Inspection on 08/08/08 for Southview

This inspection was carried out on 8th August 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 but made no statutory requirements on the home.

Other inspections for this house

Southview 26/02/10

Southview 09/07/09

Southview 09/08/07

Southview 11/09/06

Southview 13/03/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE Southview Woodside Lipson Plymouth Devon PL4 8QE Lead Inspector Stella Lindsay Key Inspection (unannounced) 8th August 2008 8:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Southview DS0000064360.V360437.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southview Address Woodside Lipson Plymouth Devon PL4 8QE 01752 667853 01752 667853 southview@yahoo.co.uk 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) Ashley Residential Care Ltd Vacant Care Home 19 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (19) of places Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The categories of registration are OP and DE(E). The home may accommodate a maximum of 19 older people (over the age of 65) who may also have dementia. 11th December 2007 Date of last inspection Brief Description of the Service: Southview is a care home that is registered to provide accommodation and personal care for up to 19 older people, aged over 65, who may also have dementia. Nursing care is not provided in this home. It is privately owned by Ashley Residential Care Ltd. The Responsible Individual is Mrs Anna Chapman. The present owners took over the running of the home on 7th March 2006. The home is a single storey detached property situated in the residential area of Lipson, Plymouth. It is close to local amenities and transport links. Southview offers 17 single bedrooms and one double bedroom: eight of the single bedrooms have en-suite toilet facilities. There are two bathrooms and four toilets for communal use. The home has a large lounge and a dining room. Accommodation is centred around an attractive courtyard and garden and all areas are accessible to the residents. There is on-street parking available outside the home. The current weekly fees for the home range from £313 to £345 dependent upon individuals’ care needs. Information relating to the services provided at Southview can be obtained directly from the home. Southview DS0000064360.V360437.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 inspection was unannounced and involved a tour of the premises, and examination of care records and staff files, the medication system, and some of the home’s policies and procedures. Care practice was observed, and we met three residents in their rooms as well as spending time with residents in the lounge and at meal times. This approach aims to gather information about what living at the home is like, and make sure that residents’ experience of the home forms the basis of this report. We met with the home owners and the Head of Care for the company who was Acting Manager at the time of this inspection. We met with two visitors to the home and five staff on duty. Prior to this inspection the previous Manager had provided information about the running of the home. The Commission for Social Care Inspection had sent questionnaires to 18 residents and received five completed, and sent ten surveys to staff, receiving five replies. What the service does well: What has improved since the last inspection? A new kitchen had been fitted, to provide to raise the standard of cleanliness, improve the quality of food being produced and reduce waiting times. Refreshments provided during the evenings had improved. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 6 A record was being kept of the meals taken by each person to enable an assessment to be made of their nutritional intake, when necessary for health reasons. A hard-backed book had been introduced to record any complaints made to the home, and the action taken, to show how responsive the home is to the views of its residents and their families. Protective gloves and aprons were readily available for staff providing personal care, and hand cleaner was available in communal toilets. Two cleaners are now employed, in order to maintain a clean and sweet smelling home in spite of increasing health problems of residents. What they could do better: Good clear information is provided for prospective residents and their families. It could be presented in a form to make it more easily understandable, perhaps with photographs. Full and accurate care plans had been written for each resident. A new system of recording had been introduced, but was not yet presented in a way that was easy for staff to read, to help them provide consistent care to residents. The details held on residents’ files to identify lifestyle choices and preferences had not yet been completed for all residents. Medication should be better organised inside the trolley, to help staff administer it without making mistakes, and the trolley should be secured to ensure safe storage. While staff worked hard to ensure that residents daily routines and health care needs were well met, they did not always have time to provide for peoples’ needs for individual attention for emotional support and protection from potential harm. Newly recruited staff had been working without proper supervision, before the checks made to protect residents from potential harm had been completed. The external doors needed reviewing to ensure that people would be able to get out in an emergency and to encourage and enable peoples’ access around the house and garden. There should be a qualified first aider on duty at all times, to protect residents from potential harm in an emergency. As the home is owned by a company, there must be a Manager registered with the Commission, to take responsibility for day to day running of the home. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 7 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. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is readily available for the public, and admissions are arranged with careful consideration of individual needs. EVIDENCE: Information is readily available for prospective residents and their representatives. It is not yet presented in a form that would be easily understood by prospective residents. It includes details of what is included in the fee, and the terms and conditions of residence, and copies were in folders in residents’ bedrooms. One resident was admitted on the day this inspection was started. The Acting Manager visited them promptly in hospital, in order to assess their care needs and enable a speedy discharge. The Social Worker visited, bringing further information from Health Care Workers, and was pleased with the work done to Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 10 assess and meet this person’s needs. ‘very welcoming’. The resident said that staff had been Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health and personal care needs were being met. People might be at risk of inconsistent care, as the newly introduced care plans were not yet keeping the staff well informed about residents’ care needs. Staff had been trained in the administration of medication, but the storage of medication was not entirely safe. EVIDENCE: A new system of care plannng was being introduced. Tasks were listed and recorded by number, and were seen to be accurate. The home owner told us that Senior staff had received training in the new system. However, the new care plans were not yet easily accessible to care staff, who said they mostly gathered information about residents’ requirements by word of mouth. The previous Manager acknowledged in the AQAA that the details held on residents’ files should be improved to identify lifestyle choices and preferences. Care plans were task based, though some had personal instructions such as ‘Mr.X will let staff know when he wants to go to bed.’ The care plan of the Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 12 newly admitted resident was in the process of being written. Some but not all staff had read it. Staff said the information given at ‘handover meetings’ was useful, but they did not have time to look a care plans. Updates were also included in staff meetings, which was useful to ensure that knowledge was shared. A system was in place to review care plans monthly. One of the Senior carers on duty said that they evaluate the care given on every shift they work. Instructions on a care plan with regards to catheter care had been crossed out, with no new information provided to staff to enable them to provide consistent care to the resident. Not all GP visits had been recorded. A visiting health professional told us they were happy with the attention from care staff at Southview, and found that her instructions were followed. Fluid and weight charts were seen to be properly kept where needed. Of the five residents who returned surveys, three said they always get the care, support and medical support they need, while two said ‘usually’. Social histories were not available for all residents, and we did not see evidence of residents’ involvement in care planning, or recording of peoples’ social preferences or aspirations. The home owner said that efforts were being made to involve families and health care professionals in care plan reviews. The home had a detailed policy and procedure with respect to the administration of medication. There was a risk assessment available to record the competence and agreement of a resident to manage their own medication, and one was seen completed on a resident’s file, which is good practice to support continuing independence where this is safe. Staff training in the administration of medication had been provided during March and May of this year. One person’s tablets were crushed in jam with the person’s agreement, for easier swallowing. The pharmacist had not been consulted with regards to whether this would chemically affect the medicine, or whether it is available in another form, more suitable for this resident to take. There was a suitable medication trolley, but it was not secured in a safe place. The contents were not well ordered, so that it was not easy for staff to find each individual’s requirements. During our visit the staff were seen to be at all times respectful, patient and cheerful with the residents. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A good variety of social activities was provided, but residents’ needs for individual attention were restricted, due to lack of staff time. There was choice and variety in the meals provided. EVIDENCE: The time that people like to get up in the morning was recorded in their care plan. The Acting Manager told the staff in their team meeting that there were to be activities twice a day, and had drawn up a weekly programme of social activities with the intention of providing social stimulation morning and afternoon. It was displayed on the dining room door, but although there was always the intention of providing activities, due to the need for staff to attend to residents’ care needs, some times this would be reduced to a few minutes discussion or word games in the lounge. During this inspection, staff said they were planning to ice cakes with residents later in the afternoon. Arts and crafts materials were available. One resident said, ‘I enjoy the bingo’, and we Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 14 were told that this happens regularly for those who can still enjoy it. Staff understood the importance of providing social stimulation, but said they struggled to make time. They said they ask general knowledge questions in the mornings, and will have a game of ‘I Spy’ in the afternoons, even if it is just for ten minutes. The home owner said there were discs for sing-along sessions. Last year there had been a trip to the Aquarium, using five taxis. The homeowner said that further trips had been offered. One resident said that they liked to go out, but that their family take them. Another said that staff would get any shopping they need. The garden is safely enclosed, and there is ramped access to it. One resident who is independently mobile was seen sitting out during this inspection. More could enjoy this space if staff had time to encourage and help them. The home owners told us that some residents had planted out tubs with the gardener. Menu choices had been recorded every day. Choice offered for lunch on one day of this inspection was cottage pie with carrots and Brussels sprouts or an attractive mixed salad including both egg and meat. Two residents who had been given cottage pie with plenty of gravy said they did not want gravy, so it should be served separately to ensure that residents would enjoy their meal. The home owner said this is not representative of what normally happens. We saw that extra vegetables were offered. There was a choice of Angel Delight or home made rice pudding for dessert, and one resident was offered a yoghurt. Biscuits are offered with mid-morning coffee, and home made cake with tea at 3pm. Residents told us they were generally happy with their meals, and they could have a hot drink and a snack in the evening. Of the five residents who completed questionnaires, two said that they always enjoy their meals, one said ‘sometimes’, and two said they do not like the meals at weekends. There had been no cook on duty at weekends since March 2008, but the homeowner said that arrangements were in place to recruit another. Care staff who were on duty were detailed to prepare and serve meals. The freezer was well stocked and staff confirmed that there is always fresh fruit and vegetables, and yoghurts. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good policies and procedures were in place, but residents were put at risk of potential harm by low staff levels and failure to supervise new staff. EVIDENCE: The complaints procedure was included in the Service User Guide, and available to all residents. All those who completed questionnaires said they knew how to make a complaint. Two anonymous complaints were received by the CSCI and passed to the Registered Person to investigate. The home owner looked into issues raised by the first of these complaints (23rd January 2008), and wrote to us with his findings and conclusions. Both complaints were recorded in a hard back complaints record that had been started in the home following the previous inspection. We saw on file the result of disciplinary action that had been taken with respect to two of the issues raised. One of the issues raised in the second letter was concern over low staff levels, and this was not found to have improved. This puts residents at potential risk as some continually walk around the home, going into other peoples’ rooms. More staff attention is needed to assure their protection and the comfort and privacy of the other residents. During recruitment the Acting Manager had applied for all the checks necessary to protect residents from potential harm. However, the weekend Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 16 during this inspection had seen two new recruits on duty alone together, which put residents at risk, as they were not supervised and it was not known whether their checks would be satisfactory. They said that they were pleased that the Acting Manager phoned to see if they were alright, and that an experienced carer came in to administer medication. The home’s policy and procedure for the Protection of Vulnerable Adults (POVA) was very good, with all contact details and instructions for staff as to what to do in the event of any allegation being made. Staff were aware that they needed training in POVA, and all said they would tell the person in charge of any concerns. The Acting Manager said that she would book this training for all staff over the following three months. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Southview provides a pleasant, well-maintained home that is comfortable and which provides good facilities to meet the needs of those people living there. EVIDENCE: Investment in the environment continues and further improvements and redecoration have taken place since the previous inspection. The new kitchen had been fitted to provide a good hygienic environment for the provision of meals. No dishwasher was provided, which means that washing up was sometimes another call on staff time. The modern shower is attractive as well as easily accessible, and there is also a bath with a hoist. The dining room was well furnished, and suitable for crafts and other social activities. It was also used for staff meetings, as the manager’s office did not have space for more than two people to sit. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 18 The lounge was light and airy and attractively decorated. It was awaiting new curtains. The windows looked across the garden, and there was a ramped door to the garden, but a chair blocked this access. The home owner said that residents had objected to this door being open. There were other doors to the garden, some ramped. All bedrooms we looked at were pleasantly furnished. People had been able to bring personal items with them. Four bedrooms had doors opening onto the decked patio area making these very pleasant rooms in the warm sunny weather, and enabled some to keep a pet. The design and lay out of the house and grounds lends itself to making a pleasant walkway, as there are ramped doors to the garden at various places, and apart from one rough area of concrete, the garden paths would be manageable for people with mobility difficulties. There is scope for improving the accessibility for the residents, and providing a circular route around the house and garden. Door alarms instead of locks were not in place. Most of the external doors are kept locked. One such door is by the manager’s office. The way is opened for staff to take rubbish to the bins by keeping locked a gate across the path to the garden, thus losing access for the residents. Because of their disabilities, some residents were unable to use a call bell. Some residents’ safety would be enhanced by the fitting of an alarm on their door so that night staff could know when they left their room. A pressure mat that sounds the alarm when the resident steps out of bed was obtained for a resident shortly after this inspection. The home owners were continuing with redecoration throughout the house, and were aware of current thinking on colour schemes and signage needed to provide an enabling environment for residents with dementia. An Occupational Therapist had been commissioned to consider the home’s requirements in terms of signage and ease of getting around, and this advice was still available. Ten bedrooms had been redecorated in the past year, and a number of windows and doors been replaced. One or two cleaners are employed each day. The home was found to be clean and tidy, and those spoken to said that the home was always clean, and four of the five surveys backed this up. A new domestic style dryer had been provided, which was found to be sufficient. The laundry floor was not easily cleanable, but as the floor will need to be excavated for the upgrading of the gas main, the home owner said that this flooring will be renewed after that has taken place. One communal toilet had no hand basin, and no room to install one. Hand cleaner had been provided. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home recognises the importance of individualised person centred support, but because of low staff levels the competent and caring staff were mainly limited to meeting personal and health care needs of residents. EVIDENCE: A written rota was kept, which showed that there were normally a Senior Carer on duty with two care assistants from 8 – 2.30pm, along with a cook who worked from 6.30 – 2pm Monday to Friday, and one or two cleaners from 8 – 1pm every day. From 2.30pm onward there are two carers, one of whom may be a Senior. Residents were very positive about the staff - ‘they are excellent’ said one long term resident, but they were not available to give the necessary attention to residents with complex needs and prevent them coming uninvited into their private room. Another said that the staff are good, but ‘always in a rush – and when they say they’ll be straight back it will be half an hour’. Another said that they need help to get to the toilet, and staff do not always get there in time. It is recorded elsewhere how activities and individual attention are limited by lack of time. It was recommended at the previous inspections that staff levels should - ‘remain under review to ensure peoples’ needs can be met consistently and to their satisfaction at all times of the day’. At night there is one Night Care Assistant, and another ‘sleeping in’. The Acting Manager said that recently when a resident was ill and needed attention Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 20 by night, a second awake carer was employed, in order to meet their needs. Action needs to be taken to meet fully peoples’ needs throughout the day. The home owner said that a cook is to be employed from 8 – 5pm every day, which would take pressure off staff at tea time. The previous Manager told us in the AQAA that 67 of care staff already have achieved at least NVQ2 in care, and 17 are working towards this. Recently recruited staff said they had been pleased with the opportunity to shadow their more experienced colleagues. They had been given a short induction but had not yet received foundation training or the mandatory training. Some staff had attended training sessions on care of people with Dementia, but this knowledge needed further development in order to provide a good service for people with complex needs. Training had also been provided on stroke, control of infection, and a specialist Nurse had been booked to provide training in catheter care and continence. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Southview lacks a strong manager to ensure consistent individual care for people with complex needs. Staff are supported by some good policies and procedures, but there are some areas affecting health and safety that remain oustanding. EVIDENCE: Ashley Residential Care Ltd is the registered provider of Southview. Mrs Anna Chapman is the Responsible Individual for the company. There had not been a Manager registered with the CSCI since they took over the running of this home on 7th March 2006. The home owners told us that another Manager had been appointed, was engaged in appropriate training, and an application for registration would be made. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 22 The previous Manager had moved to another home run by Ashley Residential Care, and was still offering support to the home. The person recently appointed as Head of Care for the company was Acting Manager at the time of this inspection. Residents and their relatives had been given opportunities to give feedback and record their views of the home and care given. This had not yet fed into a plan for the home. The Acting Manager said they would liaise more closely with residents and their families before undertaking building work. Cash was kept in the office for several residents, who did not wish or were unable to keep this in their own room. Records were kept, but did not have two signatures for each transaction, and several of the accounts had been allowed to go into deficit. This should be organised in a way that avoids this necessity. The Acting Manager told us of a resident who regularly did not have the money they were entitled to. Action must be taken to remedy this. The home owner told us that arrangements had been made for the Court of Protection to take responsibility for one resident’s financial affairs. The Senior on duty told us that there is always a Manager on-call, that the team work well together and that team meetings are useful. Staff completing surveys said that they regularly receive supervision, and that they always or usually get the support they need. A photo was displayed on the wall in the hall of the ‘staff member of the month’ being presented with a bouquet by a resident. Not all staff had received mandatory training, including moving and handling. It was not possible to have a qualified First Aider on duty at all times. The home owners have said they are taking measures to ensure that a first aider will always be available. Some fire exits were locked, and the key was not immediately available. The home owners said they would be providing key boxes on the walls nearby to allow for emergency escape without putting residents at risk. Professional Fire training had been provided on 28/05/08, so all but the most recently appointed staff were up to date. Fire alarms and extinguishers were serviced professionally on 03/12/07. The Manager is authorised to contact a maintenance firm directly when problems arise, including weekends. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X 2 X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 3 X 2 Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13(2) Requirement The medication trolley must be kept securely. The medication must be organised within the trolley in such a way as to promote safe delivery by staff. The Manager must seek advice from the pharmacist with regard to the safe delivery of medication (in jam). Sufficient staff must be employed at all times to meet the personal and social care needs of residents with complex needs. As the care home is owned by a company, a manager must be registered with the Commission for Social Care Inspection. Previous timescale 31/12/07 Timescale for action 31/10/08 2. OP27 18(1)a 30/11/08 3. OP31 8(1)(b) 30/11/08 Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 25 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. 6. Refer to Standard OP1 OP7 OP15 OP22 OP38 OP38 Good Practice Recommendations The Service Users Guide should be produced in a form that would be easily understood by prospective residents. Care plans should be presented in a clear way, to help staff to provide care in a consistent way. Better arrangements should be made for cooking at weekends. Alarms should be available to meet the particular safety needs of residents. Access for residents should be promoted, with safety taken into account. The Registered person should ensure that all training that affects health and safety of staff and residents is up to date, and that a First Aider is on duty at all times. Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 26 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 Southview DS0000064360.V360437.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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