Inspection on 29/09/05 for Southleigh Residential Home

This inspection was carried out on 29th September 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Southleigh Residential Home 29/01/09

Southleigh Residential Home 21/02/07

Southleigh Residential Home 16/02/06

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 PL6 6EJ Lead Inspector Kim Fowler Announced 29 September 2005 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 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 Stationary 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 D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Southleigh Residential Home Address 55 Inchkeith Road, Southway, Plymouth, Devon, PL6 6EJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 211136 01752 211137 Ratecedar Ltd Care Home 5 Category(ies) of Learning Disability (5), Physical Disability (5) registration, with number of places Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) Age range 18-65 years 2) Learning disabled adults some of whom may have a Physical Disability Date of last inspection 15/02/05 Brief Description of the Service: Southleigh is a care home registered for five people aged 18-65 years who have a learning disability. The home is a semi-detached property that provides the care on two floors and the home also has two ground floor bedrooms. The home is situated in a residential area of Plymouth.All bedrooms are single rooms, and the home has a homely atmosphere and is well decorated and accessible in all areas. The home has a minibus. The home is conveniently situated being near shops, community facilities, and is on a bus route. Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 4 hours and was a planned Announced inspection. A pre-inspection questionnaire was received. A full tour of the premises took place and staff and care records were inspected. 2 of the staff and 4 of the 5 service users were spoken with during this inspection as well as the Registered Provider/Manager. The CSCI received 2 Relatives/Visitors comment cards. What the service does well: What has improved since the last inspection? What they could do better: The home should carry out an evaluation on the quality assurance system to allow feedback and any planned actions to service users who have completed the questionnaires. Service users will benefit from the formalisation of the acting manager position. The service users care plan reviews need signing by the individual service user to promote inclusion. Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 6 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. Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2/3 Service users can be confident that Southleigh provides well documented information in the homes pre-admission assessment to enable the home to meet the needs of the service users. EVIDENCE: The home continues to have a pre-admission assessment in place. This has not been used as no new service users being admitted to the home. One service user has been admitted via another home within the same company and this service user had visited this home had requested to move when a vacancy became available. The care plan for this service user was seen during this inspection and it had been updated to accommodate this move. One service user has recently had a hospital appointment. The Challenging Behaviour team, via the Learning Disability service, is involved with one service user in the home and this information was recorded onto individual care plans. The local Consultant has visited the home to carry out a drug review for one service user and another service user regularly visit a Psychiatrist in the community who reviews the medication for this service user. Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6/7/9 The home continues to support the needs of the service users in the home by providing as much support as needed to a service users group who have a mix level of needs. EVIDENCE: Case tracking provided evidence on service users care plans that they had been received and updated to reflect service users changing needs. The manager informed the inspector that at reviews the families, key workers and the service users are in attendance. Also in attendance is any specialist health care professional if needed. A letter seen on a service users file came form the local Clinical Psychologist confirming involvement with one service user. The manager stated that they always discuss the care plan reviews after the meetings with the service user on one- to- one bases. The service user had not signed the review minutes seen during this inspection. Seen on one service users file was a restriction that this service user only goes out with staff. This was in agreement with the clinical psychologist and the service user. One service user had moved from another home within the same company and this involved input from care manager and the service user. The service user money was checked during this inspection and was well Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 10 documented and recorded. The cash held was checked and was correct at the time of the inspection. Evidence was seen on 3 service users files of completed risk assessment in place and these included risk assessment on any risk to staff, community visits and any risks within the home. Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12/13/15/16/17 Service users can be confident that the home will continue to offer individual service users as much choice as possible and participate in the local community. EVIDENCE: The home displays an activity board that clearly indicate that each service user has a variety of activities they participate in. The inspector spoke to several service users and they informed the inspector that they attend a pottery session, several day centres and a craft session. A discussion was also held on the service users visiting local facilities including the library but due to the needs of the service users in the home none of them are able to work. The home is close to shops, pubs and library and the service users spoken with informed the inspector that they visit these regularly. During the inspection many of the service user in the home were going out to a café and then to a superstore for some shopping. The home has its own transport and now employs a driver to assist service users access the community. One service user informed the inspector that she visits her family and the manager confirmed that another service user stays overnight with a family Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 12 member every other weekend. One family member had visited the house for tea this week and this information was recorded into the individuals care plan. All the bedroom doors have appropriate locks and some service users choose to use them and these are supported by risk assessments seen in place. A discussion with a group of service users indicated that the home routines allow them individual choice to assist them to maintain their independence. The homes 4 weekly menus were sent with the pre-inspection questionnaire. All mealtimes are flexible and the kitchen is available at any time. The manager and staff both sit with the service users to plan any changes in the menu for seasonal changes. The service users spoken with agreed that the food was good and they help and assist staff. Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18/19/20 The home continues to provide excellent personal support for service users in the home. EVIDENCE: One service user has assistance with her choose of clothes and other service users informed the inspector that they choose their own clothes. 2 of the service users were having their hair done during the inspection by the manager. Case tracking provided evidence in care plans on how personal care is delivered. The same gender staff is offered as much as possible and 2 service users have use of wheelchair when out in the community. Each service user has a named key worker and the home has a policy and procedure in place for the protecting the privacy and dignity of the service users. Evidence was seen on individual care plans that showed that the home monitors and records any changes in service user needs. All service users are registered with local GP and any visits are carried out in private. The service users health is monitored and recorded and the home has a designated medical visit form. One service user has had a recent hospital day surgery appointment and evidence was seen in the care plan of the treatment, hospital appointment and all follow up visits planned. The homes accident book was completed appropriately. Medication is now administered in blister packs and the home uses MARRS sheets for recording of medication. The medication system seen in place was Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 14 checked and was well documented, recorded and case tracking provided evidence on any errors or extra medication was well recorded and explained. Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22/23 The home has a clear complaints procedure in place and has this displayed for all. Service users can be confident that their complaints or concerns will be listened to and acted upon. EVIDENCE: The home has a policy and procedure on complaints and this procedure was displayed on the homes notice board. The home has not received any complaints since the last inspection. The group of service users spoken with said they knew about the complaints procedure and could raise concerns or complaints if needed. The new staff confirmed that they had a completed CRB check and this was seen on checking the staff file. The new manager has completed the Devon Adult Protection training. One staff confirmed that they have received a staff handbook. Finance records were seen and were correct and up to date. All service users have individual saving accounts. Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24/30 The home continues to maintain a suitable environment for its stated purpose. EVIDENCE: A tour of parts of the building found it to be clean and hygienic on the day of the inspection. The home is well decorated, bright and homely. All bedrooms are single and decorated to service users individual tastes. All parts of the home are accessible to all. The home now employs a maintenance person for day- to- day maintenance. The tour of parts of the building confirmed that the home is clean, hygienic and free from offensive odours. The home has an infection control policy in place and the homes laundry room was seen and suitable for its stated purpose. The homes washing machine has a sluice facility available. Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33/34/35 Staff training is supported and promoted enabling service users to receive the best possible service. EVIDENCE: The homes staff rota was sent with the pre-inspection questionnaire and evident that the home has sufficient staff on duty to met the needs of the current service user group. Case tracking provided evidence on one new staff file that it contains all relevant information as required. One staff confirmed that they had an interview with the manager and had met the service users before the job offer. Information was seen and the manager confirmed that the staff had completed many courses including First Aid, Fire Safety and adult protection. This information is recorded into the home daily diary and the staff supervision records. The inspector recommended that the home had a separate training and development plan. The new staff member confirmed that he was part way through his induction programme and had completed a Fire Safety training session and hoped to start his NVQ training. Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37/39/42 The management of this home is very good and ensures that records are effectively maintained, staff are well trained and service users are happy and their needs are met. EVIDENCE: The home has a new manager in post and is part way through the Commission Registration process. The new manager has completed the Devon adult protection course training and is due to start the Registered Managers award. The quality assurance system was seen in place on individual files. These forms need evaluating. The manager confirmed that the staff had Food Hygiene, First Aid, Fire Safety and some staff had competed Manual Handling training. One staff file was seen with evidence of a completed First Aid certificate. Health and safety is a priority in the home, and records evidenced that fire safety training and fire precautions are in place and up to date. The accident book was accurately and comprehensively completed. Records also evidenced that gas and electrical systems in the home are regularly serviced, and portable appliance tests are Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 19 completed on an annual basis. Risk assessments are in place for the building and all staff working practices. Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score 3 x 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Southleigh Residential Home Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 2 x D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 21 yes Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 6 35 20 39 Good Practice Recommendations Care plan reviews should be signed by the service users. The home should have a training and development plan. Copies of the accident forms should be held on service users files The home should carry out evaluation of the Quality Assurance system. Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon, TQ13 7UP National Enquiry Line: 0845 015 0120 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 Southleigh Residential Home D52-D04 S3521 Southleigh Residential Home V239074 290905 Stage 4.doc Version 1.40 Page 23 - 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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