Inspection on 27/03/08 for Southside House

This inspection was carried out on 27th March 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southside House 28/01/09

Southside House 26/03/07

Southside House 15/12/05

Southside House 24/08/05

Southside House 18/03/05

Southside House 30/12/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Southside House 44 Severn Road Weston Super Mare North Somerset BS23 1DP Lead Inspector Paula Cordell Unannounced Inspection 27th March 2008 09:45 Southside House DS0000008091.V361141.R01.S.doc Version 5.2 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 Southside House DS0000008091.V361141.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 House DS0000008091.V361141.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southside House Address 44 Severn Road Weston Super Mare North Somerset BS23 1DP 01934 626540 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) Mr Lal Gunaratne Mrs Veronica Bishop Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 6 persons with learning difficulties, aged 18 64 years, requiring personal care only. The Manager to gain a formal LDAF qualification by June 2006 Date of last inspection 26th March 2007 Brief Description of the Service: Southside House provides support for up to six people with learning disabilities who spend most of their day away from the house. It contains two double bedrooms and two single ones. The emphasis of the service is on a homely approach, and it aims to provide opportunities for more able people to learn independence skills. The home is located close to the local shops, parks and seafront. It is about a mile away from the town centre. It is also located a short walk away from its sister home (Charlton House), with which it shares the manager. The current scale of charges ranges from £293 to £400. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced visit as part of a key inspection process. The purpose of the visit was to review the progress to the requirements from the previous visit in March 2007 and monitor the quality of the care provided to the people living in Southside House. There have been no additional visits between this visit and the visit conducted in March 2007. There have been no complaints or safeguarding concerns raised during this period. During the site visit, the records were examined, a tour of the premises conducted and feedback sought from individuals living in Southside, the staff and the registered manager. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including correspondence. Feedback from relatives (2), and individuals living in the home (5) and visiting professionals (3) was received prior to the visit by comment cards that were sent to the home. The visit was conducted over five hours. What the service does well: The staff interact well with the people living in Southside and are knowledgeable about the care needs and the personalities of the individuals. Individuals spoken with stated that they like living at Southside and the staff support that is in place. Individuals are supported to make choices wherever possible, and are given information so that they can make their own informed decisions. Individuals have opportunities to make full use of the community and have a structured daily plan of activities. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 6 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 House DS0000008091.V361141.R01.S.doc Version 5.2 Page 7 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 House DS0000008091.V361141.R01.S.doc Version 5.2 Page 8 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): 1,2,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a lack of information to inform prospective individuals and placing authorities, which clearly describes the service and the range of needs of the people the home can support. This could lead to people moving to the home who are not appropriately placed. Contracts do not give sufficient information about the cost of the placement. EVIDENCE: There is a statement of purpose. However, this does not reflect the service that is available to the people living at Southside. The documentation seen described the staffing two years ago when a member of staff lived on the premises. In addition it made no reference to the range of needs or the age group of the people the home intends and is supporting. The statement of purpose did describe the admission process. It was noted that two people had been transferred from Charlton House to Southside. One of these people had been diagnosed as having dementia and both were older people. At the time the home was registered to support individuals aged 1864. Both peoples needs fall outside the range of needs described in the homes Statement of Purpose. From conversations with the manager one of the person’s is moving back to Charlton House pending a review by the placing authority. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 9 The other person had chosen to return to Southside having lived there before. Social workers were involved in the moves. However, the provider must clearly describe in the statement of purpose the needs of the people it intends to support. The home has admitted one person since the last visit. Clear information was available detailing the assessment process. Relatives and the placing authority were involved in the assessment process. However, this person is considerably much younger that the group that are living in the home. People are encouraged to make as many visits as they need to before deciding to move in for a trial period. The two new people and the existing group were fully consulted about the move before it took place. One of the individuals had lived in the home previously and it was seen as a positive move to return to Southside. This was confirmed in conversations with the individual, the member of staff and documentation from the placing social worker. Each person has a straightforward contract with clear information on the terms and conditions. However, this made reference to a smoking room and lacked information about the fees that are being paid and any addition charges in respect of transport or day care provision. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 10 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): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals can be confident that their care needs are being met. Individuals must be assured that staff are consistent in their approach in relation to individuals that challenge. Individuals are involved in the planning processes. EVIDENCE: Three care plans were looked at as a means of determining the processes the home goes through to support the individuals living at the Southside House. Care plans detailed the support needs of the individuals focusing on life skills and personal care. It was evident that these had been devised based on the assessment and care plan drawn up by the placing social worker and the home’s assessment processes. The care staff on a six monthly basis and an annual basis were reviewing care plans with the individual, their relatives and where relevant the professionals involved in the planning of the care. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 11 This met with the National Minimum Standards and the Care Homes Regulations. Annual reviews were being conducted with the placing authority. However, concerns were raised about one person’s plan of care who from conversations with staff can at times become verbally aggressive. There was no plan of care to guide staff, which detailed the triggers and the actions that staff take to reduce the person’s anxieties. From talking with staff it was evident that the individual is supported in a positive way but due to the staff changes (which will be discussed later in this report) it is important that this is recorded. This would assist in demonstrating a consistent approach is in place, which is open and transparent. Risk assessments are in the process of being developed and in the main covered mobility, accessing the community and using the kitchen. Consideration should be taken to broaden these to cover more topics for example personal care, lone working, use of electrical appliances, supporting individuals that challenge to name a few. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 12 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): 12,13,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals are encouraged to lead active and full lifestyles. However, due to the home only being staffed by one member of staff this at times can be restrictive in the planning of adhoc activities. EVIDENCE: Presently the home supports five people with a learning disability. There is a vast age difference with the youngest being in their twenties and the eldest aged over seventy years of age. From talking with staff and the manager it was evident that activities were varied to suit the individuals living in the home. However, there was some emphasis that activities would be completed as a group for example trips to places of interest, holidays and social evenings. This is in the main because there is only one member of staff working in the home. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 13 The staff and the manager gave reassurances, that where four out of the five people wanted to go and the fifth wanted to remain in the home this would be accommodated. The manager stated that a member of staff would be taken from Charlton House or a member of staff would work a bank shift. This would be the same process if a person living in the home were ill and unable to attend their structured day care. The home is not staffed during the day as all the people living in the home have a five-day structured activity plan. Individuals described full and interesting lives. Several people have some sort of work, and some go to college and day placements. All the individuals are encouraged to spend time at Charlton House where a small activity centre has been set up. Because most of the individuals are fairly able people, they tend to arrange their own social lifes with a minimum of support from staff. However, the two older people require a little more support and encouragement. A member of staff stated that this could be difficult when there is only one member of staff working in the home. One person’s placement is being reviewed in light of the staffing levels and the increase in support that is required. Individuals felt that the home’s routines suited them. Staff were able to give examples of how routines are designed around individuals preferences. Weekdays all the individuals are out, and weekends are for relaxing around the home. Some of the individuals attend church or visit friends, whilst others may relax around the home or go shopping. A member of staff stated that all the individuals could choose when to go to bed and get up. A member of staff stated the individuals are involved in the menu planning and their views are sought at house meetings on what they would like to eat. Individuals spoken with said the food was good and there was a choice should they not like what is on offer. The menu was viewed and this provided evidence that a varied and healthy diet was provided. Individuals were observed choosing what they wanted for lunch. The individuals have agreed a chores list, and an easy-read rota has been put in the kitchen. Most individuals do their own washing and ironing with support from staff as necessary. Most people buy their own clothing, but staff will give support with this if it is wanted. Contact with friends and family is actively encouraged. Individuals are welcome to invite their friends over. The home provides transport so that people can go to evening clubs and social events this is shared with the sister home Charlton House. Individuals are encouraged to participate in the running of the home. They have house meetings approximately every three months. The frequency could be reviewed to see if monthly meetings would be more appropriate. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 14 Individuals said that they had been involved in the planning of the annual holiday and assist in the choosing of the décor. Southside House DS0000008091.V361141.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. People’s personal and health care needs are being met. Individuals are protected by the home’s medication systems and practices. EVIDENCE: Care plans clearly documented the personal and health care needs of the people living in Southside House. Systems for monitoring an individual’s wellbeing were in place and concerns about health were quickly addressed. Individuals had access to other health professionals including a GP, opticians, chiropody, dentist and the community learning disability team. The home has demonstrated compliance to a requirement from the visit in March 2007 review how health care needs are recorded and monitored. There were clear records detailing the personal care support needs of the individual and a daily record of care given. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 16 The member of staff on duty assisted people in a good humoured and courteous manner, and the individuals had evidently built good relationships with the staff member. Individuals spoke positively about the two staff that cover the majority of the shifts in the home. The home has robust procedures and practices on the administration of medication. The member of staff on duty stated they had completed training on medication with they last employer and this had been covered in the home’s induction. The manager stated that all staff involved in medication administration would shortly be completing a distant learning pack. This will be followed up at the next visit to the home. Southside House DS0000008091.V361141.