Inspection on 18/06/08 for Southway

This inspection was carried out on 18th June 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Southway 19/06/07

Southway 05/01/07

Southway 25/01/06

Southway 25/11/05

Southway 15/02/05

Southway 23/07/04

Southway 12/03/04

Southway 27/08/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Southway 290 London Road Bedford Bedfordshire MK42 0PX Lead Inspector Louise Bushell Unannounced Inspection 18th June 2008 10:00 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 Southway DS0000014971.V366570.R02.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. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southway Address 290 London Road Bedford Bedfordshire MK42 0PX 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) 01234 345284 01234 360340 fosterri@bupa.com BUPA Care Homes (Bedfordshire) Ltd Rita Foster Care Home 42 Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (42), of places Physical disability over 65 years of age (42) Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th June 2007 Brief Description of the Service: Southway residential care home was purpose-built in 1975 and is operated by BUPA Care Homes (Bedfordshire) Ltd. The manager has now been registered with the commission for social care inspection. The service was registered to provide care for 42 people over 65 years old, who may also have dementia and/or physical disabilities. Single room accommodation was provided. Accommodation was distributed over two floors and arranged in five units that each had a dining area, lounge and kitchenette facility. A large room for communal activities was located on the ground floor, as was a combined hairdressing room and shop. Bathroom and toilet facilities were distributed for convenient access throughout the building. A well laid out central quadrangle garden was available in addition to small gardens attached to each of the ground floor units. Parking for several vehicles was located close to the entrance to the building. Weekly fees for accommodation were between £345 and £602. Southway DS0000014971.V366570.R02.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. Standards identified as ‘key’ standards and highlighted through the report were inspected. In addition to the key standards a number of other standards were inspected to assess the services ability as part of case tracking people that use the service from the admission stage to placement stage. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of existing evidence, the previous annual quality assurance assessment, pre-inspection planning, an unannounced inspection visit to the home, any information sent to us from the service and other professionals, collating information received in person from relatives and the people who use the service, and drawing together all of the evidence gathered. The service has not received and formal written complaints since the last inspection. The pre-inspection planning was carried out over the period of a day and involved reviewing the service history, which details all contact and correspondence with the home and previous inspection reports. The last full inspection took place on the 19th June 2007, however an inspection was also carried out in January 2007, which focussed on specific issues. Information from these inspections was taken into account as part of the planning. This unannounced inspection visit was carried out by one inspector and covered the morning and afternoon of a weekday. The inspection was carried out by ‘case tracking’, which involves selecting samples of residents’ records and tracking their care and experiences. Observations of the homes routines and care provided were made and views on the care provided were sought from people who use the service, visitors and staff. Additionally questionnaires were sent to a random selection of people to ascertain their views. Responses had been received from five staff and two relatives. In addition to this the views of a visitor, staff and people that use the service were obtained on the day of the inspection. The management of residents’ medication was checked through reviewing prescribed medication for a sample of people. A sample of staff files were reviewed to check the adequacy of the recruitment procedures in protecting people who use the service. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 6 Communal areas and a sample of bedrooms were viewed and observations were made of people’s general well being, daily routines and interactions between staff and people who use the service. Verbal feedback was given to the Manager, Area Manager and the Deputy Manager on the day of the inspection. What the service does well: What has improved since the last inspection? Medication systems have improved in the service, with internal monitoring and auditing procedures in place. The receipt, storage and administration of medicines was vastly improved. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 7 The provision of training and supervision is increasing gradually. The manager has been successfully registered with the Commission. What they could do better: Staff must be provided with periodic supervision / appraisal and development opportunities. A detailed fire risk assessment is to be implemented to ensure the health and safety the people who use the service. Risk assessments are required for the safe use of and access to the kitchenette areas. All risks must be suitably managed. The environment is in need of some refurnishing and redecorating. Records are not stored securely ensuing that the confidentiality of people who use the service is maintained. People should be offered opportunities to take part in a varied range of activities. The complaints procedure should be up dated with the correct contact details of the Commission. The home’s training plan should show how personnel will be supported to achieve NVQ awards in care, so that 50 of the team achieve this qualification. A training programme should be introduced that has taken account of an analysis of individual staff training needs. The guide should be reviewed and contain the findings from the last Commission for Social Care Inspection, and experiences of people that use the service. The results from the quality assurance surveys should be included in the guide. This will assure residents and relatives that their comments are listened to and enable perspective residents to gain an insight into living in this home. COSHH data sheets should be made available to laundry staff in the laundry area. Detailed Dementia training must be provided to all staff. