Inspection on 26/05/05 for Southminster Residential Home

This inspection was carried out on 26th May 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

Southminster Residential Home 18/08/08

Southminster Residential Home 21/08/07

Southminster Residential Home 20/07/06

Southminster Residential Home 29/09/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Southminster Residential Home Station Road Southminster Essex CM0 7EW Lead Inspector Alan Thompson Final Report Unannounced 26th May 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 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. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Southminster Residential Home Address Station Road Southminster Essex CM0 7EW 01261 773462 01206 774032 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) Top Care Homes Ltd Mrs E Wynn Care home 29 (twenty nine) Category(ies) of Dementia - over 65 years of age (15 places) registration, with number Old age, not falling within any other category of places (29 places). Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 29 persons) 2. Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 15 persons) 3. The total number of service users accommodated in the home must nnot exceed 29 persons. Date of last inspection N/A Brief Description of the Service: Southminster Residential Home provides residential and personal care for up to 29 older people. The home has changed owners since the last inspection and is now run by an organisation named Top Care Homes Ltd. Southminster R.H. is located in the rural village of Southminster a few miles from Maldon, Essex. The premises was originally built as the village Manor House. There are two floors to the home, accessed by stairs and a passenger lift. In total there are thirteen single bedrooms and eight double bedrooms on both floors, with two lounge/dining rooms on the ground floor. There are gardens to the front and side of the property that are attractive and accessible. Southminster is accessible by road and rail. The nearest station is in the village, approximately 300 metres away from the home. Visitor car parking is available to the front, side and rear of the property. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place at 1100 hours on Thursday 26th May 2005. This was the first inspection of this home in the inspection year 2005/6, and since the home changed ownership in February this year. The content of this report reflects the inspectors findings on the day of the inspection, and from taking account of relevant findings from previous inspections of the home. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Residents, visitors and staff were spoken with. Random samples of records, policies and procedures were inspected and a tour of the premises took place. All residents spoken to expressed satisfaction with the care they received and with the quality of the food and accommodation offered. Visitors spoken with confirmed that they considered the home provided a good care service to residents. Staff confirmed they received support from management. They also confirmed that they had been offered NVQ award level 2 training. What the service does well: What has improved since the last inspection? What they could do better: Staff recruitment records need to include a photograph to confirm identity. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 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. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 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 Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 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 The home’s assessment format and process was adequate for ensuring that initial perceived needs were identified upon admission. EVIDENCE: The manager and deputy manager or senior carer always visit prospective new residents to carry out an initial assessment of needs. The format seen included assessment of needs under headings of mobility, toilet, continence, dressing, feeding, washing, bathing, speech, sight, hearing, comprehension, memory, orientation, awareness, behaviour, sociability, travel. Immediately following admission into the home further information is recorded including background information, next of kin details, social worker name, GP, weight, dietary needs, mental state, psychological status, medical history, personal details, dental needs, foot care, social profile, religious and cultural needs. Since the last announced inspection an additional section has been added by the manager to take account of the possible higher dependency needs of those suffering with dementia. After admission a care plan is compiled. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 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 &10 Care plans were in place and were considered to set out the residents daily needs. Staff appeared to pay attention to ensuring that residents privacy and dignity was respected. EVIDENCE: Three care plans were inspected. These had been compiled utilising and including the assessment format detailed in the previous section of this report. In addition sections included in care plans recorded a description of the resident, background information and personal inventory, waking routine, food and mealtime needs, bedtime routine, daily routines and interests (including social and hobbies), like & dislikes, allergies, medication, personal hygiene, special service needs, social needs, relationships, activities, occupation, links with community, general health. These sections included a detailed breakdown of needs under each main heading. A working daily plan of care was then shown for staff to follow headed: area of difficulty, aims for staff, objectives for the resident, with recorded interventions. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 10 Plans were reviewed in-house on a monthly timescale, with additional recorded reviews taking place involving appropriate relatives according to assessed needs. Individual care plan files also included a self medication assessment, with risks, fluid charts, daily nutritional records, daily care notes, bowel chart, turning chart, records of GP visits, manual handling care plan and risk assessment. Residents spoken with confirmed that they wear their own clothes and that staff show respect towards their privacy and dignity when providing personal care support. Screens were provided in shared rooms. Some residents had their own private telephone lines in their rooms. A cordless telephone was available for all residents to receive (and make reasonable) phone calls in private. GP and other consultations were carried out in private. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 11 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 Activities had been offered in the home. This included opportunities for meeting community contact and religious observance needs. The home had maintained good contact with and encouraged involvement from relatives. Involvement had also been welcomed from community contacts. EVIDENCE: A new activities coordinator had been recently employed to work part time five days a week. Activities offered included bingo, walks, shopping trips on the train, indoor games, reading, ball games, reminiscence, videos/DVDs. Visiting entertainers are booked regularly and a volunteer visits weekly to sing to residents. There was also a monthly visit to the home from an independent advocate. A monthly church service takes place in the home. Residents’ interests were recorded in care plans and those spoken with said they were satisfied with the interests and activities offered, although one did say he would like there to be more activities available. This comment was relayed on to the manager and registered person who undertook to ensure that the new activities person takes full account of the wishes of residents. Visitors spoken with confirmed that they were made welcome by staff. One resident said that his visitors had a meal with him in the home. The manager said that visitors were welcome at all times. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 12 Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 13 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 The home’s complaints procedure allowed for residents and relatives to formally raise any concerns or areas of dissatisfaction with the service. EVIDENCE: The complaints procedure was displayed in the home and is included in the statement of purpose. Included was guidance to the prospective complainant on who to complain to along with expected response times. The manager advised that written records would be kept of any complaints received and actions take taken. Contact details of the registration and statutory placing authority were also shown. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 14 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) 19-21, 23-26 The home provided an apparently comfortable living environment. The premises appeared safe, accessible and had sufficient (according to these standards) numbers of toilets and bathrooms. The home was considered clean and hygienic. EVIDENCE: The new owners had begun a programme of decoration of the interior of the home and decorators were working on the day of this inspection. Also planned was the fitting of new carpets in all communal living areas and corridors. Improvements had also been effected to the fire warning system in the main ground floor corridor, laundry room and office. The home had two communal lounge/dining rooms. There was no designated visitors room and the inspector was advised that the office is made available for residents/relatives to meet in private where required. Screens were also fitted in shared bedrooms to provide some privacy. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 15 Lighting and furnishings were domestic in character and considered suitable for the residents accommodated. Gardens at the front and side of the home were spacious and accessible, the grass was due for cutting. There were twenty one bedrooms, comprising thirteen single and eight shared. One shared room had ensuite wc. There were three bathrooms, of which two provided fixed assisted bathing facilities and the third allowing assisted bathing through use of a portable hoist. The home also had a ‘walk-in’ shower on the ground floor. Private rooms seen were all furnished and carpeted according to individual preferences and needs. Residents spoken with confirmed that they were satisfied with the accommodation provided them. The manager confirmed that locks are fitted to bedroom doors on request and according to assessed risks. All rooms seen were centrally heated with temperature controls. Emergency lighting was seen throughout the home. Water storage had been tested for legionella and hot water for bathing and washing is delivered at or close to 43 degrees celcuis (not tested). The laundry rooms were accessed off a main corridor well away from dining/food preparation areas. Washing machines were fitted with minimum 65 degree wash cycles (actually provided up to 90 degree cycle) and also had sluice cycle programmes. There was a separate sluice room nearby. Policies and procedures on infection control and disposal of clinical waste were in place. Risk assessments were in place for individuals and premises. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 16 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 & 29 Staffing levels and skills appeared to meet the needs of residents. Recruitment procedures aimed at safeguarding the protection of residents had been followed, however photographs were needed to confirm identity. EVIDENCE: Staffing rotas inspected evidenced a minimum of five carers on duty AM shifts with four on duty from 1400 – 2100 hours and one extra on from 1800 – 2300 hours. Night staffing begins at 2100 hours with two waking staff on until 0730 hours the next morning. Separate and additional staff were employed for cooking, cleaning, kitchen assistant, tea person, handyperson, activities, administrative and gardening duties/tasks. Evidence was provided to confirm that appropriate references, applications and Criminal Records Bureau checks were undertaken for all staff employed. One omission from staff recruitment records was the lack of photographs to support identity. There is a requirement on this issue in this report. Staff receive copies of the General Social Care Council code of conduct for social care workers. Staff spoken with confirmed that they received written terms and conditions of employment. The staff handbook provided to new staff contained detailed guidance on employment issues. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 17 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, 37 & 38 The home appeared to have been run and managed competently and professionally. The health and safety of residents and staff was generally assured. EVIDENCE: The Manager of the home is a second level registered nurse, has experience as a community nurse and has 10 years experience managing a care home. There was evidence that the manager had undertaken training in infection control, supervisory management, safe handling of medication, risk assessments and first aid and had recently completed the NVQ level 4 award in management, (certificate awaited). She also holds a ‘Manual Handling’ Instructor award. Random samples of records required to be kept were inspected including: care plans, assessments, fire drills, background information and next of kin details, visitors book, regulation 37 notices, staff rota, nutrition records, menus, accident records, and staff recruitment records. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 18 All were considered appropriately maintained at the time of this inspection except the shortfall requiring photographs of staff to confirm identity. Evidence was available to indicate that appropriate manual handling, fire safety, first aid, food hygiene and infection control training has been provided to staff. The control of substances hazardous to health regulations were considered met by the provision of information datasheets. Detailed assessments were in place covering safe working practices. Certificates/service were available for inspection to confirm that the homes fire alarms and fire equipment, gas supply, electrical installation, staff call bell system, passenger lift, emergency lighting, hoists and water storage facilities had all been tested/serviced within recommended timescales. Electrical portable appliance re-testing was due around the time of this inspection. Accident records are maintained and were seen. Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 19 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x x 3 3 Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 20 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 29 Regulation 19 Requirement The registered provider must ensure that staff recruitment records include a photograph to confirm identitiy. Timescale for action 31/7/05 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 None Good Practice Recommendations Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Fairfax House Causton Road Colchester Essex, CO1 1RJ 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 Southminster Residential Home I56 I05 S63215 Southminster V221986 UI 26.5.05 Stage 4.doc Version 1.30 Page 22 - 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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