Inspection on 27/02/07 for Southmead

This inspection was carried out on 27th 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

Southmead 20/01/06

Southmead 11/07/05

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 Poole Dorset BH18 8ES Lead Inspector Catherine Churches Unannounced Inspection 27th February 2007 10:00 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 Southmead DS0000004060.V331331.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 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 DS0000004060.V331331.R01.S.doc Version 5.2 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 Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th January 2006 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. At the time of the inspection fees ranged from £350 to £500 per week. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key, unannounced inspection undertaken on 27th February 2007. The inspection took place as part of the regular, programmed inspection schedule for the home. The last inspection was January 2006. The purpose of this visit was to monitor the homes compliance with National Minimum Standards and compliance with recommendations made during the previous inspection. Also, to check that the home is 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, visitors and staff. Prior to the inspection survey/comment cards were sent out to residents, relatives, GP’s, healthcare professionals and care managers. Twenty nine responses were received in total: 14 from residents, 10 from relatives and five from GP’s. This is an exceptionally high return rate and all were positive about the home. Analysis is included within the relevant sections of this report. Some of the comments that were added to the surveys or received during the inspection were as follows: “A delightful caring environment” “The residents are very happy and the staff extremely caring” “I am extremely satisfied with the standard of care provided by Southmead” “A wonderful residential home. We feel we are very lucky to have our Mother in it” “ The home is lovely and so are the staff” “The activities are very good. I really enjoyed “Shall we Dance”” “ I have been here a very long time and live very happily” “I enjoyed the trip around the harbour to Wareham and the cream tea” This report refers throughout to “residents” meaning to include persons accommodated in the residential units of the home, patients in the nursing units and the overall term “service users”, which is the preferred term of the Commission. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 6 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. Minor improvements in the recording of accidents are also required to ensure that the information recorded in kept in accordance with the Data Protection Act 1998. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 7 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. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 8 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 Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of prospective residents needs continue to be satisfactory. This means that residents can be certain that the home is aware of their requirements prior to their admission to the home and that the staff will therefore be able and prepared to meet these needs. EVIDENCE: Documentation for three residents was examined as part of the case tracking procedure used during this inspection. Two of these residents had been newly admitted to the home since the last inspection. Both pre-admission assessments were viewed. They contained good information about each persons needs and a letter was also available on file to Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 10 confirm, that having carried out the assessment, the home could meet the persons needs. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. 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 at the home and their privacy is respected. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 12 EVIDENCE: Care Plans and related documentation regarding care for 3 residents were examined. Files were well laid out and risk assessments had been undertaken. Reviews were being undertaken on a monthly basis or more frequently if changes dictated this. Evidence was available on file and through discussion that GP’s, district nurses, specialist nurses and other health professionals are called upon whenever the need arises. 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 counter signed by a second member of staff. During conversations with a number of residents, they confirmed (where they were able to) that they were happy with the care they received and that either they or their representatives are involved in reviews. They also confirmed that they feel respected by staff and are able to maintain their privacy when receiving personal care or 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. The home has a good policy for the promotion of privacy and dignity but not all staff and had signed to confirm that they had read this Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social, cultural and recreational activities are dependent on individual preferences and the resident’s capacity for involvement. Open visiting arrangements are in place enabling residents to retain contact with families and friends. Residents have the opportunity to choose their own lifestyle within the home and this means that their individual preferences and routines are respected. Dietary needs of the residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and needs. EVIDENCE: Residents are encouraged to continue any interests that they followed prior to moving to the home. They are assisted to get to a community and church Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 14 meetings twice a week, there is a weekly communion service in the home, visiting entertainers, various activities, crafts and reminiscence within the home and various videos, music etc is available in the lounge. Question 7 of the resident’s questionnaire sent out prior to the inspection asked “Are there activities arranged by the home that you can take part in?” 14 people responded “Always” 0 people responded “Usually” 0 person responded “sometimes” 0 people responded “never” 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. 