Inspection on 21/02/07 for Southleigh Residential Home

This inspection was carried out on 21st February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Southleigh Residential Home 29/01/09

Southleigh Residential Home 16/02/06

Southleigh Residential Home 29/09/05

Southleigh Residential Home 01/03/05

Southleigh Residential Home 14/10/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Southleigh Residential Home 55 Inchkeith Road Southway Plymouth Devon PL6 6EJ Lead Inspector Antonia Reynolds Key Unannounced Inspection 21st February 2007 10:40 Southleigh Residential Home DS0000003521.V327479.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 Southleigh Residential Home DS0000003521.V327479.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. Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southleigh Residential Home Address 55 Inchkeith Road Southway Plymouth Devon PL6 6EJ 01752 211136 01752 211136 paulmillard@hotmail.com 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) Ratecedar Ltd Mrs Teresa Margaret Hosking Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Age range 18-65yrs Learning disabled adults some of whom may have a physical disability Date of last inspection 16th February 2006 Brief Description of the Service: Southleigh is a care home providing personal care and accommodation for five people, aged 18 – 65, with a learning disability, who may also have physical disabilities. The home is privately owned by Ratecedar Ltd, which also owns another care home in Plymouth, and the Responsible Individual is Paul Millard. The fee levels are between £380 and £780 per week, although these may vary depending on the individual needs of service users. Information about the home and copies of inspection reports can be obtained from the Registered Manager, Teresa Hosking. The home was opened in 1987 and is a semi-detached two storey property situated in the Southway area of Plymouth. It is within walking distance of local shops and amenities, central Plymouth is accessible by public transport, and the home has its own vehicle. All the bedrooms are single and are located on each floor. The home has separate lounge and dining rooms on the ground floor. There is a bathroom on the 1st floor, a shower room on the ground floor and a toilet on each floor. There is a small garden at the rear of the building that is accessible to all the service users. The home has a parking area at the front of the house and on street parking is available nearby. Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection consisted of an unannounced visit between 10.40am and 10.45am, and 1.10pm and 5.45pm, on Wednesday, 21st February 2007. The Registered Manager, Teresa Hosking was present throughout the visit and the Responsible Individual, Paul Millard, was present for part of the visit. A tour of the premises took place and records/documents relating to the care of the service users, staff and the home were inspected. A pre-inspection questionnaire had been completed by the Registered Manager, which contained information relevant to the inspection. Five service users were spoken with or observed during the visit and staff were observed carrying out their normal duties. Verbal feedback was received from a health care professional who was present in the home at the beginning of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide need to be updated to ensure that service users and their relatives/representatives have clear information about the services the home provides. A copy of each should be sent to the Commission for Social Care Inspection. The Statement of Terms Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 6 and Conditions should be updated to include information about additional charges that service users are expected to pay, such as transport. The Registered Manager should review the system of charging service users for the use of the home’s transport so that it is fair and equitable and to ensure that some service users are not subsidising others. Service users and relatives, representatives and/or advocates should be consulted about charging for the use of transport and any agreements made should be documented. Where service users are expected to pay for the staffs transport costs, the relatives, representatives or advocates of service users should be consulted and any agreements should be documented. The home’s policies on charging for transport and service users paying for staff transport should be included in the Statement of Purpose, Service User Guide and terms and conditions of residency. Locks should be fitted to all bedroom doors that are suitable to service users’ capabilities and accessible by staff in an emergency, that will promote service uses’ privacy and enable their belongings to be kept securely should they be absent from the home. As part of the quality assurance system the Responsible Individual, or a designated person who is not directly concerned with the conduct of the care home, should produce a written report on the conduct of the care home and supply a copy to the Registered Manager and the Commission for Social Care Inspection. The quality assurance system should be developed to include an annual internal audit and feedback from relatives, representatives and other professionals involved with the home. 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. Southleigh Residential Home DS0000003521.V327479.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 Southleigh Residential Home DS0000003521.V327479.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): Standards 1, 2, 3, 4 and 5 Quality in this outcome area is adequate. The home’s admissions procedure ensures that prospective service users and their relatives/representatives know that the home will meet their needs and aspirations, but the home’s information is out of date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pre-admission assessment process ensures that the needs of prospective service users are identified. Service users and their relatives/representatives are welcome to visit the home prior to admission to meet other service users, staff and have a look around the home. Discussions with service users and the Registered Manager, as well as observation, show that staff are aware of the needs of the service users. The Statement of Purpose and Service User Guide were out of date and did not include information relating to additional financial charges that service users are expected to pay, such as transport. The Statement of Terms and Conditions also needs to be updated with this information and relatives, representatives and/or advocates should be consulted. Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 9 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): Standards 6, 7, 8 and 9 Quality in this outcome area is adequate. Service users are supported to make decisions about most aspects of their lives, but the management of service users’ money needs to be reviewed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two service users’ files were inspected and these contained care plans and risk assessments relating to health and personal care needs that are regularly reviewed. Discussion with service users and the Registered Manager confirmed that personal care is maintained, service users can bathe/shower when they choose to and are encouraged to be as independent and make as many choices as possible. Service users are expected to pay for personal items as well as making a contribution towards the cost of transport. The Registered Manager confirmed that each service user has his/her own bank account and the Responsible Individual, Paul Millard, is the Appointee for benefits. All the service users are Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 10 expected to give the mobility component of Disability Living Allowance to the home as a contribution towards going out in either small groups or on their own for various activities, that may include the use of the home’s vehicle. All the service users had signed a document agreeing to this, but these forms had not been signed by relatives, representatives or advocates. If service users use public transport, for example, taxis, they are expected to pay for this from their personal allowance. This system should be reconsidered so that any financial charges made to service users for the use of the home’s transport should be fair and equitable and be determined by the extent to which each service user makes use of the transport. Also, service users and relatives/representatives or advocates should be consulted about charging for the use of transport and any agreements need to be documented and signed by relatives, representatives or advocates who are independent from the care home, as well as service users. The home’s policy for charging for transport should be included in the Statement of Purpose, Service User Guide and terms and conditions of residency. If service users require staff support to leave the home, service users are expected to pay for the staffs transport costs, for example, bus fares. Wherever this type of additional charging is occurring, the relatives, representatives or advocates of service users should be consulted and any agreements need to be documented and signed by everyone involved. The home’s policy for service users paying for staff transport needs to be included in the Statement of Purpose, Service User Guide and terms and conditions of residency. At the time of inspection, service users were expected to contribute £3 per week (recently increased from £2) into a ‘residents fund’. Money was used from this fund when service users went out with staff but no record was kept of who had used how much money, so service users could have paid into this fund for years and not received back as much as they had paid in. Following discussion with the Registered Manager and Responsible Individual, it was agreed that this practice would stop immediately. Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 11 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): Standards 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. Service users can feel confident that they will have opportunities for personal development, various activities are available to fulfil their aspirations, and independence and choice are promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with service users and the Registered Manager confirmed that service users are enabled to live as full a life as they wish to and have opportunities for personal development. Service users have opportunities to participate in voluntary work, education and leisure activities. The Registered Manager said that, following the withdrawal of day services by the local authority, staff at the home are looking for alternative occupation for service users. She is well aware that some service users may experience a level of discrimination within the local community and, where this has occurred, the staff team have addressed it and the situation has improved. Contact with Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 12 relatives and friends is encouraged and there are no limitations in place regarding visitors to the home. The Registered Manager said that all the service users have two or three holidays each year, the costs of which are shared between service users and the home. Service users are encouraged to participate in all the domestic activities in the home and leisure activities of their choice. The home has a seven-seater people carrier and service users are also encouraged to use public transport where possible. It was evident, through observation during the inspection, that service users feel very ‘at home’ and are empowered to make decisions. The service users confirmed that they like the food and choices are always available. Service users are able to enjoy their meals in an unrushed and sociable atmosphere. Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 13 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): Standards 18, 19 and 20 Quality in this outcome area is good. Service users can be confident that personal support is provided in the way, and at the time, that they want and need. Health care needs are monitored and advice is sought when necessary. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service user plans provide information about personal, emotional and health care needs and a person centred planning system has been introduced into the home. External professional advice and guidance is sought when necessary from local health care professionals or social services. A speech and language therapist from the learning disability team was present in the home at the beginning of the inspection and was very complimentary about the effort the staff team have put into total communication skills. Visits to the doctor, dentist and other health appointments are recorded in individual files. Through observation it is clear that timings are flexible and the choice of the service user. Each service user has a designated key worker and service users said they could discuss any personal issues with their key worker or other members of staff. Records pertaining to the administration of medication are up to date Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 14 and a staff member demonstrated the medication administration practices in the home, which are satisfactory. The home uses a monitored dosage system for medication and the home has a British National Formulary so that different medicines can be looked up to find out how they should be administered or what the possible side effects may be. Advice was given to the Registered Manager to ensure that a particular medicine (lactulose) is always given to the service users with water. Records pertaining to the administration of medication are up to date and the practice of administering medication was demonstrated by the Registered Manager and found to be satisfactory. Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 15 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): Standards 22 and 23 Quality in this outcome area is good. Service users can be confident that any concerns or complaints will be listened to and addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure but there have been no complaints since the last inspection. Service users are well aware of how and to whom they can make a complaint and feel free to do so. They each have a designated key worker and said they could speak to this person, the Registered Manager, Responsible Individual, or any other member of staff. Regular house meetings are held where any issues can be raised and are dealt with immediately, although it was also clear from discussion and observation that service users can raise any issue at any time. The Registered Manager confirmed that staff had received, or are expected to attend, training in the protection of vulnerable adults. The home has a copy of the Local Authority’s Alerter’s Guidance available for staff with a procedure for notifying any alleged incidents of abuse or concern. Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 16 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): Standards 24, 25, 26, 27, 28 and 30 Quality in this outcome area is adequate. Service users live in a clean, safe and comfortable home, although communal space is limited for the numbers of service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Southleigh is in a residential part of Plymouth and indistinguishable from the neighbouring properties. The home is comfortable, safe and clean with a good standard of décor and furnishings. The Registered Manager confirmed that repairs, maintenance and redecoration are ongoing projects. Service users and the staff team have started to use communication boards with symbols, particularly related to service users’ activities, and these are in the office and individual bedrooms. Service users confirmed that they are responsible for cleaning their own bedrooms if they wish to and the staff clean the communal areas. The home has separate lounge and dining rooms on the ground floor, that are rather small for the number of service users and staff. Whilst the communal space for service users is 4.3 sq m each, the useable space in the Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 17 dining room is reduced as it is a thoroughfare to a service user’s bedroom. The kitchen and laundry room are also on the ground floor, as well as an office with sleeping-in facilities for staff. Each service user has a single bedroom, three of which are on the 1st floor and two on the ground floor. All the bedrooms contain wash hand basins and are individually furnished, containing many personal possessions. Service users and the Registered Manager confirmed that, wherever possible, service users choose the colour and décor of their bedrooms. Only one bedroom was fitted with a suitable lock and the Registered Manager said that the other four service users did not want locks fitted. A discussion took place about the importance of fitting suitable bedroom door locks so that service users may have privacy if they wish to and their belongings can be secured when they are absent from the home. The home has a bathroom, with an over bath shower, and toilet on the 1st floor and a shower room and toilet on the ground floor. All bathroom and toilet doors are fitted with locks that can be opened from the outside by staff in an emergency. The home does not have many aids or adaptations, apart from hand rails and a seat fitted in the shower, because these are not required for the service users. At the rear of the building is a small garden, which is accessible by all the service users in the home. Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 18 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): Standards 32, 33, 34, 35 and 36 Quality in this outcome area is good. Recruitment procedures are robust and service users’ benefit from a wellsupported and supervised staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with service users and the Registered Manager confirmed that there are always enough staff on duty to meet the needs of the service users. There are usually at least two care staff on duty during the day and early evening (until 7pm) and one member of staff who sleeps in at night. The Registered Manager is part of this care team but has some supernumerary hours on a Tuesday and Thursday. The Responsible Individual is usually available if additional staffing is required. Service users confirmed that the staff team are very good and it was evident that there was a good rapport between service users and staff. Two staff files were inspected and the information in them show that the organisation has a robust recruitment procedure. The Registered Manager confirmed that verbal references are usually obtained as well as written Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 19 references. Criminal Record Bureau (CRB) checks are made for every new staff member and the Registered Manager confirmed that new staff are never left unsupervised until all the checks and references