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Inspection on 12/12/06 for Southwater Residential Home

Also see our care home review for Southwater Residential Home for more information

This inspection was carried out on 12th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Very positive feedback was received from service users about the choice and quality of the meals provided. Policies and procedures are in place and staff training has been provided to protect the service users from the threat of abuse. Overall a good standard of cleanliness in maintained within the home and the arrangements made for handling the resident`s laundry are good. Four of the six Care Assistants have gained National Vocational Qualifications in Care at Levels 2 and/or 3.

What has improved since the last inspection?

A professional recording system has been purchased which should lead to improvements in the assessments of the service users needs and care planning. The dining room has been redecorated and new tables and chairs have been purchased. This makes the dining room a very pleasant room for the service users to eat in. All of the radiators are now covered and hot water outlets have been fitted with thermostatic values. This removes the risk of residents being scalded. A quality assurance/quality monitoring has been carried out using questionnaires to gain feedback from the service users and their representatives and a report of the findings has been produced. Over fifty percent of the Care Staff now hold National Vocational Qualifications in Care.

What the care home could do better:

The Statement of Purpose and Service Users` Guides must be reviewed to ensure that they provide accurate information about the home and the service provided. Copies of the Service Users` Guide, statement of terms and conditions and contracts must be given to the service users. The assessments practices need to be improved to ensure that the home does not offer or provide a service for any resident or prospective resident without providing assurance that their needs will be met. Care planning and review practices needs to be more thorough as the service users needs are not fully recorded. In particular, more attention needs to be given to identifying the service users mental health and mobility needs. The residents who handle their own medication need to be provided with safe storage facilities to keep it in. All medication administered by the staff should be stored in the medication cabinet and recorded when administered. Pharmacy labels must be left on all prescribed creams and must only be used by or for the person they have been prescribed for. The premises are not suitable for people with limited physical ability and because of this some residents feel unable to leave their bedrooms safely. This means that they cannot use the communal rooms or join in any social, occupational or recreational activities. The home does not have a bath hoist or assisted bath and therefore the residents who cannot climb into the baths must do without. The resident`s rights to receive visitors at a time of their choosing may be restricted by the management policy of imposing visiting times. The complaints procedure is not made available to service users and complaints are not always appropriately received and dealt with by management. No waking night staff are employed and very low staffing levels are maintained in the afternoons and at weekends. This means that the home is unable to meet the needs of the more dependent residents, and in particular those who need help to leave their bedrooms, residents with dementia and residents with mental health problems.Safe staff recruitment practices are not being used therefore unsuitable staff could be employed to provide care for the residents. Some of the staffs Certificated training in health and safety related areas is out of date and needs updating. Some of the fire doors do not close properly and others are being wedged open, this means that that they would be ineffective in the event of a fire.

CARE HOMES FOR OLDER PEOPLE Southwater Residential Home Southwater Residential Home 3-4 Conway Crescent Paignton Devon TQ4 5LG Lead Inspector Judy Hill Unannounced Inspection 9:45 12 & 13 December 2006 th th 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 Southwater Residential Home DS0000018427.V293318.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. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southwater Residential Home Address Southwater Residential Home 3-4 Conway Crescent Paignton Devon TQ4 5LG 01803 524140 NONE 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 Thomas Lamont Mrs Mary Lamont Mr Thomas Lamont Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate two named service users with the category DE(E) Key Inspection 8th March 2006 Random Inspection 12th July 2006 Date of last inspection Brief Description of the Service: Southwater Residential Home is registered to provide accommodation and care for a maximum of eighteen people in the registration category of ‘Old Age, not falling within any other category’. A condition is in place enabling the home to provide a service for two named service users who have dementia. Southwater is situated in a residential area of Paignton and is within walking distance of the town centre and the bus and railway stations. Information is available from the home on request in the form of a written Statement of Purpose and a Service Users’ Guide. Copies of inspection reports are kept at the Home and are also available on the CSCI website. The current fees range from £310 to £350 a week, although additional charges may be made for extra care, professional hairdressing, newspapers, clothing and all other items of a luxury or personal nature are extra. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days. The first day of the inspection was unannounced. Most of the information contained in this report was gained in conversation with the service users, management and staff and through direct and indirect observations carried out during an inspection of the premises. Information was also gained from documentary evidence, including a pre-inspection questionnaire that had been completed by the registered service providers, the Homes Statement of Purpose and the Service Users’ Guide, and an Occupational Therapists Report. Additional information was gained from an inspection of service users assessments and care plans in relation to the service provided (case tracking), from staff recruitment records, training records and staff rotas and from records of medication. What the service does well: What has improved since the last inspection? A professional recording system has been purchased which should lead to improvements in the assessments of the service users needs and care planning. The dining room has been redecorated and new tables and chairs have been purchased. This makes the dining room a very pleasant room for the service users to eat in. All of the radiators are now covered and hot water outlets have been fitted with thermostatic values. This removes the risk of residents being scalded. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 6 A quality assurance/quality monitoring has been carried out using questionnaires to gain feedback from the service users and their representatives and a report of the findings has been produced. Over fifty percent of the Care Staff now hold National Vocational Qualifications in Care. What they could do better: The Statement of Purpose and Service Users’ Guides must be reviewed to ensure that they provide accurate information about the home and the service provided. Copies of the Service Users’ Guide, statement of terms and conditions and contracts must be given to the service users. The assessments practices need to be improved to ensure that the home does not offer or provide a service for any resident or prospective resident without providing assurance that their needs will be met. Care planning and review practices needs to be more thorough as the service users needs are not fully recorded. In particular, more attention needs to be given to identifying the service users mental health and mobility needs. The residents who handle their own medication need to be provided with safe storage facilities to keep it in. All medication administered by the staff should be stored in the medication cabinet and recorded when administered. Pharmacy labels must be left on all prescribed creams and must only be used by or for the person they have been prescribed for. The premises are not suitable for people with limited physical ability and because of this some residents feel unable to leave their bedrooms safely. This means that they cannot use the communal rooms or join in any social, occupational or recreational activities. The home does not have a bath hoist or assisted bath and therefore the residents who cannot climb into the baths must do without. The resident’s rights to receive visitors at a time of their choosing may be restricted by the management policy of imposing visiting times. The complaints procedure is not made available to service users and complaints are not always appropriately received and dealt with by management. No waking night staff are employed and very low staffing levels are maintained in the afternoons and at weekends. This means that the home is unable to meet the needs of the more dependent residents, and in particular those who need help to leave their bedrooms, residents with dementia and residents with mental health problems. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 7 Safe staff recruitment practices are not being used therefore unsuitable staff could be employed to provide care for the residents. Some of the staffs Certificated training in health and safety related areas is out of date and needs updating. Some of the fire doors do not close properly and others are being wedged open, this means that that they would be ineffective in the event of a fire. 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. Southwater Residential Home DS0000018427.V293318.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 Southwater Residential Home DS0000018427.V293318.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users do not have the information they need to make an informed decision about whether or not the service will meet their needs. EVIDENCE: The management has produced a written Statement of Purpose and Service Users’ Guide. Copies of both of these documents were requested and made available. Both documents were reviewed and seen to contain the required and recommended information, although some of the information provided was inaccurate (for example references the ability of the home to provide “wound dressing” and “pain control”) and some was out of date. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 10 Four of the service users were asked if they had received a copy of the Service Users’ Guide, but only one said that she had. Mrs Lamont confirmed that current and prospective service users are not always given a copy of the Service Users’ Guide. The service users contracts/statement of terms and conditions are not included in the Service Users’ Guide but available in a separate document. Four of the service users were asked if they had received a copy of this document, which provides information about their rights and responsibilities and none of them had. Mrs Lamont confirmed that these documents are kept on the service users files but not routinely given to the service users. The recorded needs assessments for four of the service users were inspected and discussed with a senior member of staff. Since the last key inspection a new recording system has been introduced, however the assessment records that were seen had not been fully completed either before or after the service users had been admitted into the home. Written assurance is not given to prospective service users and/or their representatives that the service can meet their needs. Southwater Residential Home DS0000018427.V293318.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the service is meeting the needs of the most independent service users, better care planning, mobility aids and staffing levels are needed to ensure that less independent service users needs are met. EVIDENCE: Since the last key inspection a new care planning and review system has been introduced. The care plans for four of the service users were inspected and discussed with a senior member of staff. The care plans seen had not been fully completed and did not provide sufficient information about the service users health, personal and social care needs or how their needs should be met by the care staff. The Statement of Purpose identifies that the range of needs met as follows: Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 12 “The home aims to provide a service for the elderly and respite care. The sorts of needs or levels of dependence, with which, the home specifically cannot cope are – EMI and disabled people. The home has no discrimination for the above mentioned groups, but is simply not registered and sadly can not meet their specific needs.” During the inspection most of the service users were seen and/or spoken with and although the service appeared to be very well suited to the most independent service users, it was observed that eleven of the sixteen service users rarely leave their bedrooms. This was discussed with some of the service users who said that they remained in their rooms because they could not manage the stair lifts and/or because they did not feel able to negotiate the small steps between rooms. One service user said that she did not ask for help from the staff because she did not like to bother them. Although the provision of personal care was observed to be good, two of the service users said that they could not use the bath because the home does not have a bath hoist. The service users physical health care needs are monitored and evidence was seen of timely referrals being made to their GP’s and the District Nursing Service. However, conversations with the service users, management and staff demonstrated that insufficient attention is being given to understanding and meeting the mental health needs of the service users. This was noted in relation to residents with dementia and functional mental illness. The staffing levels are very low in the afternoons and at week-ends and no waking staff are employed at night, although Mr & Mrs Lamont live above the home and are available on call. It was observed that two of the service users have dementia and would not be able to use their call bell to request assistance and that the call bell of a third service users was located away from the bed. Other service users were observed to require a high level of staff support because of functional mental illness and/or sensory impairment. The home uses a Pharmacy controlled system to order, administer and dispose of the resident’s medication. Suitable storage facilities are available in the form of lockable, wall mounted metal cupboard and a controlled drugs cabinet. During an inspection of the premises it was noted that several of the residents have prescribed creams in their bedrooms. Mrs Lamont confirmed that the application of prescribed creams was not always recorded on the medication administration record sheets. Some of the creams which had been prescribed did not have the original pharmacy label on them and a tube of cream was being used by a resident it had not been prescribed for. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 13 One service user administers her own medication and is able to do so safely, but her medication is kept on the bedside table and she needs to be provided with a lockable facility to store it in. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The social, occupational and recreational needs of the most dependent service users are not being identified or met. The meals are good and the resident’s benefit from being offer a wide range of options. EVIDENCE: A member of staff arranges social activities for one hour each afternoon in one of the communal lounges. These sessions were seen being enjoyed by the residents who attend them, but are poorly attended because not all of the service users can access the communal rooms. There was no evidence that the social, occupational and recreational needs of the residents who remain in their rooms are being considered or provided for Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 15 and some of the residents spoken with expressed feelings of being lonely and isolated. Mrs Lamont said that entertainers are occasionally invited into the home to provide social activities for the residents but that the last time this happened was in August. The residents who are able to go out unescorted may do so at any time and several residents have family and friends to take them out. Mrs Lamont does occasionally arrange individual outings for some of the more ambulant service users. Although the Statement of