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. Individuals can be confident that their concerns would be listened to and that they are protected by the home’s safeguarding policies. EVIDENCE: The home has a written complaints procedure. Individuals said they felt very comfortable raising any concerns with the staff or the manager. Staff felt encouraged to raise any concerns on individuals behalf. One relative comment card received prior to the visit confirmed that they had not been given a copy of the home’s complaint procedure, however, they felt that the home usually responded well to any complaints raised. One person living in the home said that it is much better now and staff do listen to what they are saying. No complaints had been received by Commission for Social Care Inspection since the last visit. The home has recorded two complaints, which was really minor grumbles. This was quickly resolved, and the complaint book record shows that the response was very positive. It was evident that the individuals felt staff would listen to their concerns and suggestions and act upon them. Staff spoken with had a good awareness of peoples’ rights. Staff said they would report any concerns to the manager, and felt confident that these would be dealt with appropriately. The two staff that work in Southside have both recently completed a course on safeguarding. Policies and procedures for safeguarding and whistle blowing were accessible to staff. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 18 The staff on duty had a good awareness of what constitutes abuse and what they should do if abuse is suspected. Finances were checked for a random group of people. People have a financial care plan which describes the level of support and the control the individual has in respect of their finances. People are given some element of control with their personal allowance with varying amounts being given to the person. Records were maintained which included signature of the staff and the person living in Southside. Individuals have a lockable storage facility in their bedroom to keep their finances safe. Whilst the individuals have access to their personal allowance, bank records and surplus cash for individuals is kept at Charlton House. This will be inspected at the next visit to Charlton House. The member of staff stated that if individuals request additional money then the manager could accommodate this. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 19 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): 24-30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals live in a clean and homely environment. The home is decorated to a good standard. The shared bedrooms are compromising the rights of the individuals to privacy and their own space. Safety is being compromised due to fire doors being left open, radiators not being covered and water temperature not being controlled. EVIDENCE: Southside is a residential property in keeping with the local neighbourhood, close to the town centre and the seafront. There is a large lounge and separate dining room, both of which have a TV and comfortable seating. Areas were decorated to a good standard and were homely in appearance. There is an upstairs bathroom and a downstairs shower room. There were sufficient handwashing facilities including soap and paper towels. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 20 Doors were lockable but staff in the event of an emergency could override these. Radiators throughout the home were not covered and could potentially put individuals at risk from scalds. There was no risk assessment detailing the level of risk within the home or to the individual. One person’s bed was next to a radiator and could potentially pose a risk to the individual should they fall out during the night. Similarly the water was not temperature controlled, as evidenced with the weekly temperatures that were being taken which exceeded the recommended temperature of 43°c. A risk assessment must be conducted in relation to both the radiators and the water temperature where the level of risk is particularly high then the provider must take appropriate precautions to minimise the risk. A member of staff stated that only one person has a key at present, as it has been difficult as two of the bedrooms are shared rooms. There is one vacant single bedroom at present. The manager stated that they were exploring ways in which they might be able to reduce the number of double bedrooms. This has been discussed at the last three visits to the home and remains an outstanding recommendation. Visiting professionals in completed surveys commented on the concerns that they had about the shared rooms. The home is still looking at plans to turn the two double bedrooms into three single rooms. Where a vacancy occurs in a double room it would not be appropriate for this vacancy to be filled. Given the wide range of needs currently being accommodated, it is even more important that the people living in Southside have their own space. One person clearly stated that they did not like sharing and would prefer their own space. Whilst there is a single room perhaps this person could be given priority. Again fire doors between the lounge, kitchen and dining room were wedged open. Given the layout of this home and the low staffing levels, this could be particularly dangerous. The manager and the member of staff confirmed that the home is installing magnetic door closures for these areas. Confirmation of this must be sent to the Commission for Social Care Inspection within one month, but in the interim the doors must be kept closed. This remains outstanding. All areas of the home were clean and free from odour. The home employs a member of staff to assist with the cleaning. In addition individuals confirmed their involvement and participation in the household cleaning. The home has had an Environmental Health inspection in March 2007 and has gained a four star rating. The kitchen was well organised with good procedures being adopted to ensure safe food handling as evidenced through the records maintained, discussion with staff and observation. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 21 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): 32,3435,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Competent staff support individuals. The home is staffed on a minimal basis, which could potentially put individuals at risk where their needs have significantly changed. The minimal staffing levels means that individuals do not have opportunities to go out on a one to one basis. EVIDENCE: The home is staffed only when the people residing at Southside are home. So the home is not staffed during weekdays when individuals are out doing their structured day care. In the main there is one member of staff on duty. This was not reflected in the statement of purpose. Two staff cover the house with a core group of relief staff covering holidays, sickness and one additional shift per week usually a Sunday. One of the members of staff is leaving and interviews were being conducted during this visit. It was evident that staff employed in the home would need to have experience of working in the care setting and the ability to work on their own. It was evident that the manager was taking this into account with the candidates that she was interviewing. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 22 Whilst one member of staff was sufficient when the individuals were all younger and less dependent. This may not be adequate for older, frailer people with dementia, particularly in the event of an emergency. This must be kept under constant review. The two staff who mainly work in this home have some rostered time on duty together at the weekend. This helps to ensure adequate communication and provides an opportunity for individuals to go out in smaller groups. The manager stated that in response to the requirement from the last visit, there is now a pool of staff that can assist at Southside and staff can be utilized in an emergency from Charlton House. Staffing must continued to be reviewed taking into account the changing needs of the people living in the home due to the ageing process ensuring staffing is adequate to meet the needs of the people living at Southside both individually and collectively. There are good systems in place to assist the two staff with communication ensuring a consistent approach including a message book and a daily written handover. Evidence was provided at the last visit in relation to the recruitment of newest member of staff. These were found to be satisfactory and met with the Care Homes Regulations. Staff stated criminal record checks are carried out on all staff before they start work in the home. There has not been any new staff employed since the last visit. Training records were viewed for the two staff that predominately work in the home. Good evidence was provided that there is an ongoing training which is relevant to the needs of the people living in the home. A member of staff stated that there is a commitment from the manager to ensure staff have training made available to them. Both staff have a Level 2 National Vocational Qualification in care and one of them has completed a Level 3 National Vocational Award. A member of staff stated that they were planning to complete a NVQ assessors award to enable them to support staff working in the two homes. A member of staff stated that supervision has been patchy and not consistent. In practice, staff felt very well supported and regularly get to talk issues over with the manager. A member of staff stated that meetings are held once a month at Charlton House. There were no minutes available as these are kept at Charlton House. Copies of these should be made available to staff. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 23 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): 37,39,40,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals benefit from a well-managed service, where the management team are approachable. Individual’s safety could be compromised due to the lack of safety measures being taken in relation to scalds from exposed radiators and hot water temperatures and safety in the event of a fire. EVIDENCE: Mrs Veronica Bishop is an experienced manager and holds the Registered Managers Award. She is registered as manager of both this home and Charlton House, which is 5-minute walk away. She spends most of the day in the sister home but visits Southside House on a daily basis. This was confirmed in conversations with the people who use the service and the staff on duty. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 24 The owner also visits regularly and spends time talking with people who use the service and staff. The reports in respect of the monthly regulation 26 provider visits were held at Charlton House. Good practice would be that the reports in respect of Southside House are held in the home. This will be followed up at the next visit. People who live in Southside House and the member of staff described a happy atmosphere with approachable management staff. Staff felt that they get a good combination of support and autonomy. Health and safety checks are done regularly. The maintenance book shows that any necessary repairs are carried out promptly. As already mentioned there were no risk assessments relating to the water temperatures and the need for radiator guards. Fire records provided evidence that routine checks are completed on the equipment and that staff take part in regular drills. Less apparent was formal training in fire at least every three months for staff that work at night and six monthly for day staff. A fire risk assessment was in place. As noted previously in this report fire doors were being propped open, which puts individuals at risk in the event of a fire. A member of staff stated that automatic closures are being purchased but this was not within the timescale as set at the last inspection. Further non-compliance could lead to enforcement action. In addition a member of staff stated that the fire alarm cannot be heard from the staff sleep in room and again the provider is planning to address this. This must be completed as a matter of urgency as this could put both the staff and the individuals living in the home at significant risk. Policies and procedures were accessible to staff. It was noted that the policies and procedures were not dated so it was difficult to determine whether the policies were current and had been formally reviewed. Accident records were made available during the visit. There have been no accidents or reportable incidents for a significant period of time. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 X 4 X 5 2 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 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 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 2 X 2 X Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 26 Yes 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 YA1 Regulation 4 Sch 1 Requirement The statement of purpose must be kept under review and clearly describe the staffing levels and the needs of the people that the home intends to support. Contracts to be reviewed and amended to include the fees and additional charges and who is responsible for plying them. Care plans must include how the staff are to support individuals with episodes of aggression including the triggers. Timescale for action 27/05/08 2. YA5 5A 27/05/08 3. YA6 15 (1) 27/04/08 4. YA42 13 (4) (a) (c) 5. 6. YA26 YA24 12 (4) (a) 23 (4) (a) (c) (ii) Risk assessments must be 27/05/08 developed in relation to radiator covers and water temperatures where a high risk has been identified then appropriate action must be taken to address the risk. Where individuals share 27/04/08 bedrooms consideration must be taken to ensure their privacy. Adequate precautions must be 27/04/08 taken for containing fires. This refers to the practice of wedging open the downstairs fire doors. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 27 (Outstanding since 26/03/07) Ensure that the fire alarm can be heard from the staff sleep in room. 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. 4. 5. Refer to Standard YA26 YA33 YA8 YA36 YA40 Good Practice Recommendations Individuals should have the opportunity to have single bedrooms. Copies of the staff meeting minutes to held in the home. To seek the views of the people living in the home on the frequency of house meetings. For staff to have formal supervisions at least six per year with records maintained. Date and sign policies and procedures held in the home and keep under review. Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Southside House DS0000008091.V361141.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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