Inspection on 19/06/07 for Southway

This inspection was carried out on 19th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 18/06/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Southway 290 London Road Bedford Bedfordshire MK42 0PX Lead Inspector Leonorah Milton Unannounced Inspection 19th June 2007 10:50 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.V338327.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. Southway DS0000014971.V338327.R01.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 briggsde@bupa.com BUPA Care Homes (Bedfordshire) Ltd ** Post Vacant *** 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.V338327.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 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’s post had been vacant since February 2007. Since then the service had been managed on site by the deputy with support from registered manager of another home and the organisation’s operation’s manager. 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 £478 and £549-50. Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report sets out the significant evidence that has been collated by the Commission for Social Care Inspection (CSCI) since the last visit to and public report on, the home’s service provision in January 2007. Reports from the home, other statutory agencies, and information gathered at the site visit to the home, which was carried out on 19th June 2007 between 10.50 and 19.10, were taken into account. The visit to the home included a review of the case files for three people living in the home, conversations with six people and three visitors to the home to gauge their opinion of the service and also with four members of staff. The home had carried out a quality audit that involved consultation with people living in the home. The questionnaires returned by people and their representatives during this process were reviewed. Comments from these were also taken into account to form judgements about the service. Much of the time was spent in the three lounges with people living in the home, where the daily lifestyle and the practice of personnel were observed. A partial tour of the building was carried out and other records were reviewed. The manager’s post had been vacant since February 2007. The deputy was on site to assist with information throughout the visit. The manager from another home who had supported the deputy since January arrived before lunchtime and the operations manager attended from the late afternoon. What the service does well: As had been noted at the previous inspection, the design of the building into five separate living units had enabled the home to develop a more homelike environment in which people’s independent living skills could be more readily promoted. The daily routines took place in a relaxed and unhurried atmosphere that was conducive to people’s well being. Personnel on duty were observed to treat people with respect and to show sensitive skill when working with those who were unable to articulate their needs. People living in the home who were able to contribute to the inspection passed positive comments about the skills of the team. Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 6 The home had a core of long serving staff. Their experience, knowledge about people’s needs and the home’s routines and their commitment to the welfare of the people living in the home had been of considerable benefit to the home whilst it had operated without a full time manager on site. Feedback from staff showed that teamwork had improved during this time, as had staff morale to the benefit of all who lived and worked in the home. What has improved since the last inspection? What they could do better: Medicines must be stored securely at all times. This must include any medicines that have been delivered by the pharmacist for the monthly delivery of repeat prescriptions. Records must be maintained to show when prescribed skin preparations have been applied. There should be written individual written guidance to ensure that staff are aware of the appropriate administration of medicines prescribed for use on an “as and when” basis. Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 7 As noted at the previous inspection, records of complaints investigation and response to complaints must be maintained in the home. The organisation’s timescales for investigation and response to complaints should be adhered to so that any identified need for an improvement in practice takes place in a timely fashion. The home should consider the provision of more physical activities for exercise and stimulation in response to comments noted on the home’s annual review questionnaires. Personnel must be provided with training that is appropriate to the role they are to perform. This must include safe handling of food and infection control. All staff must be provided with supervision. This should happen six times in any year. 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.V338327.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 Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,3, 6.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had obtained information about people’s needs before admission to ensure the home had the capacity to properly care for them. EVIDENCE: A copy of the Statement of Purpose was given to the inspector. It provided an easy read guide to the service. The details however were not entirely accurate as a central administrative office was listed as the registered address, which was not the case. Service user guides were available to people in their bedrooms. One person confirmed that they had seen the guide and “I found it helpful”. Three cases files were assessed at this inspection. Each showed that detailed pre-assessments of need had been carried out before people had been admitted. These had included information from placing authorities, and health Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 10 care providers where people had been admitted from hospital. The home had an established admissions procedure that included its own written assessment of need that was also used unless people were admitted under an emergency situation. In most instances, people moving into the home had been reliant on their relatives to visit and assess the home on their behalf. One relative had commented, “I have never had any regrets choosing Southway for my xxx”. The home provided a respite care service but not an intermediate care service. Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was sufficient written information about individuals’ personal care needs to provide staff with the guidance to care for people. However guidance about the use of medicines on an “as and when” basis was needed to maintain staff’s level of understanding about the use of these drugs and the consequent wellbeing of those living in the home. EVIDENCE: Three case files were assessed. Care plans had been developed in line with BUPA’s corporate care planning procedures and written format. The care plans seen were based on detailed assessments of need. Plans covered people’s personal, physical, health, recreational, social and emotional needs. Assessments of need and corresponding care plans had been reviewed on a regular basis and updated as needs had changed. Documents listing peoples’ preferences for their daily lifestyle had been completed. These listed preferred times for getting up and going to bed, preferred meals, beverages, frequency for bathing, hairdressing and similar. Observation of the daily lifestyle and Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 12 conversations with staff showed that personnel were familiar with people’s needs and how these were to be met. People who contributed to the inspection at the visit and who had responded to the home’s recent questionnaire were positive about the conduct of staff, describing them as “Very kind, you can’t fault them”, “They will always help you, you only have to ask”, “Very professional”. One person described the service as “Value for money” and another referred to the home as “Marvellous”. Others comments showed that a small percentage of relatives were not satisfied with the level of support provided, “Staff do not always explain or talk to xxx when moving xxx.” A visitor expressed concerns about the lack of stimulation for their relative, “I am not sure that staff encourage xxx to come out of their room. I feel that, if someone isn’t much trouble then they are left to their own devices.” There was evidence to show that people had been supported to access health care appointments for routine treatments such as chiropody, optical tests and had been referred to their doctors and other specialists as need be. Medicines were only administered by members of the team who had received training in safe practice. Medicines had not been stored in secure conditions as required in all instances. Most medicines were stored in purpose built, lockable trolleys that were in turn stored in a lockable office when not in use around the home. Some spare medicines were stored in locked cupboards within that office. Those recently delivered by the pharmacist for the monthly restocking of repeat prescriptions were seen in a box on the floor of this room and there were other spare medicines in two locked cash type tins on a work surface. Records inspected showed that medicines had been administered as prescribed for those for use at specific times. Written guidance for the use of medicine prescribed for use on an “as and when” required basis was not in place for each individual. Members of staff spoken to had an awareness of the appropriate use of such medicines. However, given the potential consequences of inappropriate use medicines described to the inspector for use to “settle” people, there must be written guidance in place for all personnel. Appropriate records had been maintained for the receipt of medicines, those returned to the pharmacist and in relation to the administration of Controlled Drugs. People living in the home had been treated with kindness and respect. One person described how staff knocked on the door before entering their room. Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 13 They described staff as “respectful” and said that this was very important to them. Southway DS0000014971.V338327.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. People living in the home had predominantly been supported to experience a lifestyle that, within the limitations of their abilities and needs, met their expectations. EVIDENCE: A high percentage of the people in living in the home had some form of cognitive impairment/short term memory loss. The arrangements for the dayto-day lifestyle in the home therefore were required to be extremely flexible. It was noted that daily routines varied according to need. Meals were served at set times but these could be varied for individuals who wished to eat at other times. Similarly, getting up times and bedtimes were individual. Residents were free to move around the home as they chose. Arrangements for activities for stimulation and recreation had taken account of abilities. Activities included organised events such as sing-a-longs, dominoes, arts and crafts, parties and such like but also meaningful domestic and similar activities for those who wished to carry on as they had before admission to the home. One person was seen to assist with the wiping up of crockery in a Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 15 kitchenette area and said they liked to keep busy. Another was seen sweeping the patio adjacent to their dining area. It was explained that people living in the home had contributed to the planting out of the flower tubs on the patio. One person had been able to bring their piano into the home. They were seen playing to others in a dining area to the evident enjoyment of all those present. One person described their daily lifestyle, “ I can do as I like. The ones who work at night are all right. They let me get ready for bed on my own and they knock on the door and come in and see if I’m all right. It reassures me to know they are there. We can have a bath when we like and go to bed late. I’m sometimes still up at 22.00. There are activities in the clubroom. I am invited to go. It is art classes today. Food is smashing. We can always have something different. There is plenty to drink all day. They look after our clothes all right. We get clean ones every day.” Another person said, “The food is marvellous. The home does everything you want and more. There are activities if you want, pictures today and reminiscence. Usually go to bed at 22.00/23.00 and get up when we like.” A visitor expressed concerns as recorded previously and stated that they felt their relative in the home was bored and under occupied. Two questionnaires stated they would like more physical activities and another stated they “would like to see staff sitting and chatting to residents.” People described the catering service as “Very nice”, “Marvellous”, “I get enough to eat”. Records indicated that nutritional needs had been assessed. Special diets were catered for as required. The menus seen showed a nutritious choice throughout the day. A “nite bite” menu had been introduced for those who required something later in the evening. The inspector joined people for the mid-day meal. It was tasty and well cooked. The atmosphere in the dining area was congenial. The meal took place at an unhurried pace and was an enjoyable social experience. The carer serving the meal were aware of peoples’ needs and appetite, so that those who preferred smaller portions were not put off by larger servings of food. Records of people’s food preferences and special dietary needs were recorded in the kitchenette areas around the home for the guidance of staff. Southway DS0000014971.V338327.