Purpose and Service Users’ Guide state that the service users may receive guests at any time, this statement is contradicted by a notice in the entrance hall that identifies that there are set visiting times (10am to 12 noon and 2pm to 5pm) and that appointments must be made if the service users wish to receive guests at any other time or in the evening. Several residents were asked for their opinion on the quality of the meals served in the home and all of them said that the food was very good and that they were offered a very wide range of choices at breakfast and tea-time. The cook, who was seen and spoken with at lunchtime, said that the residents could have alternatives to the set lunch time menu and was able to demonstrate this by discussing the different meals that she had prepared for the residents lunches that day. The dining room has recently been re-decorated and attractive new furniture has been purchased. Mrs Lamont said that only five of the sixteen residents regularly used the dining room, the rest eat their meals in their bedrooms. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Accessibility to the complaints procedure is poor and the service users and their representatives cannot be confident that their complaints will be handled appropriately. Policies and procedures are in place and staff training is provided to protect the residents from abuse. EVIDENCE: The Homes complaints procedure is not displayed in the home and as many of the service users and visitors to the home do not have access to the procedures included in the Statement of Purpose and Service Users’ Guide, inaccessible to them. A record book is kept to record complaints in and this was inspected. Insufficient information was recorded about the process that had been used to deal with complaints and the outcome of one complaint, which had been dealt with by the Commission, was not accurately recorded. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 17 The Commission had received two complaints since the last key inspection. One, referred to above, concerned the care provided to a service user who has since left the home and the attitude of the registered manager to the service users family. This complaint was partially substantiated and a number of requirements and recommendations were made. The requirements not met will be included in the ‘Requirements’ section at the end of this report. The second complaint was discussed with Mrs Lamont during this inspection but was not substantiated. Evidence was seen that some of the staff have received training in the Protection of Vulnerable Adults and the pre-inspection questionnaire identified that policies and procedures are in place to protect the service users from the threat of abuse. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The communal rooms are very well presented, but underused because some of the service users find it difficult to use the stair lifts and/or negotiate steps. A good standard of cleanliness is maintained. EVIDENCE: Southwater residential home is situated in a residential area of Paignton and is within a short walking distance of the town centre. The gardens to the back of the home are attractively landscaped and well maintained. The land to the front of the home provides a generous amount of off street parking. The outside of the home and the communal rooms are very well presented, but some of the service users bedrooms and the bathroom and toilet facilities would benefit from redecoration and/or refurbishment. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 19 A full inspection of the premises was carried out and a high standard of cleanliness was maintained in all but one bedroom, in which the smell of urine was detected. Radiator covers had been fitted to all of the radiators to remove the risk of the residents scalding themselves on them. It was observed that some of the recommendation made in a report of the premises that was carried out by an Occupational Therapist in June 2006 had not been dealt with. As these recommendations have implications for the safety of the service users, arrangements must be made to ensure they are dealt with. The home has five very comfortably furnished and attractively decorated lounges and a recently redecorated and refurnished dining room. Sadly these rooms are under used because some of the residents are unable to use the stair lifts and/or negotiate the small steps between rooms to gain access to them. Some of the residents cannot use the baths because the home does not have a bath hoist. Consideration should also be given to providing raised toilet seats to ensure that service users do not have to use commodes because the toilet is too low. The home uses outside contractors to launder soiled linen and this and the arrangements for dealing with the service users personal laundry are satisfactory. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service users benefit from being care for by staff who have appropriate qualifications and/or have received training. However, the staffing levels are not high enough to meet the needs of the current residents and unsafe practices are being used to recruit staff, which could place the service users at risk. EVIDENCE: Copies of the staff rota were provided for inspection purposes. The staff rotas show that no care staff are employed from 9pm to 9am. Mr & Mrs Lamont live in a flat above the home and most of the residents can use call bells if they need attention during the night. However, three of the service users may not be able to use the call bell, two because they have dementia and one because the bell is not located near to the bed. The night staffing levels do not meet the assessed needs of the more dependent service users who will require regular monitoring throughout the night. