continue to be completed by staff in line with good practice guidance. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of people are monitored to ensure their well-being is maintained. EVIDENCE: People living at the home are supported in various ways depending on their needs and wishes, where necessary staff will offer encouragement and assistance. This is outlined within individual plans to promote independence and ensure their dignity is maintained. The health and well-being of people continues to be monitored. Records are held in relation to personal care, weight and health appointments. People have access to a variety of health care professionals including GP, consultants, chiropodist, dentist, occupational therapist, CPN and social workers. The information examined for the two new people showed that both had a formal care programme plan (CPA), which had been agreed by mental health professionals. Review meetings are held on a 6 monthly or annual basis depending on the person’s level of need and support. Consideration is given with regards to risk management. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 16 It was noted for one person they were refusing to comply with any medication. They had also had two recent re-admissions to hospital. The psychiatrist and CPN were monitoring this, with additional support having been put in place from the ‘home treatment crisis team’. As already identified information in relation to this persons changing needs and behaviours needs to be expanded upon within the care plan and risk assessments. This will ensure that information clearly reflects their needs and behaviours as well as the support required from staff to minimise any potential risks to themselves and others living at the home. The two relatives who provided feedback were overall satisfied with the support provided. One person described the service as ‘giving a personal family style of support’ and ‘I feel the home is run to a high standard’. Both felt that the staff have the skills to support peoples needs and that they were kept informed of any issues. Medication continues to be held safely. All items are stored within a lockable cupboard secured to the wall in the office. Records are maintained for all items received and retuned to the supplying pharmacy. A signature form is in place and individual records have an up to date photograph of the person with their date of birth and doctors details. A homely remedies document has also been signed by the individual doctors agreeing alternative medication that may be administered by the staff at the home. Administration records were examined. Good practice was noted with regards to the administration of PRN medication. Staff had detailed on the back of the MAR sheet the date of administration and reason why. There were a number of handwritten entries on the records. These should be checked and signed by two members of staff to ensure that the information recorded reflects that of the prescription and includes all relevant details in relation to the dose. It is also advised that staff make a record of medication where it states ‘give one or two’ showing what they have administered. One of the residents continues to self medicate. A risk assessment has been completed and is held within the care file. Staff have previously received training in medication administration however the manager should review this ensuring this is up to date and all new staff complete the course. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Up-to-date policies and practices to protect people from abuse are not in place. All staff members need to undertake safeguarding training so that they know what action to take in the event of an allegation or suspicion of abuse. EVIDENCE: Information provided on the AQAA showed that no complaints had been received by the home. This was clarified during our visit. The manager informed us however that the recent safeguarding issue and a theft had been reported to the complaints department of the local authority. The first incident had not been reported to the safeguarding co-ordinator in line with the local authority safeguarding procedure. We discussed safeguarding with the manager. Although she appeared to be aware of the protection of vulnerable adults procedures she was not familiar with the term safeguarding and did not know whom the safeguarding coordinator was for the local authority. The manager advised us that the provider was making referral to POVA in relation to the first issue and that the police had been contacted with regards to the theft of property. Information had been forwarded to the CSCI with regards to the safeguarding issue however the second incident had not been reported to us in line with regulation 37. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 18 The manager has recently received training in relation to the local authority complaints procedure and safeguarding training has been planned for the newest member of staff. This needs to be undertaken by all staff including the manager so that they know what action to take in the event of an allegation or suspicion of abuse. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home appeared clean, comfortable and well maintained, providing a safe environment for people living at the home. EVIDENCE: Southlea is small domestic dwelling, which provides comfortable accommodation for 5 people. Accommodation is provided on 3 floors and comprises of a lounge, dining room and kitchen. There are 5 single bedrooms all of which have en-suite toilet and shower facilities. One of the bedrooms is situated on the ground floor. The basement area is designated for staff providing an office, sleep-in area and separate toilet. There is also a small rear yard, which people use to sit out during the fine weather. We spent sometime looking round the home. The home was warm, clean and tidy. The lounge, dining room and two of the bedrooms have previously been decorated and have a more modern and fresher appearance. Some of the Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 20 other bedrooms are decorated with pattern paper, which has not been changed for sometime. Consideration should be given, as part of the homes annual development plan, to these and other areas of the home being decorated to the standard already achieved in other areas. Bedrooms were comfortably furnished and had been personalised with the persons belonging including pictures, ornaments etc. A washer and drier are provided within the kitchen area however enclosed within a small cupboard. Provisions are available to prevent cross infection including protective clothing. The washing machine also has a boil wash so that items can be washed thoroughly. Information was requested from the manager with regards to staff training including mandatory courses such as health and safety and cross infection. Information examined for the two new members of staff showed that this has yet to be undertaken. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems in relation to staff recruitment, training and supervision need to be improved so that people are protected and staff are supported with their continued personal and professional development. EVIDENCE: The team currently comprises of 7 support staff, which includes the manager. Single cover is provided throughout the day with a sleep in staff member at night. Whilst there are no formal on-call arrangements, a staff member told us that in the event of an emergency they would either contact the manager or the providers. Information about staff recruitment, training and supervisions was examined. Two staff have commenced employment since our last visit. Their recruitment files were looked at. Information included; an application form, references, copies of identification and contract. On the first file we saw an application with detailed employment history, a declaration had been signed with regards to criminal records. However there was only one reference. A copy of the POVA Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 22 first check and CRB were seen however the CRB had been received by the home following the staff member commencing their employment. On the second file there was a detailed CV, an application and 2 references. There was also a POVA first check and a criminal record check. However this too had been received following the commencement of their employment. Both these staff members had been rota’d to work alone during the day and overnight prior to the criminal record check being received. This should not be done. The manager said that she was unaware that this was required and is reminded that new staff are not able to commence their employment unless they are supervised, ensuring people are not placed at risk. Staff training information was also looked at for the new staff. On one file the staff member had not received any training. On the second file the staff member had since April 2007 undertaken fire safety, medication and food hygiene training. Plans had also been made for them to attend safeguarding training and first aid. The manager expressed that she had developed a training matrix with regards to what training staff had completed. A training plan should now be developed to show what training has been planned for staff along with timescales for completion. Copies of these documents should be forwarded to the CSCI. We also spoke with the manager about the local training partnership group, as the home has been a member of the group. The manager has been attending the meetings and accessing some of the training for the team. Staff supervisions were also looked at. Only two staff had received support. One was dated November 2007 and the other March 2008. None of the other staff had received any formal supervision. The manager must ensure that all staff receive a minimum of six supervision sessions per year to ensure they are supported and assisted in their personal and professional development. Surveys received from staff stated that they were provided with relevant training, felt supported in their role and that they occasionally met with the manager. One staff member spoken with felt the new manager had sorted out certain things quickly. The manager advised us that the skills for care induction had been accessed. On one file the document had been transferred from their previous employer however remained incomplete. This had yet to be undertaken with the second member of staff. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The manager must ensure that the service is well managed with clear and robust systems ensuring people are protected. An application to register with the Commission must be made without further delay. EVIDENCE: The manager has now worked at the home since November 2007. Until recently occupancy at the home has been low. The manager explained that this had been the reason why an application to register with the CSCI had not been made. This must now be done without further delay. We were advised that due to the vacancies the provider had been considering the long-term future of the home. The manager has been a registered manager during her previous employment. She has completed the NVQ level 4 and registered managers award. Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 24 In relation to quality assurance, the provider undertakes monthly monitoring visits in line with regulation 26 and copies of the reports are held on file. This was a recommendation made during our last visit. Surveys have been sent out to people who use the service to find out their views of the service and what they think could be improved. In developing the homes annual development plan the manager should consider this feedback as well as other areas of improvements including staff training and development and the environment. A copy of the report should be provided to those people using the service as well as other stakeholders, including the CSCI. A random check was carried out with regards to formal safety check. Up to date servicing certificates were seen for gas safety, electric circuits, fire alarm, emergency lighting and small appliances. Other in-house checks are carried out in relation to fire safety and fridge and freezer temperatures. The last fire drill was carried out in December 2007. As there have been new staff and people move into the home a further drill should be carried out to ensure that people are aware of the evacuation procedure. Water temperatures are not checked. The manager explained that thermostatic valves have been fitted to outlets. Arrangements should be made for periodic checks to be carried out to ensure that the temperature is maintained at a safe level ensuring people are not placed at risk of harm. This information should be recorded. The accident and incident book was also looked at. There had been 12 incidents since our last visit. The majority of these had been in relation to one person due to their frail health. The manager is again reminded that any incidents involving the well-being of people living at the home should be reported to the CSCI in line with Regulation 37. Southlea Residential Care Home DS0000061330.V368947.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 Adults 18-65 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 1 X 2 X X 2 X Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 YA2 Regulation 12/14 Requirement A comprehensive assessment must be undertaken in relation to the specific needs of the person ensuring that the placement is suitable and their needs will be safely met. Care plans must provide clear information about the person, their needs, behaviours and level of support required. So that staff have a clear and consistent approach and needs are fully met. Risk assessments must be completed in all areas of potential risk, clearly outlining the intervention required so that people are not placed at risk of harm. Accurate administration records must be maintained to evidence practice is safe and peoples health and well-being is maintained. Safeguarding training must be undertaken by all staff including DS0000061330.V368947.R01.S.doc Timescale for action 30/11/08 2 YA6 15(1) 30/11/08 3 YA9 13(4) 30/11/08 4 YA20 13(2) 30/11/08 5 YA23 13(6) 30/11/08 Page 27 Southlea Residential Care Home Version 5.2 the manager so that they know what action to take in the event of an allegation or suspicion of abuse ensuring people are protected. 6 YA34 19 schedule 2 New staff must not commence their employment until all relevant information and checks have been received ensuing people are no placed at risk. Staff training plan must be developed ensuring staff have the knowledge and skills required to meet the specific needs of people living at the home. All new staff must complete a comprehensive induction in line with the skills for care specification so that they are clearly aware of their roles and responsibilities and the procedures to follow. All staff must receive a minimum of six formal supervisions sessions ensuring they are supported and continuous personal and professional development. Application must be made by the manager to CSCI with regards to becoming the registered manager. (Outstanding requirement 30.11.06 and 30.9.07) All incidents involving the wellbeing of people at the home must be report to the CSCI in line with regulation ensuring the appropriate action has been taken to ensure their safety. 30/11/08 7 YA35 18(1) 30/11/08 8 YA35 18(1) 30/11/08 9 YA36 18(2) 30/11/08 10 YA37 9 30/10/08 11 YA42 37 30/11/08 Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 28 12. YA42 23 Periodic checks must be made to the water temperatures ensuring people are not placed at risk of harm. 30/11/08 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 YA20 Good Practice Recommendations Hand written entries on the MAR sheets should be signed and dated by two staff ensuring the information recorded is correct. The registered provider is asked to forward confirmation to the CSCI of the recent referral to POVA following a recent matter. A copy of the up to date staff training matrix should be forwarded to CSCI. An annual business plan should be developed showing how they intend to develop the service whilst considering the views of those living at the home. A copy of the report should be distributed to people using the service as well as other stakeholders including the CSCI. Arrangements should be made for a fire drill to be completed so that people at the home and staff are aware of the procedure to follow. 2 YA23 3 4 YA35 YA39 5 YA42 Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Southlea Residential Care Home DS0000061330.V368947.R01.S.doc Version 5.2 Page 30 - 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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