Inspection on 18/07/07 for Southlea Residential Care Home

This inspection was carried out on 18th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southlea Residential Care Home 18/08/08

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 09/07/2008.

CARE HOME ADULTS 18-65 Southlea Residential Care Home 23a Cross Lane Radcliffe Manchester M26 2QZ Lead Inspector Lucy Burgess Unannounced Inspection 18th July 2007 10:00a Southlea Residential Care Home DS0000061330.V339279.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.V339279.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.V339279.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 ** 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.V339279.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered numbers 5 , there can be up to 3 MD(E) Adults with Mental Disorder over 65 ; 2 MD Adults with Mental Disorder. The service should at all times employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection 13th September 2006 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 £339.00 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.V339279.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home carried out over 1 day for a period of 5 ½ hours. As part of the inspection process the Provider was asked to complete an Annual Quality Assurance Assessment (AQAA), which was then forwarded to CSCI. Information provided was detailed and looked at both the strengths and weaknesses of the home and what plans had been made to develop and improve the service further. Feedback surveys were also distributed. Comments were received from 2 relatives, 2 residents and 1 social worker. The home is registered to provide accommodation for 5 people. At the time of the visit there was 1 vacancy. Since the last visit there has also been a change in the management of the home. During the visit the inspector spent time talking with residents, speaking with staff and the Provider as well as looking at records. Sometime was also spent looking round the home at the improvements made to the environment. All the key standards were looked at during the inspection. What the service does well: Southlea is a small home providing comfortable, homely accommodation for those living there. Some of the residents have lived at the home for a number of years providing them with a very settled home life. The inspector spent some time speaking with the Provider. It was clear that she is involved and informed about the running of the home. She was also fully aware of the needs of residents and the support that they require. The home has a clear assessment process, which ensures that when individuals move into the home they are able to have their needs fully met. This is planned over a period of time to allow for time to get to know each other. One resident said that prior to moving into the home, ‘my social worker gave me a lot of support and advice, I felt it was the right place for me with having people around for support’. Feedback received about the service and support provided was very positive. Comments included, ‘the care service promotes care and support for my client with a very person centred approach, fitting the support around their needs and requirements’, ‘we’re kept informed’, ‘they provide accommodation of a high standard and it is friendly’, ‘the staff are always nice and seem to be well organised’ and ‘they are very supportive’. Southlea Residential Care Home DS0000061330.V339279.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. Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 7 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.V339279.R01.S.doc Version 5.2 Page 8 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): 1, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The process of assessing prospective residents prior to admission to the home gives an assurance that a resident is only admitted if the home is able to meet their needs. EVIDENCE: Information has been developed with regards to the statement of purpose and service user guide. The Provider was advised to review these documents ensuring that they reflect the information required under the National Minimum Standards and Regulations as well as reflecting the changes that have taken place with regards to the management of the home. Once completed it is requested that copies are forwarded to CSCI. Since the last visit, one new resident has moved into the home. Information was looked at with regards to their assessment and how the placement was arranged. The placing social worker and community psychiatric nurse (CPN) provided information. The documentation was extremely detailed and included background information about the resident’s family/relationships, mental health history, treatment, significant life events, risks and support needs. Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 9 The Provider also discussed current plans with regards to the vacancy at the home. A prospective resident has been identified and met with. Discussions have been held and an opportunity to visit the home has taken place. Before a decision is made the Provider stated that further plans would be made for the individual to visit and spend time at the home meeting with staff and other residents. This would enable all parties to make an informed decision about the suitability of the placement ensuring needs can be met. An early review would be made to establish the suitability of the placement. Feedback received from the newest resident about moving into the home was positive. Comments made included ‘my social worker gave me a lot of support and advice, I felt it was the right place for me, with having people around for support’. Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 10 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 good. This judgement has been made using available evidence including a visit to this service. Information is up to date and reflects individual needs and choices in relation to how they wish to live their lives. EVIDENCE: Records held in relation to each of the residents is detailed and addresses their social, emotional and physical needs. Files were orderly and easily accessible for staff to refer to. Information held on file personal information, admissions documents, contract agreement, missing persons information, financial details, appointments and visits, care plan, menus, daily reports, current list of medication, weight records and minutes from reviews. Residents are encouraged to be involved in the development of their plans. Once information has been drawn up, this is the read and discussed with them and they sign to evidence their agreement. Discussion was held with the provider about the reviewing process carried out by the home. Previously this had been on a monthly basis however Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 11 arrangements are to be made to complete a ‘pen pictures’ of each resident with additional information about specific needs. These will be reviewed at least 6 monthly or more frequently if needs change. Risk assessments continue to be reviewed and updated where necessary. Assessment address areas of concern, such as, mental health, personal care, medication, use of appliances, nutrition. Information seen identified possible triggers and symptoms as well as what support was required to minimise risk to themselves and others. As the home is relatively small, informal day-to-day contact is made between residents and staff with the views and opinions of both parties being easily aired. From general discussions and observations it was clear that residents continue to enjoy the company of staff. Interactions with staff were seen to be open and friendly. Feedback was received from a social worker that has placed some one at the home. Support was described as, ‘the care service promotes care and support for my client using a very person centred approach, fitting the support around their needs and requirements’. Two of the resident were spoken with during the visit. Both appeared relaxed and well cared for. One resident had been unwell however explained that ‘staff had been looking after him’. Another resident said that they ‘kept busy and helped staff around the home’. Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 12 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. Residents follow a lifestyle of their choosing enabling them to maintain their independence and living skills. EVIDENCE: There are currently 4 residents living at the home. The two younger residents are more active, accessing the local and wider community independently. Others have a more relaxed routine. Some of the activities include watching TV and ‘soaps’, crosswords, local shopping centres, attending a gym, walks and helping staff with tasks within the home such as washing up, preparing meals etc. It was noted on one of the care plans that one of the residents would like a voluntary job, this was being explored by the social worker. One of the residents said that they liked ‘helping with the dusting, cleaning their room and preparing things for some of the meals’. One of the relatives also commented Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 13 that their relative was, ‘involved in going shopping, doing things in the kitchen, trying to keep some independence’. Mail is received unopened, however support would be provided from staff should this be needed or a response is required. Residents also have keys for their rooms and it is at their discretion whether they are used. Residents also have bus passes, which enable them to travel easily within the local community. Residents continue to maintain contact with their family and friends. One resident visits his relatives several times a week, another had recently spent the weekend with family. Visitors are also welcome at the home. Staff offer support and encouragement where necessary. Arrangements regarding meals remain relaxed with individuals deciding on a daily basis when they would like to eat. Those able to prepare there own breakfast do so, with lunch and evening meals being prepared by staff with some assistance from residents. Residents stated that the food was ‘good’, ‘nicely cooked’ and ‘always a choice’. Records are made of all meals served along with regular weight checks ensuring residents are well. One of residents had been experiencing some difficulties in eating and maintaining weight. Support and advice had been sought from the relevant health professionals and was being monitored. In line with good practice the Safer Food Better Business was being completed by staff. Training has also been undertaken in food safety and nutrition and health. Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 14 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. Individualised support is provided in meeting resident’s personal, physical and emotional health ensuring their well-being is maintained. EVIDENCE: Each of the residents are independent and in the main able to address their own care needs however where necessary staff offer encouragement and assistance. The staff are clearly aware that the health needs of one resident is changing. This is being monitored and where additional support and advice is required this is being sought. Residents continue to make decisions in relation to the daily routines whether in or away from the home. Residents were seen to come and go as they choose. Records are maintained with regards to all contact with health and social care professionals and where appointments have been attended. Residents have access to a variety of health care professionals including GP, consultants, chiropodist, dentist, dietician and incontinence advisor. Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 15 Where residents have been placed at the home under a formal discharge programmes (CPA), this has been agreed by mental health professionals. Any concerns identified could result in residents being returned to hospital ensuring risks are minimised and individuals are protected. Periodic reviews are held as part of the discharge programme. Discussion includes the residents’ stability, progress or concerns in relation to their mental health and minutes are recorded. Further information is also recorded within the care plans outlining the specific support needs of individuals and how they are to be met giving clear direction to those offering support. Additional support and advice would also be provided form social workers and community psychiatric nurses (CPN) should this be needed. Relatives were satisfied that the needs of residents were being met. They were aware that staff would provide support where necessary. Relatives said that, ‘staff make sure that appointments are attended and that medical needs are met’, ‘they look well looked after’ and ‘ we’re kept informed of health issues and appointments or if there are any changes’ The medication system was examined. This is now being provided by a different supplier. However both the staff member and Provider said that they had been experiencing problems and that they were closely monitoring what was being supplied to the home along with the correct records. Medication was found to be stored safely. Records are maintained for all items received by the home and retuned to the supplying pharmacy. A signature form is in place and individual records have an up to date photograph of the resident 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. Where this had been given appropriate records had been made detailing the time and dosage given. MAR sheets are completed on administration of medication. It was noted that some items had been written on the sheets. The provider was advised that hand written entries are checked and signed by two members of staff to ensure that information recorded reflects that of the prescription. One of the residents continues to self medicate. A risk assessment has been completed and is held within the care file. The majority of staff have completed medication training. Arrangements had already been made for the newest members of the team to attend the course. Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Systems are in place with regards to complaints and adult protection issues. Relevant training is undertaken ensuring residents are safe and protected. EVIDENCE: A copy of the home’s complaints procedure is displayed within the home as well as being included within the home’s guide. No issues have been raised with either CSCI or the home. Comments made by those who returned the surveys confirmed that they were aware of whom to speak to should they need to. Residents also said that they were aware of whom to speak with if they had any issues or concerns. In relation to protection the majority of staff have received training, however this has yet to be completed by the newest members of the team. Dates have been arranged with the Partnership training group. With regards to residents finances support is offered. Individuals have there own accounts, which are managed by the Provider or local authority. Individual records are held with regards to statements, fees payable and personal allowances. Residents sign to evidence that they have received their money. Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 17 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. Southlea is a small domestic dwelling accommodation for those who live there. EVIDENCE: Southlea is small domestic dwelling providing accommodation for 5 residents. 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 room and separate toilet. At the time of this visit the home was found to provide a clean, warm and comfortable providing a very homely environment for residents. Residents were spoken and some of the bedrooms were looked at. Residents said that they were ‘happy and settled’ living at the home, one resident also said ‘I have everything I could need’. Resident’s bedrooms, of which 3 were seen, were comfortably furnished and personalised with individuals belonging including Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 18 providing pleasant comfortable pictures, ornaments etc. One of the rooms was the empty room, this had been redecorated with new furniture, bedding and a new carpet had been fitted. One of the relatives expressed, ‘they provide accommodation of a high standard, I’m impressed’. Work has recently been carried out within the home and included redecoration of both the lounge and dining rooms. The front window had been also been replaced. The provider explained that whilst the home does not have a refurbishment plan, action is taken to address any areas requiring attention as they arise. Laundry facilities are provided within the kitchen area however enclosed within a small cupboard. Adequate 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. The majority of staff have received training in infection control, food hygiene and health and safety, further dates have been set for those yet to complete the course. A comment received from one relative was that ‘the home is always clean and tidy’. Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 19 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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The process of staff recruitment and training ensures that residents are supported by a team that has the knowledge and skills in meeting their specific needs. EVIDENCE: Changes have taken place within the staff team. Information was examined for the two newest members of the team. This included recruitment information, induction and training. As part of the recruitment process individuals had been asked to complete an application form and attend a formal interview. Information was recorded of the interview process and how a decision had been made in relation to their suitability. Application forms include 2 referees and a full employment history. References had been sought as well as copies of identification, photograph, POVA 1st check and Criminal Record Check. Information was orderly and detailed ensuring the practice followed was safe. There are currently 4 residents living at the home and 1 vacancy. Staffing within the home comprises of single cover throughout the day and night. Each Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 20 of the staff on duty are responsible for carry out the domestic tasks or cooking. The home does not use agency staff. Comments received from relatives about the staff team included, ‘the staff are always nice and seem to be organised’, ‘they keep us informed’ and ‘they are very supportive’. Information regarding training was also looked at. The home is a member of the Bury Partnership Training Group and has accessed a number of courses in dementia, adult protection, infection control, first aid, challenging behaviour and food safety. Other courses have also included fire safety, nutrition and health, medication and health and safety. The manager has also attended a course in relation to the Mental Capacity Act. Certificates are held on individual files. NVQ training is also provided for staff. Skills for care induction information was also in place, which is undertaken by all new staff ensuring they are aware of their role and responsibilities as well as policies and procedures within the home. From observations made and through discussions with staff it appeared that they have a good understanding of the needs and behaviours of residents. Residents appear to have an open and friendly rapport with staff. Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 21 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. Formal arrangements in relation to the management of the home need to be established to ensure that residents continue to receive a good quality service. EVIDENCE: Since the last inspection a further change has taken place with regards to the management of the home. This has meant that the home has been without a registered manager for some length of time. Discussion was held with the Provider with regards to this area now being addressed to resolve the matter. The newly appointed manager has worked at the home as a carer before being promoted. She has recently commenced the NVQ 4/Registered Managers Award having already completed Level 2 and 3. The Manager must satisfy the CSCI that she has the knowledge and experience required for the position of registered manager. Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 22 Discussion was held with the Provider with regards to their understanding of the Inspection process under Inspecting for Better Lives including KLORA’s and the expectation for services to evidence how they monitor and continuously develop their service. The home have already completed the National Minimum Data Set for Skills for Care, which is supported by CSCI and are a member of Bury Training Partnership Group, which has provided a number of quality training courses in line with Skills for Care. In relation to quality assurance the Provider must demonstrate that a quality review of the service is undertaken ensuring feedback from residents and other stakeholders is taken into consideration and information is reflected in an annual quality report. Information is not being documented with regards to the Providers monthly visits as required under Regulation 26. The Provider was asked to develop this area, clearly evidencing that quality auditing and monitoring is being carried out. In relation to health and safety all relevant service checks had been undertaken. These included fire equipment and alarm, gas safety, electric certificate and small applicances. In house checks were also completed completed with regards to temperature checks, fire safety checks and drills. It was noted that the fire risk assessment, dated June 2006, stated to be reviewed in 6 months, this had not been done. Arrangements should be made for this to be done. Southlea Residential Care Home DS0000061330.V339279.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 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 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 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 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 X 2 X 2 X X X 3 Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 24 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 YA37 Regulation 9 Requirement Application must be made by the manager to CSCI with regards to becoming the registered manager. (Outstanding) Timescale for action 30/09/07 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 YA1 Good Practice Recommendations The home’s Statement of Purpose and Service User Guide should be reviewed and updated to reflect current arrangements within the home. Once amended copies of the new documents should be forwarded to the CSCI. That consideration is given to the development of a quality assurance system and a report in relation to the findings. The fire risk assessment should be reviewed ensuring that arrangements within the home protect both residents and staff. Reports in line with regulation should be undertaken by the Provider evidencing that quality auditing and monitoring is being carried out. 2. 3. 4 YA39 YA42 YA39 Southlea Residential Care Home DS0000061330.V339279.R01.S.doc Version 5.2 Page 25 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. 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