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 21 Staffing levels in the afternoons very low with just one care worker on duty between 1pm to 6pm. It would appear from the staff rota that only one care worker is employed on Saturdays and that she works from 9am to 12 noon. On Sundays only two care workers are employed for two hours each, from 9am to 11am. This is not sufficient to meet the assessed needs of the service users. It is acknowledged that Mrs Lamont works in the home and provides care on a full-time basis and that Mr Lamont also works at the home on a full time basis, although he deals mainly with the maintenance of the premises. Some of the service users are fairly independent and do not need a high level of personal care and support, however it was observed that at least six of the sixteen the service users had very high needs which the current staffing levels are not high enough to meet. Records seen at the home demonstrate that staff training is provided although most of the certificates seen were out of date and refresher courses are needed. The pre-inspection questionnaire states that four of the six care assistants had completed their National Vocational Qualifications in Care at Level 2. Mrs Lamont said that one of the four had also gained her NVQ in Care at Level 3 and that one was working towards gaining this qualification. Another care assistant is working towards gaining her NVQ in Care at Level 2. In addition to the above, Mrs Lamont said that she was in the process of registering herself and to member of staff onto the Registered Managers Award. The staff files were inspected to check that safe staff recruitment practices were being used. Both members of staff have completed an application form and provided two referees but there was no evidence on their files to show that their references had been taken up. A Criminal Record Bureau check had been carried out for one of the applicants but neither a CRB or a Protection of Vulnerable Adults First check had been carried out for the other. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management are very experienced and hard working but need to focus on ensuring that the premises are safe and providing a service that is as good for the service users with the highest needs as it is for the more independent service users. EVIDENCE: Thomas and Mary Lamont are the registered service providers. Mr Lamont is the registered manager but his main role is to maintain the premises and it is Mrs Lamont who manages the care. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 23 Both Mr & Mrs Lamont have a many years experience at managing a care home but do not have any formal qualifications for this role. Mrs Lamont said that she and two of her senior staff are planning to register to complete the Registered Managers Award. A quality assurance/quality control system has been carried out and a very well presented report has been produced. The report indicates that the service users, their relatives and their representatives are generally satisfied with the care provided. The Statement of Purpose states that residents will be offered appropriate assistance in the management of their personal finances, which would not be appropriate. However Mrs Lamont said that the home did not handle any of the service users personal money. The Statement of Purpose needs to be amended to avoid any confusion. The pre-inspection questionnaire states that all of the policies and procedures relating to the safety of the premises and safe working practices are in place and that appliances, including fire safety appliances, are regularly serviced. It was, however, observed that a number of wedges were being used to hold fire doors open. Other of the doors had been fitted with approved devises for holding them open which will automatically release the door in the event of a fire. It was also observed that some of the fire doors did not close fully into their recess and these need to be adjusted for safety reasons. Southwater Residential Home DS0000018427.V293318.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 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 2 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 1 14 1 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 1 1 1 X X X X 3 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 5(2) & 6 Requirement The registered person must supply a copy of the service user’s guide to each service user. Previous timescale for compliance 12/9/06 – not met. Also the registered persons must keep under review and, where appropriate, revise the Statement of Purpose and the Service Users’ Guide and notify the Commission of any such revision within 28 days. The residents must be provided with a statement of terms and conditions in respect of the accommodation to be provided which, must include the amount and method of payment of fees and a standard form of contract for the provision of services and facilities by the registered provider to the service user. The registered persons must not provide accommodation to a service user at the care home unless, so far as it shall be DS0000018427.V293318.R01.S.doc Timescale for action 13/03/07 2. OP2 5(1) c & d 13/03/07 3. OP3 14(1) 13/03/07 Southwater Residential Home Version 5.2 Page 26 practical to do so(a) The needs of the service user have been assessed by a suitably qualified or suitably trained person; (b) The registered person has obtained a copy of the assessment; (c) There has been appropriate consultation regarding the assessment with the service user or representative of