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16, 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had detailed complaints and safeguarding procedures. However investigation of issues raised under these procedures was tardy so that there was some risk that any action required to remedy situations would be delayed. EVIDENCE: The last inspection had noted that records of complaints, investigation of the same and response to the complainant had not been maintained in the home. This inspection showed that whilst some complaints had been resolved and satisfactory records of the same were available, there was an instance where a manager from another home had carried out an investigation. In this instance there was no evidence to show how the investigation had been carried out or any conclusions drawn from the investigation or any final response to the complainant. Investigation had not taken place within the organisation’s stated timescales. There was no evidence in respect of a conclusion of the complaint that had been raised with the home verbally at the beginning of April 2007 and forwarded to the home in writing on 17th April 2007. The previous inspection had raised concerns at the lack of training for personnel in safeguarding procedures. Action had been taken to introduce a training programme since then but was still ongoing. One carer spoken to stated that they had worked in the home for several years but had not Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 17 undertaken any such training. She did however show understanding of issues that could result in the abuse of people. An allegation of physical assault of a person living in the home by an employee of the home had been reported in February 2007 to the Local Authority Adult Protection team under the home’s safeguarding procedures. Following a strategy meeting in March 2007 responsibility for investigation of the allegation was passed to the home. There was no evidence on file at this inspection in relation to any investigation. This was discussed with the operations manager who explained, that the alleged perpetrator had resigned and left the home on 5th March 2007. The investigation had been carried out by a manager from another home, who had not found any evidence of assault, there was however a concern about inappropriate handling. It was stated that the carer had been invited back to a disciplinary meeting and after this a report would be forwarded to the Adult Protection team. Southway DS0000014971.V338327.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building had been purpose built and provided a comfortable, well-adapted environment that was suitable to people’s needs. EVIDENCE: People who contributed to this inspection were mostly positive about the home’s environment. “It is always clean here. It is well kept and always neat”, “My bedroom is nice and clean. My bed is comfy. I sleep well”, ”I feel the décor and everything is very pleasant”. A few comments were less positive, “Bedrooms are too small. Very little scope for privacy without ensuite. Very little room for personal belongings”, “Some areas of the building are very shabby, need redecoration and are not up to expected BUPA standards. As detailed in previous report, the layout of the building had enabled effective working with people in a homely environment. The homelike décor and soft Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 19 furnishings throughout the home were commendable and had done much to dispel what could have been an institutional appearance in this large building. The décor was predominantly of a good standard but showing some signs of wear and tear in some of the communal areas, which was a pity after all the efforts to create this attractive environment. Information submitted by the provider showed that improvements to the environment during the last year had included redecoration of the foyer to the building and replacement of some bedroom carpets. People’s bedrooms, whilst quite uniform in layout, décor and furnishings, had been individualised by personal possessions. Many rooms had achieved a homely appearance. It was noted that the bedroom of one person who was included in the case tracking methodology was devoid of personal possessions other than clothing and toiletries. It was explained that this person’s relatives had not brought in any items of a personal nature. It was suggested that the home might, in consultation with this person, attempt to create a more personalised appearance to this bare room. Procedures were in place to ensure that the safety of the building and its equipment through regular maintenance checks and servicing by qualified contractors. Procedures were in place to control the risk of infection during laundry processes. Records indicated that ten members of staff had received training in infection control procedures. The home was planning to introduce a light box to promote thorough hand washing in the near future. Action had been taken to remove the unpleasant odours noted at the previous inspection by a thorough clean of carpets by external contractors and ongoing carpet cleaning programme. Southway DS0000014971.V338327.