Inspection on 03/10/08 for Southover Care Home

This inspection was carried out on 3rd October 2008.

CSCI found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southover Care Home 15/09/09

Southover Care Home 24/06/09

Southover Care Home 07/05/09

Southover Care Home 20/01/09

Southover Care Home 16/07/08

Southover Care Home 06/08/07

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

Inspecting for better lives Random inspection report Care homes for older people Name: Address: Southover Care Home 397 Burton Road Derby DE23 6AN The quality rating for this care home is: The rating was made on: zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Anthony Barker Date: 0 3 1 0 2 0 0 8 Information about the care home Name of care home: Address: Southover Care Home 397 Burton Road Derby DE23 6AN 01332295428 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: White Doves Residential Home Limited care home 22 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category 0 Over 65 22 Conditions of registration: The registered provider may provide the following categories of service only: Care Home only - PC To service users of the following gender: Either Whose primary care needs on admission to the home fall within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is 22 Date of last inspection Brief description of the care home Southover is a two-storey building situated on the Burton Road, approximately a mile and half from Derby city centre. A passenger lift allows access for residents all around the Home. There is ample dining space, and leading from this large room are two sitting rooms. From one of these rooms there is access to a glass conservatory and from there to the large garden. Tables and seating are also provided in the garden. Ample parking space is available outside. Care Homes for Older People Page 2 of 14 What we found: The time spent on this inspection was 3.5 hours and was a random unannounced inspection. We were accompanied by Derby Primary Care Teams Head Dietician. The senior care assistant in charge, the Deputy Manager, the cook on duty and one resident were spoken to. Records were inspected and there was a tour of the premises. This inspection was to assess the Services compliance with the requirements made following the key inspection of 16th July and the random inspection of 21st August 2008. The requirements considered were those with timescales that had passed at the date of this inspection. The outcome of this inspection is as follows: Standard 9: Medication Prescribed creams were found, in two residents bedrooms, that had been opened but no record had been made of the date of opening. Staff would therefore not know the 28-day use-by date. Two residents were prescribed Temazepam but, as at the last two inspections, this was not being safely stored in a dedicated controlled drugs cabinet. They were in the drugs trolley. Other medicines were being securely stored. The Deputy Manager said that a Controlled Drugs Register had been received the previous day and would be used to record the administration of Temazepam. This is considered good practice. Standard 12: Social Contact and Activities Table games had been newly purchased in order to provide residents with stimulation. The senior care assistant in charge, on the morning of this inspection, confirmed they were being used. She added that there were also weekly musical afternoons, quiz nights and a pub meal is planned. On the day of this inspection a group of residents were off to Blackpool for the weekend. The senior care assistant said, Ive noticed a difference - (residents) are really, really happy. The activities that residents were involved in were being recorded on Activity Sheets, although there were no sheets for six residents. The senior care assistant said there were reasons why one or two residents did not take part in activities. One resident told us that staff encourage residents in activities. Standard 15: Meals and Mealtimes Menus could not initially be found whilst the dietician was in the Home. Eventually, two weeks menus were found but it was unclear whether there may be another two menu sheets somewhere. There was no evidence that residents were being offered meals based on a structured rolling menu to which they have access. This was supported later by cross-referencing the menu sheets against Food Eaten sheets and these did not correspond. One resident spoken to at this inspection said that the food was excellent...ample. Standard 18: Protection The Registered Providers Improvement Plan states that Safeguarding Adults training will take place on 24th and 27th October 2008. It also states that staff will be trained to ensure they are aware of the Services Whistle Blowing policy, by 30th November 2008. Standard 19: Environment We were pleased to note that several health and safety hazards had been addressed since the last inspection. A number of these hazards had been noted at visits made by the Environmental Health Officer and Fire Officer. For this reason, reference is not being made to them in this report. The timescales given to Care Homes for Older People Page 3 of 14 some environmental defects and hazards had not passed at the time of this inspection and others were extended to reflect the Providers planned timescales set out in the Improvement Plan she has provided us with. However, some matters were still outstanding and had not been addressed in the Improvement Plan with clear dates for completion. These outstanding issues are identified in the requirements at the end of this report. Decorators were painting one lounge, the kitchen and dining room at the time of this inspection. Since this inspection we have been informed by the Provider that several rooms have been redecorated and re-carpeted and replacement furniture provided. Standard 26: Hygiene and Control of Infection The senior care assistant in charge pointed out that improvements had been made to the transfer of infected materials within the Home, through a new yellow bag container in the first floor toilet. Standard 27: Staff Complement There was evidence from staffing rotas to support the senior care assistants expressed view that Staffing has improved...