Inspection on 11/07/05 for Southmead

This inspection was carried out on 11th July 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 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

Southmead 27/02/07

Southmead 20/01/06

Southmead 18/01/05

Southmead 12/07/04

Southmead 12/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Southmead 159 York Road Broadstone Dorset BH18 8ES Lead Inspector Catherine Churches Unannounced 11 July 2005 10:00 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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Southmead Address 159 York Road, Broadstone, Poole, Dorset, BH18 8ES 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) 01202 694726 01202 659495 admin@southmead.co.uk Mrs Penelope Anne Fletcher Care Home only 16 Category(ies) of OP - 16 registration, with number of places Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18 January 2005 Brief Description of the Service: Southmead is registered with the Commission for Social Care Inspection to provide accommodation and personal care for a maximum of 16 older people. The home is owned by Mr and Mrs Fletcher and Mrs Fletcher is in day-to-day charge of the home. Mr and Mrs Fletcher live on the premises. The home is in a quiet, residential area of Broadstone which has a wide range of shops and local amenities. The premises consist of a lounge and dining room and 4 bedrooms on the ground floor, and 8 bedrooms on the first floor. 3 of the bedrooms are double rooms. Not all areas on the first floor can be reached by the stairlift. The home is very well maintained and has a particularly attractive garden. Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the afternoon of Monday 11th July 2005. The inspection took place as part of the regular, programmed inspection schedule for the home. No requirements or recommendations were made at the previous inspection. The purpose of this visit was to check that the home continues to run in the same satisfactory way and that the 15 people who are living in the home are properly cared for. The premises were inspected and a number of records examined. Time was also spent time observing routines within the home and talking with residents and staff. Mrs Fletcher, the registered provider, was present throughout the inspection. What the service does well: Southmead provides a homely, relaxed and comfortable environment with a welcoming and friendly atmosphere. The home is very well presented and has beautifully maintained gardens that residents reported they were very proud of. The home consistently maintains good standards with regard compliance with the National Minimum Standards. All areas inspected on this occasion were found to be satisfactory. The home is positively managed and well staffed. The staff group is stable and were observed to be respectful, helpful and caring. All residents spoken with were very positive about the care and attention that they receive. One person said, “If I couldn’t be here, I’d rather not be anywhere” another commented that they “feel like part of a big family”. All of the required documentation with regard to care planning, staffing and health and safety was up to date and detailed reflecting a responsible attitude towards this side of the work. A wide range of activities is organised and it is clear that both Mrs Fletcher and the staff spend time thinking about residents likes and dislikes in order to find suitable, varied and interesting activities. Staff are well trained and competent and there are satisfactory systems in place for the making of complaints and protection of residents from abuse. Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 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. Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, standard 6 is not applicable to this home. Assessments of residents and their needs, prior to their admission, were satisfactory. This means that residents and their representatives should feel confident that the home is aware of all the needs of the person and is able to meet them. EVIDENCE: The majority of residents have lived at Southmead for some time. The preadmission assessment for the most recently admitted resident was examined. The information in this record was detailed and informative and meets the requirements of the National Minimum Standards. The Inspector also spoke with the resident concerned who confirmed that they had been able to visit the home prior to admission and that they had been involved in the assessment process. Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8 Care plans for residents who live at Southmead are detailed and informative. This means that staff have sufficient information to provide a good level of care and the home can also demonstrate the care that has been provided. The home ensures that resident’s healthcare needs are met through seeking appropriate input from GP’s and other healthcare professionals. EVIDENCE: Care plans and related documentation regarding 3 residents were examined. Files were well laid out and regular risk assessments had been undertaken. Reviews were being undertaken on a monthly basis or more frequently if changes dictated this. All of the residents whose documentation was examined were spoken with. They confirmed (where they were able) that they were happy with the care they receive and that either they or a representative are involved in reviews and are assisted appropriately to seek help from healthcare professionals such as Doctors, District nurses, chiropodists and opticians. This was also recorded in their files. Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 and 14 Residents have the opportunity to choose their own lifestyle within the home and this means that their individual preferences and routines are respected. The social and recreational activities provided by the home meet the expectations of residents. Open visiting arrangements are in place enabling residents to retain contact with families and friends. The home also places great emphasis on involvement with the local community, particularly as the majority have spent much of their lives in the area. EVIDENCE: Notices were displayed within the home giving information on the range of activities on offer. There are regular in house activities such as gentle exercise classes, singalongs and music as well as outings and events such as cream teas. A number of resident mentioned the activities when speaking with the Inspector and all said they enjoyed them. An exercise class was taking place during part of the inspection, residents were encouraged to take part to whatever degree they felt comfortable or could even just sit and watch everyone else. The visitor’s book showed that there is a constant stream of visitors to the home and discussions with staff confirmed this as well as the fact that many residents are taken out by visitors. Staff also explained that the home has a good relationship with the local church and day centre. Residents are Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 11 encouraged to attend these and the home will take them there if there are no volunteers from the community to do this. Discussion with residents and staff as well as examination of records evidenced that residents are assisted appropriately to exercise choice and control over their lives. Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a satisfactory system for making complaints. This means that residents and others involved in the home that may wish to make a complaint should feel confident that they would be listened to and matters of concern will be acted upon. Arrangements for protecting service users from abuse were satisfactory: staff had a good knowledge and understanding of Adult Protection issues. This means that Southmead is a safe environment that will protect residents from abuse. EVIDENCE: The home has a satisfactory complaints procedure that is displayed in the home as well as included in the Service Users Guide. Those spoken to said that they would feel comfortable in making a complaint but also commented that they could never foresee such a need arising. No complaints had been made either to the home or the Commission for a considerable period. Staff have received training in recognising and preventing abuse as well as the action to take should they believe abuse has taken place. It was evident from discussion that they were clear about their responsibilities. Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home is very well presented: it is nicely decorated and furnished and has a homely atmosphere. The grounds are also very well maintained, providing lots of colour and interest as well as a variety of places to sit and relax. The home maintains a good standard of hygiene and all areas seen were clean and free from offensive odours. EVIDENCE: A tour of the premises confirmed that the home is well decorated, furnished and equipped. Dorset Fire and Rescue Service has visited the home and confirmed that it complies with their requirements. The laundry area is well organised and equipped: there are 2 washing machines, one with a sluice programme, and one tumble drier. The walls and floors were easily cleanable and separate hand washing facilities were available. Staff had a good understanding of infection control procedures and the relevant protective clothing was available. Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 The home was well staffed ensuring that residents receive the care and attention they need in an unrushed manner. Staff clearly enjoyed working in the home, there was a positive atmosphere and residents had a happy, relaxed relationship with the owner and staff. There is an ongoing staff training programme and over 50 of staff have now achieved an NVQ level 2 qualification. Such training has lead to an increased level of competency among the staff. EVIDENCE: Examination of the staff rota and observation throughout the inspection demonstrated there was a sufficient number and skill mix of staff to meet the needs of residents. Staff and residents spoken with confirmed that they were satisfied with staffing levels. The staff group is very stable and well established. There has therefore been no requirement to provide induction and foundation training for staff although systems are in place if this were to be required. Since the last inspection, 2 more staff have achieved NVQ level 2 and are so well motivated that they hope to undertake level 3 in the near future. Other training in areas such as first aid, moving and handling and fire prevention has continued as required. Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 Mrs Fletcher has owned and managed the home for over 16 years and has a wealth of experience. She is a competent, approachable and committed manager. This results in a consistently well run home where residents, staff and visitors feel supported and consulted. Management practices promote and safeguard the health, safety and welfare of the residents. EVIDENCE: Mrs Fletcher has recently completed an NVQ level 4 in management and care. This means that she is able to demonstrate further that she has up to date knowledge and skills and is able to pass this to staff to further improve the already good care and practice in the home. Fire records, staff training records, accident books and risk assessments were examined and found to be up to date and detailed. Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x x 3 Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 17 NO 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. Refer to Standard Good Practice Recommendations Southmead D55 S4060 Southmead V233439 110705 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Unit 4, New Fields Business Park Stinsford Road Poole BH17 0NF 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. 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