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 8 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. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 9 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 Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 10 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, 3. Standard 6 is not applicable as intermediate care is not provided, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is provided to help people make decisions about their care and a thorough assessment takes place, which helps to ensure that their needs can be met. EVIDENCE: The service has developed a statement of purpose, which sets out the aims and objectives that the person can expect to receive. This includes a guide which provides basic information about the service and the specialist care that is available. The guide details what the prospective people using the service can expect and gives an account of the specialist services provided, quality of the accommodation, qualifications and experience of staff and how to make a complaint. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 11 All people who use the service are given a copy of the guide. When requested the service can provide a copy of the statement of purpose and guide in a format which will meet the capacity of the resident. The guides did not contain the recent findings from the last inspection report or the comments and findings of the experiences of people who use the service. One relative commented “I looked at eleven other services before choosing this one. We had all the information we needed to make the choice and the home is very welcoming and as near to home as could be expected.” Admissions are not made to the service until a full needs assessment has been undertaken. A senior person always completes the assessment prior to admission to the service. A number of pre assessments were seen and completed well. The service also completes a secondary assessment on admission to review any changes in need; this information is used to inform the personal plan. The assessment explored areas of diversity including preferences, religious and cultural needs, involvement from family, partners and advocates, race and disability. It was evident that the service strives to seek the information and assessment through care management arrangements, prior to admission. The service has the capacity to support people who use the service and respond to diverse needs that may have been identified during the assessment process. A total of four people who use the service, one relative confirmed that they had enough information about the service. Privately funded people who use the service are provided with a statement of terms and conditions or a contract. Contracts are reviewed when there is a change in the needs of the person using the service. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 12 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, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has suitable care plans and arrangements in place for the receipt, storage, administration and disposal of medication, meeting all people’s medical, health and social care needs. EVIDENCE: A total of three care plans were case tracked fully, it was established that people who use the service receive personal and healthcare support using a person centred approach. Personal healthcare needs including specialist health; nursing and dietary requirements are clearly recorded in each persons care plan. The care plan provides clear information and a comprehensive guide for staff to know how to support the person. The care plan is generated from the pre admission assessment and includes guidelines, risk assessments for the management of falls, manual handling assessments and self medication risk assessments and care plans. One person using the service had recently had a fall, evidence was found of this is being appropriately recorded. There Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 13 was a short term care plan in place to support the person through the after care of the fall. The falls risk assessment had been reviewed, including the care plan review. The accident was recorded in the accident book and the Commission had been notified correctly. It was observed that personal support is responsive and tailored to meet the individual choices, needs and preferences. Staff were observed to respect the privacy and dignity of all people. An example of good practice was observed by a member of staff positively engaging with a number of people who use the service, laughing and chatting about daily information. It was pleasing to see a number of people engaging and being stimulated by the positive engagement. The service listens and responds to individual choices and decisions about who delivers their personal care. The care plan also details another additional personal preferences, this included food types, night time preferences, activities, religion, personal appearance, personal time and how the person would like to be addressed. People are supported and helped to be independent and can take responsibility for their personal care needs as detailed in their care plan. Residents have access to healthcare and remedial services. The health care needs of residents unable to leave the service are managed by visits from local health care services. The service is not registered as a nursing home and therefore has vital links with the district nursing team. From the information gathered it is clear that good relationships are held. Clear evidence was seen in the care plans of specialist health care support services visiting the service and in addition to the care plan there were detailed notes made by the specialist visiting the service for example the District Nursing team and General Practitioners. A number of comments were received directly from people that use the service, their relatives and friends. One person commented that, “ I am a diabetic and the staff know exactly what to do”. One relative commented that “staff are mostly excellent communicators with relatives, they always appear caring and are well informed”. The service has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries, and are signed by appropriate staff. The management of controlled drugs is effective with records being accurate and stock balances being correct. A total of four people’s medication was case tracked in order to ensure compliance. Fridge and room temperatures were being recorded in all the medication rooms. Ordering and returns documentation was up to date and accurate. The service works with individuals regarding any refusal to take medication. The people using the service are given the support they need to manage their medication. If individuals prefer or where they lack capacity, care staff can manage medication on their behalf. This is assessed and detailed in the care plan. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 14 On the day of the inspection the lift was noted to be out of order. A new part was on order and due to be fitted the following day. The service had to implement emergency plans in relation to the safekeeping and storage of medications so that administration could occur in line with the services. Suitable arrangements had been made. However the home must implement a risk assessment to support the action that was taken and to reduce any further risk and future occurrence. The service should ensure that new stock medication is accurately transferred to the new sheets ensuring that balances carried forward tally with the stock. Risk assessments are in place for the self administration of medicines. The service has recently transferred to using Boots as the provider of the medication. Feedback from staff determined that this appears to be a successful transition. Staff have completed and passed an appropriate medication course. An assessment has been carried out to ensure each member of staff is competent to handle, record and administer medication properly. On the day of the inspection it was directly observed that people who use the service were being supported and provided with specialist treatment in their own rooms and in private if they wished. The majority of care plans tracked contained suitable and sensitive plans and arrangements for the management of end of life. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 15 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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Not all people who use the service are able to access activities of their choice, so that they are suitably engaged, stimulated and encouraged to socialise. EVIDENCE: People who use the service have the opportunity to develop and maintain important personal and family relationships. Feedback from one relative on the day of the inspection confirmed that relatives / representatives are always welcome into the service. One relative stated that “I am visiting my mother next week and we are having lunch together, as long as I let them know they are happy for visitors to have a meal with their relative / friend, its very welcoming”. On the day of the inspection a number of visitors were seen in the building visiting their relatives / friend / partners. A number of relatives made the following comments. “Excellent liaison”. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 16 “They give my mother the care and the attention she needs, she is always clean and well dressed. She is much happier than she ever was in the community”. The service respects the human rights of people using the service with fairness, equality, dignity, respect and autonomy underpinning the care and support being provided. This was indirectly observed through the practices of the staff on duty. A number of people who use the service were seen to be very relaxed and calm within their own environment and engaging with staff in an equal manner. Residents are involved in some meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. The care plan details life maps for each individual which supports the service in providing meaningful activities of their choice. There is also reference in the care plan to the preferences of each individual for activities and previous interests. Residents can access and enjoy the opportunities available in their local community, such as a library services, the local pub, and local leisure facilities. Trips were arranged and planning taking place. The manager discussed a number of local trips that were being arranged for the people using the service. Each of the smaller living areas have a television and DVD player including a music system. A limited amount of activity materials is available direct on the unit. There is also a large communal activity room, which people who use the service can access. On the day of the inspection, movement to music was cancelled due to a training course being held. The manager commented that an external entertainer had visited the service the previous day The manager has also identified in discussion, that the service is aiming to further develop the provision and variety of activities being made available to all. The service does not currently have an activities coordinator working. The manager stated that the staff are facilitating activities in the interim. The people who use the service stated that they enjoy the activities provided. However during the inspection, a number of people were seen not engaging in any activity. The manager stated that the service would be reviewing the static activity plan in place and making these more varied and specific to the likes and dislikes of each person. The manager added that the activity plans would be drawn up on a weekly basis in consultation with the people who use the service. The menu is varied with a number of choices including a healthy option. It includes a variety of dishes that encourage individuals to try new and sometimes unfamiliar food. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. A number of the units Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 17 within the service have white menu boards on display so that at any time the person is able to see what is available for that day. During the inspection a number of these were seen not to be completed. The food provided appeared appetising and well presented. Comments received included; “we like the food, we want good English food and that’s what we get, I have no complaints, if I did I would not be here”. Snacks are available 24 hours a day and the kitchenette areas were seen to be well stocked. One person who uses the service commented that “the food is good and I do get a choice, I can always have something else later”. The care staff are sensitive to the needs of those residents who find it difficult to eat and give assistance with feeding. They are aware of the importance of feeding at the pace of the resident, making them feel comfortable and unhurried. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 18 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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a robust complaints procedure in place, good staff awareness and attitude towards safeguarding issues so people who use the service are safe and protected. EVIDENCE: The service has an open culture that allows people who use the service to express their views and concerns in a safe and understanding environment. People who use the service have commented that they are happy with the service provided; feel safe and well cared for. A number of comments received determined that people who use the service and relatives and friends are aware of what to do if they have any concerns. A new verbal complaints log is now in place and records appeared to be effective. One person using the service commented “the staff always listen to me, if I need anything or unhappy, they are all very kind”. It was evident that verbal complaints are also well managed, resolved quickly in the best interest of the person using the service. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 19 The service has a complaints procedure that is clearly written and easy to understand. It is available in a number of formats such as different languages on request. The complaints procedure is supplied to everyone living at the service and is displayed in a number of areas within the service. There is a detailed record of all complaints and compliments made and received. The service has not received any written complaints since the last inspection. Feedback from a relative determined that if they have any concerns that the staff are always attentive. The complaints procedure needs reviewing to ensure the correct contact details are available for the Commission for Social Care Inspection. The service should also consider the recording of compliments made to the service. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. Staff commented that they have received training in safeguarding and felt confident in reporting any issues as they occurred. Staff had a clear understanding of the Whistle-blowing policy and when the use of this may be put into practice. The service understands the procedures for safeguarding adults and attends meetings or provides information to external agencies when requested. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 20 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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the service enables the people who use the service to live safely, however attention needs to be taken to improve internal furnishing and decoration to ensure the service continues to meet people’s needs and choices. EVIDENCE: The service provides a physical environment that is appropriate to the specific needs of the people who live there. The environment provides a homely feel with specialist aids and equipment to meet needs as required. The service is a pleasant, safe place to live; the bedrooms and communal room provide a personal and homely feel. The decoration throughout the building is tired with some areas being significantly worn. Some of the furniture and fixings throughout the building are tired and require replacing. The layout of the Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 21 building enables people to move freely where they reside, with several different seating areas throughout to encourage socialising or enabling the person to have privacy. People are encouraged and supported to move amongst different living areas on the same level. The people who use the service appear to like the environment, were relaxed, comfortable, and settled. Each of the ground floor units has a small courtyard garden, which is secure, and people who use the service can use this space with support. The garden areas have flowers and tables and chairs, promoting independence and a homely feel. The people using the service can not access these area independently as exits are secured. Following discussion with the management team the service must evidence and document any limitations and restrictions on the people that use the service. This must be supported through detailed risk assessments and controls measures put into place. Each area has a kitchenette so snacks and drinks can be readily accessed by all. The service must ensure that risk assessments are in place to ensure the safety of all people using the kitchen area as per the needs identified in the care plan The people who use the service are encouraged to personalise their bedrooms. All the home’s fixtures and fittings meet the needs of individuals and can be changed if their needs change. The building design supports the needs of people with Dementia. The manager discussed the improvements that she is planning on making to the environment and this included a rolling programme of redecoration, some refurbishment, the introduction of memory box’s and themes in the units encouraging reminiscence. The dining rooms are laid out to encourage communal dining with a calm relaxed atmosphere. The environment promotes the privacy, dignity and autonomy of residents. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. The home has an infection control policy. The service is clean, well lit and smells fresh. One comment was received from a relative about the need to complete redecoration and refurbishment. There was restricted access to high risk areas such as the main kitchen and the laundry areas to reduce the risk of cross infection. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 22 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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some staff were trained; however a number of staff did not have detailed Dementia Care Training and were not receiving supervision on a regular basis to ensure that they were able to meet the needs of people living at the service. EVIDENCE: Feedback from the people who use the service shows that they have confidence in the staff who care for them. Staff Rotas were seen and displayed adequate numbers of staff on duty to meet the needs of the people using the service. A deputy manager was usually on shift as the duty supervisor in addition to the care staff. This enables staffing levels to be maintained for the safety of all and that record keeping was completed and monitored as required. Staff members are able to undertake external qualifications beyond the basic requirements. One staff member commented, “Southway has always been very supportive and encouraged me to do my job in a professional way. I have completed numerous trainings courses and have completed my NVQ (National Vocational Qualification) within six months of joining the company”. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 23 Managers encourage and enable this and recognise the benefits of a skilled, trained workforce. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. People who use the service report that staff working with them are very skilled in their role and are consistently able to meet their needs. There is a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. Four staff files were audited and were seen to contain all the required documentation. Four individual staff commented on the strong team culture of the service and felt that following recent recruitment, there are enough staff on duty to meet the needs of the people who use the service. Staff confirmed that the service was clear about what was involved at all stages and was robust in following its procedure. There are clear contingency plans to cover for vacancies and sickness and the use of agency staff is monitored through the management team. The manager of the home is currently recruiting to fill the vacancies. Once recruited staff receive induction and training. The induction process, known as “personal best” is a process where the staff member is trained and mentored through a complete programme. The programme is then signed at the end of each stage. Following discussions with a number of staff and the manager it was determined that this process was being reintroduced to the service to ensure that all staff had fully received this and that evidence was held on their file. Staff confirmed that the senior team provide supervision, however records showed that formal supervision was not occurring at regular intervals. The manager of the service also commented that the supervision schedule for 2008 needed to be followed and that members of the senior team conduct these. Progress had occurred following the last inspection. The last inspection identified that the service must introduce and implement a staff development plan that has been based on an analysis of individual need. This requirement has been met. The service has scheduled specific mandatory training for each month and is conducted by qualified trainers within the group. Following discussion with the staff and manager, it was determined that the analysis of individuals needs were being added to a central matrix and personal training plans. Comments were received from staff regarding the Dementia training that is made available to staff. BUPA offers all staff an initial awareness training into supporting people with Dementia, this is later backed up through the attendance on the Dementia course. Staff feel that there is a need for more specific Dementia training to ensure that they are suitably equipped to meet the changing needs of the people who use the service. The manager discussed the developments and improvements that she is hoping to Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 24 implement into the service, one of these is through the commencement of a distant learning Dementia course for all staff through a local university. A number of staff are due to commence their NVQ II in care whilst a number have already completed. However this does not represent 50 of the staff team. Feedback from staff determined that the staff turn over is quite high and that consideration should be made to the terms and conditions for the staff encouraging them to stay. Feedback from one member of staff determined that they were not being offered NVQ III in care. Staff confirmed that staff meetings occur and a number of comments received on the staff surveys determined that the staff feel fully involved and updated. The mix of staff is suitable to meet the cultural needs and mix of people that use the service. Staff reported that they felt supported in their roles and that they were able to discuss issues with a member of the senior team if required. A comment received from a staff member states that; “I feel that the manager and the other team leaders do support and discuss how I am getting on and if I have ever needed some one to listen if I have had any worries I am always given a fair hearing”. A number of staff who were surveyed, commented that they would like more staff to be on duty to ensure that activities and individual needs are being met. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 25 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, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People benefit from living in a well-managed service but some improvements are needed in relation to health and safety, record storage and staff management, in order to ensure that all people are protected and safe. EVIDENCE: The Registered Manager has the required qualifications and experience and is competent to run the home. The Registered Manager and the deputy managers have a clear understanding of the key principles and focus of the service, based on organisational values and priorities. They work to continuously improve the service. Feedback received on the day of the inspection from staff Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 26 and as part of the feedback questionnaires received determines that the management are effective and approachable. With the introduction of the new care planning format and training around its implementation, there is a focus on person centred thinking, with the people who use the service becoming increasingly more involved. The Registered Manager and deputy managers lead and support a stable staff team who have been recruited and trained to satisfactory levels. The manager is aware of the continued need to ensure that enough staff hold a National Vocational Qualification In Care Level 2. The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. The service has sound policies and procedures, which are corporately and internally reviewed and updated, in line with current practice. The manager ensures that staff follow the policies and procedures of the home. The