(there is a) more stable staff group. New staff had been appointed and the rota showed that suitable experienced staff were leading each shift. Standard 29: Recruitment The key to the office was not available at the time of this inspection. It was therefore not possible to confirm whether Criminal Records Bureau (CRB) Disclosures were in place for all staff. These Disclosures indicate the fitness of staff to work with vulnerable adults. However, one care assistant spoken to, who had worked at Southover for two weeks, said a CRB Disclosure for her was received before she started work. Standard 30: Staff Training Staff training sheets showed that First Aid and Moving & Handling training courses had been provided and Fire training was planned for November 2008. The Providers Improvement Plan made no mention of plans for staff training in Basic Food Hygiene. Standard 32: Ethos The senior care assistant in charge said that there wasbetter teamwork now (at Southover)...we can talk to (the Provider) and shes making changes. One resident spoken to referred to,improved staff attitudes. Standard 33: Quality Assurance As at the last inspection, there were no records of any monthly, monitoring visits to the Home, undertaken by the Registered Provider. Standard 35: Service Users Money The key to the office was not available at the time of this inspection. Therefore, as at the last inspection, residents who wished to access their money were unable to unless they had requested money in advance. Standard 36: Staff Supervision The senior assistant in charge said that the Providers plan to provide formal, planned one to one supervision of staff was discussed at the last staff meeting, five/six weeks previously. We were not able to check whether the Provider was providing this supervision, as records were not available. Standard 37: Record Keeping It was noted that residents confidential records were being stored in an unlocked cupboard. The Deputy Manager confirmed that the cupboard lock handle had still not been repaired. Care Homes for Older People Page 4 of 14 Standard 38: Safe Working Practices The Registered Providers Improvement Plan states that electrical equipment, gas and heating appliances and the shaft lift have all been serviced. In a telephone conversation with the Provider, following this inspection, she confirmed that the hoist, chair lift, bath lifts and wheel chairs had not been serviced. This potentially puts residents at risk. What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 5 of 14 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These requirements were set at the last inspection. They may not have been looked at during this inspection, as a random inspection is short and focussed. The registered person must take the necessary action to comply with these requirements within the timescales set. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 6 of 14 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 4 18 18(1)(a) Residents assessed 31/10/2008 needs must be met by a staff group which has the necessary skills and experience. This requirement has been given a new timescale agreed with the Provider. This will ensure that staff are meeting residents current needs. 2 7 15 15(2)(b) Care plans and risk 30/11/2008 assessments must be kept up to date. This requirement has been given a new timescale agreed with the Provider. This will ensure that staff are meeting peoples current needs. 3 9 13 13(2) There must be a date 01/11/2008 of opening recorded on all medication with a reduced expiry once opened. Previous timescale was 01/09/08. This will ensure the safety of service users. Care Homes for Older People Page 7 of 14 4 9 13 13(2) Controlled drugs must 01/12/2008 be stored in a wall cabinet specifically designed for their safe storage. This timescale had not passed. This will ensure that medicines are not at risk of being stolen or accidentally taken by a resident. 5 15 16 16(2)(i) There must be a systematic system in place, through the use of menus. Previous timescale was 21/08/08. This will ensure that residents have a balanced and nutritious diet. 01/11/2008 6 18 13 13(6) Staff must be made 30/11/2008 aware of the Services Whistle Blowing policy and it must be reinforced with those that have already read it. This requirement has been given a new timescale agreed with the Provider. This will ensure staff speak up about any abuse they suspect and people using the service will be protected from harm. 7 18 13 13(6) All care staff must be 01/11/2008 provided with safeguarding adults training. This requirement has been given a new timescale agreed with the Provider. This will ensure they are fully aware of how to respond to evidence of abuse and people using the service will be protected from harm. 8 19 23 23(2)(o) The clothes lines, strung across the tarmac area at the side of the 01/11/2008 Care Homes for Older People Page 8 of 14 premises, must be moved. Previous timescale was 01/09/08 This will ensure they no longer cause a potential obstruction and hazard to residents. 