the service user; (d) The registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his/her health and welfare. Previous timescale for compliance 30/03/06 & 12/09/06 – not met. The registered persons must ensure that the home is conducted so as – (a) To promote and make proper provision for health and welfare of service users; (b) To make proper provision for the care and supervision of service users. To meet this requirement the service users care plans need to include more information about their mental and physical health needs, their personal and social needs and how their needs can Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 27 5 OP7 12(1) a & b 13/02/07 be met by the care staff. Previously timescale for compliance 12/09/06 – not met. The registered persons must ensure that the care home is conducted so as(a) to make proper provision for the health and welfare of the service users; (b) to make proper provision for the care and supervision of service users. The service users mental health needs to be monitored regularly and preventative and restorative care provided. Opportunities must be given to enable the residents to take appropriate exercise and physical activity. The registered person must make suitable arrangements for moving and handling the service users so that they are not confined to their bedrooms. Suitable equipment, including bath hoists and raised toilet seats must be provided. The registered person must make suitable arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Any resident who administers their own medication must be provided with a lockable storage facility to keep it in. 6 OP8 12(1) a & b, 13(5) & 23 (n) 13/02/07 7 OP9 13(2) 13/01/07 Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 28 The administration of prescribed creams must be recorded on the medication administration record sheets. The original pharmacy label should not be removed or separated from any item of medication. Prescribed medicines, including creams, must only be used by the person that they have been prescribed for. Previous timescale for this requirement 30/07/06 – not met. 13(4)(c) & The registered persons must 13(7) ensure that none of the service users are subjected to physical restraint and isolation because they cannot safely access the communal areas of the home. 16(n) The registered persons must consult the service users about their social interests, and make arrangements to enable them to engage in local, social and community activities. The residents should be able to invite and receive visitors at any reasonable time. Any restrictions on the admission of the resident’s visitors to their home should only be made at their request. Previous timescale for compliance 30/07/06 – not met. The registered persons must ensure that the premises are suitable for the residents by improving access around the home. The registered persons must DS0000018427.V293318.R01.S.doc 8. OP10 13/02/07 9. OP12 13/02/07 10 OP13 12, 16 & 23 13/01/07 11. OP14 23(1)a 13/04/07 12. OP16 22(5) & 13/01/07 Page 29 Southwater Residential Home Version 5.2 17(2)11 supply a copy of the complaints procedure to every resident. Accurate records must be kept of each complaint, the process used to deal with the complaint and the outcome to the complaint. Previous timescale for compliance 30/07/06 – not met. The registered persons must ensure that the premises meet the needs of the service users by providing suitable mobility aids, removing obstacles which restrict the residents mobility (such as small steps) and providing sufficient staff to enable all of the residents to access the communal rooms and to use the baths safely. As above. As above. The registered persons must, having regard to the size of the care home and the needs of the service users, ensure that there are sufficient care staff on duty at all times. In particular this relates to the current lack of provision of waking night staff, as some of the service users would not be able to use their call bells, and the very low care staffing levels at weekends and on weekday afternoons. Previous timescale for compliance for the provision of waking night staff 30/07/06 – not met. Two references and a current CRB and POVA first check must be obtained for all newly appointed staff. DS0000018427.V293318.R01.S.doc 13. OP19 23(2)a & e 13/04/07 14. 15. 16. OP20 OP21 OP27 23(2)a & e 23(2)a & e 18(a) 13/04/07 13/04/07 13/02/07 17. OP29 19(1)(4) & (5) 13/04/07 Southwater Residential Home Version 5.2 Page 30 Previous timescales for compliance 30/04/06 and 30/07/06 not met. 18. OP30 18 The registered persons must ensure that the staff receive appropriate and relevant training. Certificated staff training in health and safety related areas must be updated if the current certificates are out of date. The registered persons make sure that the premises are maintained safely by; (a) Arranging for the fire doors which do not close properly to be adjusted. Removing any wedges or other unsafe objects used to hold doors open and if necessary providing approved devises to hold doors open. Storing all domestic chemicals safely and in compliance with COSHH guidance. Fit window restraints on all windows above ground floor level. 13/05/07 19 OP38 13 & 23(4) 13/02/07 (b) (c) (d) 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 Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 31 1. OP31 The Manager should be enrolled on an NVQ Level 4 and Registered Manager Award programme. Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Southwater Residential Home DS0000018427.V293318.R01.S.doc Version 5.2 Page 33 - 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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