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. Residents confirmed that a suitable and varied diet is provided in the home. . 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. Question 8 of the resident’s questionnaire sent out prior to the inspection asked “Do you like the meals at the home?” 11 people responded “Always” 2 people responded “Usually” 1 person responded “sometimes” 0 people responded “never” Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 taken seriously and that matters of concern will be acted upon. Arrangements for protecting service users from abuse were satisfactory. This means that Southmead is a safe environment that will protect residents from abuse. EVIDENCE: The complaints procedure was displayed in the main hallway of the home and included in the Service Users Guide/Terms and conditions of residence that is given to all residents/representatives. No complaints have been made to CSCI or to the home since the last inspection. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 16 Question 9 of the resident’s questionnaire sent out prior to the inspection asked “Do you know who to speak to if you are not happy?” 14 people responded “Always” 0 people responded “Usually” 0 people responded “sometimes” Question 10 of the resident’s questionnaire sent out prior to the inspection asked “Do you know how to make a complaint?” 14 people responded “Always” 0 people responded “Usually” 0 people responded “sometimes” Policies and procedures for adult protection and whistle blowing were checked and found to be satisfactory. Staff have all had copies of the homes policy and procedure for recognising and preventing abuse as well as specific training in this matter. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 nicely decorated and furnished. Dorset Fire and Rescue Service have visited the home and confirmed that it complies with their requirements. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 18 Bedrooms are nicely furnished and residents have brought personal items such as furniture, pictures, photographs, ornaments and other items to help them personalise their rooms. The lounge and dining room are nicely decorated and furnished with a choice of seating available to residents. Staff had a good understanding of infection control procedures and the relevant protective clothing was available. There was a detailed infection control policy in the home that covered all of the required areas. Training records were available to demonstrate that most staff have undertaken appropriate training and a plan was in place for those still requiring training. Question 11 of the resident’s questionnaire sent out prior to the inspection asked “Is the home clean and fresh?” 14 people responded “Always” 0 people responded “Usually” 0 people responded “sometimes” Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 manager and staff. Staff have experience in caring for the elderly, a number have already achieved the minimum vocational qualification and others are undertaking training to further develop their abilities and competencies. This means that the home exceeds the requirement of 50 of staff to be trained and demonstrates that the home is committed to staff development and providing good care for its residents. Recruitment procedures are satisfactory and this gives further protection to residents. Induction of new staff is undertaken within the timescales and to a good standard. This means that staff have the necessary skills to enable them to undertake all aspects of their role competently. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 20 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. Five of the nine care staff have achieved NVQ level 2 and a further 2 are studying the qualification. Staff records were examined for three members of staff. These demonstrated that appropriate recruitment practices are in place: application forms were completed; interviews documented and appropriate evidence of identity and qualifications had been obtained. References, Criminal Records Bureau and POVA checks had also been completed as required. The new Skills for Care induction programme has been implemented in the home and evidence that new staff were undertaking this was available. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mrs Fletcher has completed the necessary training and has many years experience in caring for the elderly. She is a competent, committed and approachable manager and both residents, visitors and staff confirmed this. The home regularly reviews aspects of its performance through a well thought out programme of self-review and consultations, which include seeking the views of residents, staff and relatives. Resident’s finances are safeguarded with clear policies and procedures and management guidance. The health, safety and welfare of residents and staff is protected by the systems that the home has in place for staff training, maintenance and risk assessment. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 22 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. The home has detailed policies and procedures for the promotion of quality assurance in the home. Mr Fletcher showed the inspector the results and analysis of the 2006 survey and confirmed that annual surveys and analysis is due to be undertaken again later in the year. Mrs Fletcher 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. No cash or valuables are held in the home for residents. Fire records, staff training records and accident books were examined and found to be up to date and detailed. It was noted that the accident book was not being used in accordance with requirements of the Data Protection Act and this was highlighted to Mrs Fletcher. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 24 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 OP38 Good Practice Recommendations Hand written entries on Medication Administration Records should be signed and then checked and counter signed by a second person. All accidents should be recorded, and the information stored, in accordance with the Data Protection Act 1998. Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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. Extracts may not be used or reproduced without the express permission of CSCI Southmead DS0000004060.V331331.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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