9 19 23 23(2)(b) Wood rot in the 01/02/2009 eaves of the roof and the exterior window sills must be treated. This timescale had not passed. This will ensure the soundness of the building is not compromised and residents and staff not put at risk. 10 19 23 23(2)(p) Adequate lighting 01/11/2008 must be provided in all areas of the Home used by residents. Previous timescale was 01/09/08 This will reduce the risk of them falling or otherwise hurting themselves. 11 19 12 13(4)(a)(c) A highly visible strip must be placed on the wooden step immediately beyond the two fire escape doors. Previous timescale was 01/09/08 This will minimise the potential for residents to trip and harm themselves. 12 19 13 13(4)(a)(c) A risk 30/11/2008 assessment must be produced that addresses the risk to residents through there being no alarm on either of the two fire escape doors. This requirement has been given a new timescale agreed with the Provider. 01/11/2008 Care Homes for Older People Page 9 of 14 This will ensure the safety of residents who may wander out of these doors. 13 19 23 23(2)(b) Repairs must be 01/07/2009 made to the boundary fences and walls of the property to reduce the risk of intruders entering the grounds at night. This requirement has been given a new timescale agreed with the Provider. This will reduce the risk of intruders entering the grounds at night. 14 29 19 19(1)(b) Sch.2 The Provider must ensure that staff receive a check by the CRB. Documents were not available in order to assess compliance with this requirement. The previous timescale was 01/09/08 This will show they are fit to work with vulnerable adults and not likely to put them at risk. 15 30 16 16(2)(j) All staff must be provided with training in basic food hygiene. This timescale had not passed. This will ensure that residents health is not put at risk when staff handle their food. 16 30 23 23(4)(d) All staff must be provided with fire safety training. This requirement has been given a new timescale agreed with the Provider. This will ensure that the safety of residents is not compromised, particularly at Care Homes for Older People Page 10 of 14 01/11/2008 01/11/2008 01/12/2008 night. 17 33 26 Monthly audit visits to the Service by the Registered Provider, as required by Regulation 26, must take place and be recorded. Previous timescale was 01/09/08 This will provide an oversight of the Service and identify matters requiring attention, to ensure that residents needs are met. A copy of this report must be supplied, each month, to the Commission. 18 35 23 23(2)(m) The Provider must 01/11/2008 ensure that arrangements are made for residents to have access to their personal monies when the Provider is absent. Previous timescale was 01/09/08 This will ensure that residents have control of their own money at all times. 19 36 18 18(2) Staff must receive formal supervision. Previous timescale was 01/09/08 This will ensure that the Services policies and procedures are put into practice and residents needs met. 20 37 17 17(1)(b) All records required 01/11/2008 by Regulation to be maintained by the Service must be kept secure. Previous timescale was 01/09/08 This will ensure that residents personal and confidential documents are not read by persons who Care Homes for Older People Page 11 of 14 01/11/2008 01/11/2008 may abuse this information causing harm to residents. 21 38 23 23(2)(c) Equipment provided 01/12/2008 must be maintained in good, safe working order. This includes hoists, the chair lift, bath lifts and wheel chairs. Previous timescale was 01/10/08 This will protect residents from any unnecessary risks. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 1 7 The Service Users Guide should contain details of the fees payable by residents. Care planning records should reflect a person centred approach to ensure that residents preferred lifestyles are identified. Care plans should set out a record of how residents needs are to be met - for example, through a set of goals. Records of health professionals involvement should be made in one place to prevent confusion. The receipt, administration and disposal of controlled drugs, such as Temazepam, should be made in a controlled drugs register in order to provide a more robust audit of their use. Residents should continue to be provided with a varied range of activities that meet their need for mental and physical stimulation. The Activity Sheets should be used to record the nature and degree of all residents involvement in activities. The Provider should, within 28 days of the Commission submitting details of a complaint and requesting a response, notify us of the action to be taken. The Services maintenance book should have dates recorded from which an assessment can be made of the time taken to rectify defects. The flower bed to the side of the premises, and the rear lawn, should be tended and weeds removed from the front Page 12 of 14 3 4 5 7 8 9 6 12 7 16 8 19 9 19 Care Homes for Older People of the premises. 10 19 Cracks in the ceiling and walls of the first floor bathroom, and of corridor walls, should be appropriately dealt with and redecorated. The induction and foundation training of new staff should meet the current specifications laid down by Skills for Care. Staff training in Moving & Handling should continue to ensure that staff can safely work with residents who have difficulty in moving. Staff training in First Aid should continue until all staff are competent to act appropriately in the event of an accident to a resident. Staff should receive formal supervision at a frequency of six times a year and records of this supervision should be maintained. All staff should be provided with training in Health & Safety. 11 30 12 30 13 30 14 36 15 38 Care Homes for Older People Page 13 of 14 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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