Inspection on 29/09/05 for Southminster Residential Home

This inspection was carried out on 29th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 26/05/05

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 Draft Unannounced Inspection 29th September 2005 10:30 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 Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 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. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Southminster Residential Home Address Station Road Southminster Essex CM0 7EW 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) 01621 773462 Top Care Homes Ltd Mrs Elizabeth Wynn Care Home 29 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (29) of places Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 29 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 15 persons) The total number of service users accommodated in the home must not exceed 29 persons Minimum daytime staffing to include five carers on duty Date of last inspection 26th May 2005 Brief Description of the Service: Southminster Residential Home provides residential and personal care for up to 29 older people. The home changed owners earlier in 2005, 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 DS0000063215.V254016.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place at 1030 hours on Thursday 29th September 2005. This was the second inspection of this home in the inspection year 2005/6. The content of this report reflects the inspector’s 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 training. What the service does well: What has improved since the last inspection? New carpets had been laid to all communal rooms and corridors, and in the office. Internal re-decoration had continued. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 Page 6 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. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 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 Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 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): 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. The format includes a section to take account of the possible higher dependency needs of those suffering with dementia. After admission a care plan is compiled. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 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): 8&9 The health care needs of residents were generally assured. The home’s medication procedures, practices and staff training appeared to provide adequate guidance for dealing with medicines. EVIDENCE: Individual care plan manual handling assessments now include details of equipment needed/to be used by staff ie: slings/hoists/sliding sheets. Two GP surgeries were used by the home. One practice (Southminster) takes on all new residents from outside of the area. This GP also holds a fortnightly surgery in the home. The new Practioner Nurse from this surgery also visits regularly to offer support and advise regarding residents healthcare needs. Personal and oral health needs were recorded in care plans. There were pressure sore risk assessments in place, district nursing services provide support on this issue, including risk assessment. The home has provided pressure relieving equipment, in addition district nursing services are utilised for equipment needs. Advice and assessments on continence issues is obtained through the Community Continence Adviser. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 Page 10 Community Psychiatric Nursing support is utilised where appropriate, through GPs. Nutritional advice is obtained via the Community Dietician and the diabetic nurse has provided advice to staff when need identified. Chiropody services and eye tests are provided in the home (by visiting practitioners). Visiting dental services are no longer available unless in an emergency. Residents visit the dentist in the community with family or staff support. The home’s medication policy and procedure was unchanged since last inspected. A self assessment was still in place but there were no residents self administering their own medication. The manager confirmed that lockable facilities would be provided for any future residents who self medicate. The home’s pharmacist no longer provides update training to staff. All senior’s had, in the past, undertaken the certificated ‘Safe Handling of Medicines’ course, run by a local college, also two staff were currently undertaking this training The manager advised that only senior staff deemed ‘as competent’ by the manager administer medication. Written guidance for staff was seen on the side effects and what to do if a dose missed or overdose administered for all medication currently prescribed to residents. Records of medications received, administered and returned were inspected, all seen were considered appropriately maintained. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 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 the following standard(s): 14 & 15 Residents were supported in exercising choice regarding day to day routines in the home. Meals provided would appear to ensure a wholesome, varied and nutritious diet for residents. EVIDENCE: At the time of this inspection no resident managed his/her own financial affairs. Relatives or court of protection provided this support. Some personal allowance monies were held by the home, records were maintained of balances and transactions. The manager confirmed that contact details of independent advocacy services was displayed in the entrance hallway. Records of personal items brought into the home on admission were recorded in care plane files. Nutrition records evidenced choices available. Menus were displayed daily. Residents spoken with said they were satisfied with the food provided, one said the food was ‘smashing’. The main meal is lunch with two choices available at the mealtime. A further option is provided if requested. Drinks are provided at regular intervals and available at all times, teatime meals offered a hot or cold alternative. The manager confirmed that supper snacks of sandwiches are provided to residents on request. Staff provide support at mealtimes. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 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 the following standard(s): 18 Procedures and polices in place were aimed at protecting residents from abuse. EVIDENCE: The home had an adult protection procedure and whistleblowing policy in place. There was also a copy of the Essex County Council ‘Adult Protection Guidelines’ document. The home was also provided a copy of the Dept of Health’s guide to POVA (protection of vulnerable adults) procedures. NVQ & dementia training includes adult protection issues however staff would benefit from further training on this subject. A recommendation has been made in this report on this. The manager and deputy manager had attended the half day training provided by Essex Vulnerable Adults Protection Committee. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 23, 24, 25, 26 The home was generally comfortable and well maintained. Residents’ outdoor space to the front and side of the property was accessible and well kept. 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 continued the programme of decoration of the interior of the home. New carpets had been fitted in all communal living areas, corridors the office and four bedrooms. 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 DS0000063215.V254016.R01.S.doc Version 5.0 Page 14 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. 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. One of the bathrooms in the ‘Stable’ block is scheduled for conversion and refurbishment into a second ‘walk-in’ shower. 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. Individual lockable facilities were being fitted in rooms. All rooms seen were centrally heated with temperature controls. Radiators were guarded. 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 DS0000063215.V254016.R01.S.doc Version 5.0 Page 15 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): 27 & 30 Staffing levels and skills appeared to meet the needs of residents. Staff were provided induction and training opportunities to ensure competency in undertaking their roles. 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 1700–2100 hours. Night staffing begins at 2100 hours with usually three (occasionally reducing to a minimum of 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. Staff files were seen to include a photograph to prove identity, this met the requirement made in the last report. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 Page 16 Individual staff training records evidenced training provided has included: dementia (includes a three month distance learning course), safe handling of medicines, NVQ, manual handling (the manager is a M.H trainer), good care practice, first aid, infection control, safety in the workplace, H & S, fire prevention, food hygiene. Nine staff have the NVQ 2 and one had the NVQ 3. Two were undertaking NVQ 3. The manager is a qualified nurse and has the NVQ 4 in management award. All new staff receive induction training which is modular based and links in with NVQ level 2 training, which is provided to all new staff as soon as possible. The induction format was an impressive document offering a thorough and comprehensive introduction, and the manager’s expectations, for the role of carer. Sections included: layout, health and safety, fire and emergency, communication, records, policies and procedures, team work, team building, specific tasks, personal care, supervision, training and development needs, first aid, adult protection, hygiene and manual handling. All new staff are also issued with a staff handbook. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 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 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): 33, 35 & 37 Procedures for gaining the views of residents and relatives had been implemented, however evidence should be available of any resulting actions taken. Residents’ financial interests appeared to have been safeguarded. Records required by regulation were in place and up to date. EVIDENCE: The home had a quality assurance questionnaire that had been circulated to residents and relatives. The format included seeking views on staff attitudes, care provided, safety, food, privacy and activities offered. Results of responses were available for inspection. However there was no documentary evidence to confirm what action (if any required) had been taken by the home. There is a recommendation regarding this point in this report. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 Page 18 There were no residents managing their own financial affairs. Relatives or the Court of Protection provided this support. Personal allowance monies were held for safekeeping for two residents. Records were maintained of balances and transactions. Records of personal items brought into the home on admission were recorded in care plane files. Random samples of records required to be kept were inspected including: assessments, fire drills, background information and next of kin details, visitors book, regulation 37 notices, staff rota, nutrition records, menus, accident records, money held for safekeeping and fire procedures. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 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 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 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 3 3 X 3 3 3 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 X X 2 X 3 X 3 X Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 Page 20 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 3 Refer to Standard 18 19 33 Good Practice Recommendations The registered provider should ensure that staff training includes POVA (protection of vulnerable adults) procedures and guidance. The registered provider should ensure that the carpet in room 31 is replaced/renewed. The registered manager should ensure that a written summary is available for inspection of any actions taken resulting from the home’s quality assurance process. Southminster Residential Home DS0000063215.V254016.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, 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 DS0000063215.V254016.R01.S.doc Version 5.0 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. 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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