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The potential for an improvement in the delivery of the service had been brought about by better training arrangements. EVIDENCE: People who contributed to this inspection praised staff in the home and the care they had received from them, “Staff are attentive. If you ask for something they will do their best to get it.”, “The staff understand what we need”, “Staff are excellent in their attitude to residents”. A visitor remarked that they had seen, “ a member of staff showing patience and insight into working with those with dementia”. Observed practice showed that members of staff on duty worked effectively and safely with those in their care. It was noted that staff adopted a kind, calm approach to people and encouraged dialogue that was of interest to the people living in the home. One such conversation was skilfully handled by a carer and promoted a lively dialogue that was interesting to both parties. Rotas seen indicated that sufficient numbers of care and ancillary staff had been rostered to care for people living in the home. Staff were employed to carry out administration, catering, house keeping, laundry, and maintenance Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 21 tasks so that the care team could concentrate their efforts on assisting people with their care needs. The previous report had identified that the standard of training fell below the National Minimum Standards for the operation of care service for older persons. Action had been taken to improve this situation. Evidence was seen of induction training and the gradual introduction of training in dementia care and safeguarding procedures. There remained however gaps in training that must be addressed. Information by the provider showed that seventy percent of the catering team and forty percent of the care team only had received training in safe food handling. The numbers of permanent and relief staff totalled forty-eight. Of these eleven had achieved a National Vocational Qualification in care or equivalent. There was no indication that other members of staff were working towards this award. Two personnel files were seen. They showed that recruitment practice had been robust to safeguard people living in the home. Checks on background and employment history had been obtained via the Criminal Records Bureau and references from previous employers. Records indicated that equal opportunities procedures had been followed during recruitment. External and internal applicants for jobs had completed written application forms, and attended for interviews, the results of which had been recorded. Southway DS0000014971.V338327.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The deputy and senior team had managed the home to a satisfactory standard with the aid of managers from elsewhere in the organisation, so that the service delivered to people living in the home met their needs. EVIDENCE: The home had been without a full time manager on site since February. Personnel had worked hard since then to maintain and improve the operation of the service as has been shown throughout this report. Whilst there were actions still to be taken to continue this development, the efforts of the team during this challenging period are to be acknowledged. The home had an established senior team to support the rest of the team. There was evidence of regular meetings of senior personnel and of more Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 23 frequent meetings with the rest of the team than had been seen at the previous inspection. This had served the home well. Staff commented on the improvement in communication and the general organisation of the team. A review of the quality of the service had taken place since the last inspection. It had involved consultation with people living in the home and their representatives. The report of the findings was scheduled for preparation. Few people living in the home held any of their personal monies. Relatives in the main held this responsibility and left small sums of money with the home for routine purchases. BUPA’s systems to manage monies held on behalf of service users are thorough. Records seen showed that small sums of money were held on site. Most purchases were for services such as hairdressing chiropody treatment, newspapers and similar. Records showed that transactions for income and expenditure had been well maintained. Given the management situation in the home it was inevitable that supervision for personnel would lapse in some aspects. However there must now be some effort to provide some supervision to all personnel. One member of staff spoken to at the inspection in January had not received supervision for a significant time. At this inspection they stated they still had not received supervision. Systems to manage health and safety throughout the home were thorough. The corporate procedures were detailed, as were risk assessment and safety monitoring systems. Information provided pre-inspection showed that equipment had been regularly serviced and maintained. This was confirmed during the inspection by visual checks. The organisation will need to ensure that safety training is provided in all aspects. Southway DS0000014971.V338327.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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 3 Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement The registered person must ensure that: Medicines are stored securely at all times to ensure that unauthorised persons cannot access them. Written guidance is introduced in relation to the administration of medicines for use on an “as and when” basis to ensure that there is no risk to people living in the home. The registered person must maintain records of complaints to include acknowledgement, investigation, any actions arising and a response to the complainant. (Previous timescale of 31/01/07 had not been met) The registered person must provide staff with training that is appropriate to the role they are to perform. This must include safe handling of food and infection control. DS0000014971.V338327.R01.S.doc Timescale for action 30/07/07 2. OP16 12(1)(a)2 2(3)(4) 30/07/07 3. OP30 18(1)(c) (i) 30/09/07 Southway Version 5.2 Page 26 4. OP36 12(1)(a)1 8(2) The registered person must ensure that personnel are provided with supervision. (Previous timescale of 31/03/07 had not been met in full). 30/09/07 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 physical activities for exercise and stimulation in accordance with their wishes/assessed needs. Complaints investigation should take place within the home’s procedural timescales to ensure that any identified actions for improvement of the service take place in a timely fashion. Investigations of safeguarding issues should take place without delay to ensure that any identified actions to safeguard people/improve practice take place in a timely fashion. 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 inspection of 5th January 2007) A training programme should be introduced that has taken account of an analysis of individual staff training needs. (Carried forward from the inspection of 5th January 2007) 3. OP18 4. OP28 5. OP30 Southway DS0000014971.V338327.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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.V338327.R01.S.doc Version 5.2 Page 28 - 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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