are returned. Service users are asked for their opinion of potential new staff and the views expressed are taken into account as part of the interview process. The Registered Manager, as well as pre-inspection documentation confirmed that staff are expected to complete various training courses. These include topics such as adult protection, first aid, health and safety, fire safety, safe handling of medication, food hygiene, person centred planning, infection control, National Vocational Qualifications (NVQs) and several courses related specifically to working with service users with learning disabilities, such as challenging behaviour and total communication. The home has recently devised a structured induction training that complies with the Skills for Care requirements and this will be put in place for all new staff. All training and supervision meetings are documented in staff files. The home has a copy of the General Social Care Council’s code of conduct for care staff but the Registered Manager was advised to obtain enough copies so that each staff member has their own copy. Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 20 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): Standards 37, 38, 39 and 42 Quality in this outcome area is good. The management approach is open, inclusive and positive, providing clear leadership and guidance. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager has been managing this home since April 2005. She is presently in the process of completing a level 4 National Vocational Qualification in Care and will then complete the Registered Manager’s Award. Discussions with the service users confirmed that the ethos of the home is very good. This is because the management approach is open and inclusive with the home being organised to meet the needs and aspirations of the service users. The quality of care provided is continually being monitored and reviewed by the Registered Manager and Responsible Individual as they spend Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 21 a great deal of time at the home talking with service users, their relatives/representatives and staff. The Responsible Individual, or another designated person independent of the care home, should be writing monthly reports on the conduct of the care home, which should be part of the quality assurance system. Service user meetings are held regularly and chaired by the Registered Manager from another home owned by the same organisation. Service users, with assistance from staff, complete questionnaires about their life in the home. This quality assurance system should be developed to include an annual internal audit and feedback from relatives, representatives and other professionals involved with the home. Records and documents relating to health and safety issues are up to date. The Registered Manager confirmed that all staff are expected to attend training in health and safety, emergency first aid, food hygiene and fire safety. Manual handling training is being arranged for all staff. Accident records and incident reports are kept and regularly monitored by the Registered Manager. Tests and checks of fire safety equipment are carried out as required and the Registered Manager confirmed that service users and staff attend fire drills and fire safety training. Information provided by the Responsible Individual verified that all staff attended a fire safety training course on 15th August 2006. The Registered Manager confirmed that all hot water outlets accessible by service users are thermostatically controlled to ensure that hot water is kept to a temperature where service users will not be scalded. Pre-inspection documentation stated that comprehensive safety checks are carried out including gas appliances and electrical equipment. Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 22 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 3 4 3 5 2 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 3 26 2 27 3 28 3 29 N/A 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 3 X LIFESTYLES Standard No Score 11 3 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 3 3 3 X X 2 X Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 23 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. Refer to Standard YA1 Good Practice Recommendations The Statement of Purpose and Service User Guide should be updated to ensure that service users and their relatives/representatives have clear information about the services the home provides. A copy of each should be sent to the Commission for Social Care Inspection. The Statement of Terms and Conditions should be updated to include information about additional charges that service users are expected to pay, such as transport. The Registered Manager should review the system of charging service users for the use of the home’s transport so that it is fair and equitable and to ensure that some service users are not subsidising others. Service users and relatives, representatives and/or advocates should be consulted about charging for the use of transport and any agreements made should be documented. 2. 3. YA5 YA7 Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 24 Where service users are expected to pay for the staffs transport costs, the relatives, representatives or advocates of service users should be consulted and any agreements should be documented. The home’s policies on charging for transport and service users paying for staff transport should be included in the Statement of Purpose, Service User Guide and terms and conditions of residency. Locks should be fitted to all bedroom doors that are suitable to service users’ capabilities and accessible by staff in an emergency. The Responsible Individual, or another designated person who is not directly concerned with the conduct of the care home, should produce a written report on the conduct of the care home and supply a copy to the Registered Manager and the Commission for Social Care Inspection. The quality assurance system should be developed to include an annual internal audit and feedback from relatives, representatives and other professionals involved with the home. 4. 5. YA26 YA39 Southleigh Residential Home DS0000003521.V327479.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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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