CARE HOME ADULTS 18-65
Southside 1651 - 1653 Stratford Road Hall Green Birmingham B28 9JB Lead Inspector
Zeta Joseph Key Unannounced Inspection 5th July 2007 10:00 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 Southside DS0000068678.V339638.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 Adults 18-65. 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. Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Southside Address 1651 - 1653 Stratford Road Hall Green Birmingham B28 9JB 0121 744 1659 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 Janet Wyatt Mrs Kim Piercy Care Home 7 Category(ies) of Dementia (7) registration, with number of places Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The Registered Person may provide personal care and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: Dementia (DE) The maximum number of service users to be accommodated is 7. 2. Date of last inspection Brief Description of the Service: Southside is situated on the Stratford road, Hall Green, a short distance away from local shops where there is a good range of local facilities. The home has been converted to one large detached house and is set back behind a parking area for up to 5 cars. The main entrance to the home is accessible and suitable for wheelchair users. There is no passenger lift to where the first floor bedrooms can be accessed, but there is space for a lift to be fitted in the future; the second floor is living accommodation and can only be accessed by a lockable facility. There is a garden to the rear of the property, trees, shrubs and flowers that are well maintained, surround the garden. The home caters for up to seven people with working age dementia. The bedrooms sizes exceed the minimum standards and all are decorated in individual colours and well furnished. There is a kitchenette and dining/sitting room, a conservatory/lounge shared by the people living at the home. There is egress from the home into the rear garden. Southside is a specialist care home that provides care for adults of working age with dementia. A flexible service is provided which caters for individual requirements, such as help or supervision with all aspects of daily living. Although people may be physically fit and active, they may require help with personal care tasks. Activity and stimulation therapies are provided on a oneto–one basis so that residents can participate in sensory stimulation and discussion with people that are trained to undertake these sessions. According to the Service User Guide, the weekly charge for full time care at Southside is £850.00 per week. Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced fieldwork inspection was undertaken by one inspector and was carried out over a period of four hours. There were two people living at the home. Information was gathered from speaking with tow people living in the home, staff, and the registered manager. Following the inspection the home returned the completed CSCI Annual Quality Assurance Assessment (AQAA). Care, health and safety and staff records were audited. It was not always possible to hold meaningful conversations with some of the people living at the home because they had a form of dementia but care practices were observed in the communal rooms. What the service does well:
The service users guide was examined and this document includes all the relevant and required information to ensure that people who may want to live at the home know what is provided so they can choose whether or not they want to live there. The Adults and Communities Department of the Local Authority undertake a care assessment of people prior to them being provided with a residential placement; without this assessment people would not receive a care service. The assessment process gives people re-assurance before people move into the home. This document is detailed and clear so that people are assured that their needs can be met at the home. From the pre-assessment information examined, the service is flexible enough to provide personalised placement that people need because of their working age dementia needs. The pre-assessment information records show that people who express an interest in the home are given ample opportunity to attend the home and people are given time and reassurance to settle into the home. This means that people are assured that their care will be provided in the way they want them to be. Care plans and risk assessments are individualised and personalised so that staff know how to support each person and their needs can be met. All medication received in the home is always audited to make sure that people get the right medication at the right time. Staff were observed engaging with people so that appropriate support is provided which means that individual preferences about activities are always considered.
Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 6 People living at the home are always consulted about their life in the home including whether or not they choose to participate in activities in and/or outside the home. There are meeting notes to evidence this daily consultation and people can choose to lead the meeting or to takes notes of decisions that are made. This means that people can choose to do activities that they enjoy so that they have a good quality of life. The manager ensures that clear and accountable records is always kept of any money transactions and property for the people living at the home and this assures people that their money and property is always managed properly. The people living in the home are given the information they need so that they know how to make a complaint if needed. The manager undertakes regular audits of the cleaning schedules so that standards of cleanliness and hygiene is maintained, and this will mean that people are protected. Staffing levels are always maintained in sufficient numbers and this ensures that the needs of the people living in the home are always met. Staff recruitment records examined ensure that robust checks have been made to ensure that suitable people are employed. This means that rigorous recruitment management will always safeguard people. The manager ensures that staff are provided with the required training so they can always meet individual needs and this means that people will be kept safe from harm. A training matrix had been devised so it is clear what training each member of staff needs or has received, and this means that people are assured that staff they have the skills and knowledge to meet individual’s needs. Staff are provided with regular formal supervision from the qualified manager so that staff always know how to support the people living in the home. This assures people living at the home that they will receive care and support from staff who are supervised. From the tour of the home, it is evident that all areas of the home is safe so that people living there are not at risk of tripping or having accidents. Electrical equipment is tested to make sure these are safe to use. Fire records showed that fire equipment is tested regularly to ensure that the risks of a fire starting are minimised as much as possible. This assures people that the home is safe for them to live in. Improvements are continuing to be made to the environment so that more space is provided for people and this will mean that people will always live in a safe, homely and comfortable environment. Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 7 People do not share bedrooms and are assured their privacy and dignity. All bedrooms have ensuite shower, toilet and wash hand basin facilities. The kitchen was clean and tidy and is accessed by a coded door lock to protect the people living there from harm. The management of the home is of a very high standard this ensures that the home is well organised and staff are managed to ensure that they have the skills and knowledge to meet individual needs. The manager ensures that an effective quality assurance and monitoring system is implemented to monitor the quality of service provided and this ensures that the people living in the home benefit from good quality care. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people and their representatives are provided with information needed to choose Southside Care Home. People have their needs assessed and a contract which clearly tells them about how Southside will meet their needs. EVIDENCE: People are provided with Service User Guide information that they need to make an informed choice about whether they want to live at the home. The service users guide was examined and this document includes all the relevant and required information to ensure that people who may want to live at the home know what is provided so they can choose whether or not they want to live at Southside. Records sampled of the people who live in the home included a comprehensive service user guide and information leaflet. There were two people living in the home and one person attending for day care. Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 10 The Adults and Communities Department of the Local Authority undertake a care assessment of people prior to them being provided with a residential placement; without this assessment people would not receive a care service. From the pre-assessment information examined, the service is flexible enough to provide personalised placement that people need because of their working age dementia needs. The pre-assessment information records show that people who express an interest in the home are given ample opportunity to attend the home and people are given time and reassurance to settle into the home. This means that people are assured that their care will be provided in the way they want them to be. The assessment process was audited and this gives people re-assurance before people move into the home. This document is detailed and clear so that people are assured that their needs can be met at the home. The current assessment process is sufficient enough to ensure that people moving into the home will know that all their needs can be met. Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are involved in decisions about their lives, and this plays an active role in planning the care and support they receive. EVIDENCE: Care plans examined are robust, because people’s needs are outlined in these and it is clear to staff how they can support people to meet individual needs. Care plans and risk assessments are individualised and personalised so that staff know how to support each person and their needs can be met. People living at the home are always consulted about their life in the home including whether or not they choose to participate in activities in and/or outside the home. There are meeting notes to evidence this daily consultation and people can choose to lead the meeting or to takes notes of decisions that
Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 12 are made. This means that people can choose to do activities that they enjoy so that they have a good quality of life. The Manager said that she is researching meaningful entertainment for residents. This will mean that people living at the home will benefit from entertainment that meets their needs and aspirations. Arrangements are robust enough to ensure that the confidences, privacy and dignity of people living in the home is always respected, because their private information is stored in lockable cabinets and data on the computer system is appropriately stored. Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use Southside are able to make choices about their lifestyle. People are supported to develop their life skills. People benefit because the social, educational, cultural and recreational activities will always meet their individual expectations. EVIDENCE: Each person is supported to be involved in selecting their own activity and planning how to engage in them. The manager described “the morning meetings for the residents which results in personalised activities for residents.” Staff were observed engaging with people so that appropriate support is provided which means that individual preferences about activities are always considered. Arrangements are sufficient to ensure that people living in the home experience a meaningful lifestyle or are supported make choices and have control over their lives. This means that people are always
Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 14 supported to participate in their own personal development. For example, one person attends the local gym and swimming pool because they like to keep fit and healthy. There is evidence in personal care records sampled that people’s religious and cultural needs had been considered and how staff are to support people to meet them. Records sampled of the people who live in the home showed that people are always registered with a local GP. Contact with other professionals such as the chiropodist, dentist, district nurse, optician, social worker and working age dementia support team are documented to assist in meeting each person’s health needs. People living in the home have a balanced and varied diet that meets their nutritional needs and choices, this means that they always have the variety of food that they prefer. The manager confirmed that food is purchased from a local supermarket as well as a supply of fruit and vegetables. This ensures that people receive a balanced diet. The manager ensures that clear and accountable records is always kept of any money transactions and property for the people living at the home and this assures people that their money and property is always managed properly. The people living in the home were observed to be well dressed. Their clothes were appropriate to their age and gender. Everyone was wearing appropriate footwear that were in good repair so ensuring that they could walk around the home safely and to minimise the risk of them tripping over. There are systems in place to ensure that people do not wear clothes that do not belong to them. Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is always based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Staff were observed talking to the people living in the home with respect to their age, illness and their individual background. This will ensure that people receive personal support in the way they prefer and require. Staff were observed engaging with people so that appropriate support is provided which means that individual preferences about people’s physical and emotional needs are always considered. Staff that give medication to the people living in the home have had medication training. Records show that staff signs the Medication Administration Records (MARS) appropriately. The manager confirmed that a local pharmacist provided basic medication training for staff and supplies the
Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 16 medication and tablets are in weekly blister packs, which make it easier for staff to give them to people. All medication received in the home is always audited to make sure that people get the right medication at the right time. This means that medication arrangements are robust enough to ensure that the management of the medication always protects people living in the home and this ensures that people receive their prescribed medication. Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure. This means that people are protected from abuse, and have their rights protected. EVIDENCE: The people living in the home are given the information they need so that they know how to make a complaint if needed. There had been no complaints recorded and no complaints about the home received by the CSCI since the home was registered. The manager spoke about introducing concerns, suggestions and complaints box for those people who prefer to use this facility so that their concerns are heard and actioned. Current arrangements show that people living in the home can be confident that their complaints will be acted upon. Arrangements are sufficient to ensure that people living in the home are always protected from abuse Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people at Southside to live in a safe, well-maintained and comfortable environment. This means that people’s independence is always encouraged. EVIDENCE: From the tour of the home, it is evident that all areas of the home is safe so that people living there are not at risk of tripping or having accidents. Electrical equipment is tested to make sure these are safe to use. Fire records showed that fire equipment is tested regularly to ensure that the risks of a fire starting are minimised as much as possible. This assures people that the home is always safe for them to live in. There is non-slip flooring in the conservatory and this means that people can use this area safely.
Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 19 People do not share bedrooms and are assured their privacy and dignity. All bedrooms have ensuite shower, toilet and wash hand basin facilities and are tastefully furnished and decorated. People are supported to individualise their bedrooms. This means that people’s bedrooms are personalised to their own choice. The manager undertakes regular audits of the cleaning schedules so that standards of cleanliness and hygiene is maintained, and this will mean that people are always protected from cross infection. Improvements are continuing to be made to the environment so that more space is provided for people and this will mean that people will always live in a safe, homely and comfortable environment. Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff at Southside are trained and skilled. There are sufficient staff on duty to support people in line with people’s terms and conditions. This means that people will always benefit from the smooth running of the service EVIDENCE: Staffing levels are always maintained in sufficient numbers and this ensures that the needs of the people living in the home are always met. There is enough staff on each shift and staff have received sufficient training and support to ensure that the needs of people living in the home are always met. The home’s recruitment practices ensure that the people living in the home are always protected. Staff recruitment records examined ensure that robust checks have been made to ensure that suitable people are employed. This means that rigorous recruitment management will always safeguard people. The manager ensures that staff are provided with the required training so they can always meet individual needs and this means that people will be kept safe
Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 21 from harm. A training matrix had been devised so it is clear what training each member of staff needs or has received, and this means that people are assured that staff they have the skills and knowledge to always meet individual needs. Staff are provided with regular formal supervision from the qualified manager so that staff always know how to support the people living in the home. This assures people living at the home that they will always receive care and support from staff who are supervised. Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems that are implemented by a qualified, competent manager. EVIDENCE: Risk and handling assessments are robust. Assessments sampled shows that a qualified manager had developed these. This means that people and staff are safeguarded from harm. The manager ensures that an effective quality assurance and monitoring system is implemented to monitor the quality of service provided. This ensures Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 23 that people living in the home benefit from good quality care based on the robustness of the management systems and policies operated within the home. Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 3 3 3 Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 25 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. 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. Refer to Standard Good Practice Recommendations Southside DS0000068678.V339638.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