staff team are positive in translating policy into practice and showed good knowledge of care principles, health and safety and safeguarding issues. This includes the management of finances within the service, where systems were directly observed to be transparent and open, with detailed records being maintained at all times. There was some evidence on staff records that staff have supervision but this is not always carried out on a one to one basis where staff have the opportunity to discuss their personal development. There is a need for all staff to be offered guidance about the role of supervision and for periodical one to one sessions to be documented. Staff confirmed that supervision does occur but not on a regular basis. The manager confirmed that continued development and progress is being made with training and supervision and it was seen that progress had been made. Discussions occurred with the manager regarding additional steps that she will be taking to ensure full compliance. The manager also identified a need to ensure that all in house training for staff including team leaders and ancillary staff is completed as scheduled. The service is also in the process of developing further standardised operating procedures to assist the staff to comply with policy and standards. Staff meetings take place regularly and minutes of the meetings are available. The home works to a clear health and safety policy. Safeguarding is given high priority and the home provides a range of policies and guidance to underpin good practice. In house training is scheduled for safeguarding. Staff showed a sound working knowledge of action to take in such an event. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 27 A training matrix has been developed, however there is a need for this system to be further developed and revised. Individual training plans are being devised along with the completion and introduction of “personal best”. Through discussions with the management team and it was determined that priority is given to ensure that all staff are in receipt of adequate training, including in house refresher courses and a full complete induction programme. Individual training plans are being developed and will be used, once complete to review the annual performance of staff in their appraisal. A number of staff have identified the need to have additional Dementia Care training. A recent inspection was conducted by Bedfordshire and Luton Fire Rescue Service. The findings from their inspection were discussed in full with the management of the service. It determined that there is a need for the service to revise and complete a detailed person specific risk assessment for fire safety and management. The area manager added that BUPA has a designated fire officer working for the company who is responding to the requirement corporately. There were no risk assessments in place for the open access for the kitchenettes. Risk management processes and procedures must be implemented to ensure that any future faults with the lift system are dealt with safely. COSHH data sheets were available in the main office are and were reviewed, however the data sheets were not available in the laundry area for staff using chemicals. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 28 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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 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 3 X 3 X 3 2 2 2 Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No 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 OP36 Regulation 12 (1) (a) 18 (2) Requirement All staff must receive periodic supervision / appraisal and development opportunities to ensure they are skilled and competent to deliver care. A detailed fire risk assessment must be implemented to ensure the health and safety the people who use the service. Risk assessments must be completed for the safe use of and access to the kitchenette area by the people living at the service. The environment must be furnished and decorated to a expectable standard. Records must be stored securely ensuing that the confidentiality of people who use the service is maintained. Timescale for action 30/08/08 2. OP38 23 (4) (a) 30/08/08 3. OP38 13 (4) 15/07/08 4. OP19 23 (2) (b) (d) 30/09/08 5. OP37 17 (1) (b) 30/07/08 Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 30 6. 7. OP38 OP30 OP27 13 (4) 18 (1) (a) Risk assessments must be completed to ensure all service users are suitably protected. Detailed Dementia training must be provided to all staff. 30/07/08 30/09/08 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. Refer to Standard OP12 OP16 Good Practice Recommendations People should be offered opportunities to take part in a varied range of activities to maintain their social wellbeing. The complaints procedure should be up dated with the correct contact details of the Commission so people are able to make contact. The home’s training plan should show how personnel will be supported to achieve NVQ awards in care, so that 50 of the team achieve this qualification. (Carried forward from the last inspection) 4. OP30 A training programme should be introduced that has taken account of an analysis of individual staff training needs so that the service can provide specific training. (Carried forward from the last inspection) 5. OP1 The service guide should be reviewed and contain the findings from the last Commission for Social Care Inspection, and experiences of people that use the service so that people can access up to date information about the service. The activities programme should be reviewed so that it reflects the views and references of the people who use the service. COSHH data sheets should be made available to laundry staff in the laundry area for people to access readily as DS0000014971.V366570.R02.S.doc Version 5.2 Page 31 3. OP28 6. 7. OP12 OP38 Southway 8 OP1 required. The results from the quality assurance surveys should be included in the service guide. This will assure residents and relatives that their comments are listened to and enable perspective residents to gain an insight into living in this home. Southway DS0000014971.V366570.R02.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE 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 Southway DS0000014971.V366570.R02.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. 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