CARE HOMES FOR OLDER PEOPLE
Southmead 159 York Road Broadstone Poole Dorset BH18 8ES Lead Inspector
Catherine Churches Unannounced Inspection 10:30 20 January 2006
th X10015.doc Version 1.40 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 DS0000004060.V279251.R01.S.doc Version 5.1 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 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. DS0000004060.V279251.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Southmead Address 159 York Road Broadstone Poole Dorset BH18 8ES 01202 694726 01202 659495 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) Mrs Penelope Anne Fletcher Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places DS0000004060.V279251.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11th July 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 stair lift. The home is very well maintained and has a particularly attractive garden. DS0000004060.V279251.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the morning of 20th January 2006. The inspection took place as part of the regular, programmed inspection schedule for the home. This report should be read in conjunction with that from the inspection in July 2005 as all key inspection standards are reported on in these two reports. The purpose of this visit was to check that the home continues to run in a satisfactory manner and that the 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 was available throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better:
Minor improvements in the recording of medication administration are required in order to ensure that administration directions are correctly recorded and therefore safeguarding residents from mistaken doses. Quality assurance systems need to be reviewed to ensure that it is fully compliant with the requirements of the standard and therefore demonstrating that the home is run in the best interests of the residents
DS0000004060.V279251.R01.S.doc Version 5.1 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. DS0000004060.V279251.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection DS0000004060.V279251.R01.S.doc Version 5.1 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 the following standard(s): None of these standards were assessed on this occasion as standard 3 was assessed at the last inspection and found to be met. Standard 6 is not applicable to Southmead. EVIDENCE: DS0000004060.V279251.R01.S.doc Version 5.1 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 the following standard(s): 9 and 10 Medication in the home is well managed, promoting good health. The ethos in the home is one of respect for the residents living there. This means that the residents feel settled and at home and their privacy is respected. EVIDENCE: Medication systems were examined. Appropriate recording systems are in place and all staff responsible for administering medication have received up dated training. Medication was stored and secured appropriately. Some medication administration records for a new resident had had to be handwritten; these entries had not been signed or counter signed. Those residents spoken with confirmed that they feel respected by staff and are able to maintain their privacy when receiving personal visits from professionals such as GP’s and solicitors, family and friends. It was observed that staff knock on doors before entering and that residents preferred form of address is recorded and used. DS0000004060.V279251.R01.S.doc Version 5.1 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 the following standard(s): 15 Dietary needs of the residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and choices. EVIDENCE: Lunch on the day of the inspection was mushroom soup followed by fish, chips and peas and then either crème caramel or diabetic jelly. Examination of food records showed a varied diet. The main meal of the day is at lunchtime. Due to the size of the home it is not practical to prepare more than one main item. Menus are displayed to enable residents to say that they do not like the meal. Records clearly demonstrated that staff are aware of residents likes and dislikes and that alternatives are provided should someone not want to eat the main meal that is being prepared. Records also showed that there is a wide variety of light items prepared in the evening. Stocks were also inspected and it was found that there was a variety of different foods available with plenty of fresh, frozen and dried goods. DS0000004060.V279251.R01.S.doc Version 5.1 Page 11 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 the following standard(s): None of these standards were assessed on this occasion as both key standards were assessed at the last inspection and found to be met. EVIDENCE: DS0000004060.V279251.R01.S.doc Version 5.1 Page 12 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 the following standard(s): None of these standards were assessed on this occasion as both key standards were assessed at the last inspection and found to be met. EVIDENCE: DS0000004060.V279251.R01.S.doc Version 5.1 Page 13 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 29 There is a stable, consistent staff group who are trained and competent to do their jobs. Residents should therefore feel confident that they are in safe hands and their care needs can be met. Previous inspections have evidenced that recruitment and vetting practices are in place to minimise the risk of unsuitable staff being employed. EVIDENCE: Three of the ten care staff have achieved NVQ level 2 and a further 2 are near to completion meaning that the home will then be fully compliant with this standard. No new staff have been employed for some time. Staff files have been examined on previous occasions and found to be satisfactory. DS0000004060.V279251.R01.S.doc Version 5.1 Page 14 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 35 The management arrangements of the home support good care practices for residents. The home undertakes reviews of its performance but needs to formalise these results in order to evidence the work that has been undertaken and the response the home has made. Management practices, with regard to the financial interests of residents, are satisfactory and demonstrate that appropriate safeguards are in place. EVIDENCE: Mrs Fletcher has owned and managed Southmead for a number of years and prior to this has experience in other care settings. She confirmed that she has now completed her NVQ4 in management and care. DS0000004060.V279251.R01.S.doc Version 5.1 Page 15 The home has a quality assurance system and this includes resident and other stakeholder surveys. A survey had been undertaken in 2005 and the results analysed but not published in the form of an annual development plan. Mrs Jenkins confirmed that residents are encouraged to retain control of their own finances for as long as possible. Where they state that they no longer wish to or they lack the capacity to do so then the home ensures that either family or other representatives such as solicitors take on this role. DS0000004060.V279251.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X X DS0000004060.V279251.R01.S.doc Version 5.1 Page 17 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 2 Refer to Standard OP9 OP33 Good Practice Recommendations Hand written entries on Medication Administration Records should be signed and then checked and counter signed by a second person. An annual development plan for the home must be created and then published to current and prospective residents, their representatives and other interested parties. DS0000004060.V279251.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Poole Office 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
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