Inspection on 05/01/07 for Southway

This inspection was carried out on 5th January 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 19/06/07

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 5th January 2007 10.25 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.V326081.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.V326081.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 briggsde@bupa.com BUPA Care Homes (Bedfordshire) Ltd 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.V326081.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 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 Mr N Cooke had been appointed in August 2006 but had not submitted an application to be registered in that post at the time of this inspection. The service was registered to provide care for 42 people over 65 years old, who may also have dementia and/or physical disabilities. All of the service users living in the home at this inspection had been admitted under the category for those with dementia. 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.V326081.R02.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 (CSCI) since the last visit to and public report on, the home’s service provision in January 2006. Reports from the home, other statutory agencies, and information gathered at the site visit to the home, which was carried out on 5th January 2007 between 10.25 and 18.30, were taken into account. A second brief visit was carried out on 9th January 2007 to assess documents that were not available at the first visit to the home. The visit to the home included a review of the case files for three service users, conversations with six service users, four visitors to the home, two district nurses, four members of staff and the manager. Much of the time was spent with service users in three lounges, where the daily lifestyle was observed. A partial tour of the building was carried out and other records were reviewed. The CSCI circulated a service user survey prior to the inspection. Responses have been taken into account and some are detailed in this report. What the service does well: What has improved since the last inspection? What they could do better: Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 6 The home must not admit service users that it does not have the expertise or legal registration to care for. The standard of management had deteriorated. Systems to consult formally with service users and/or their representatives must be reintroduced. Similarly, there must be professional management systems in place to ensure that this large group of personnel receive instruction, guidance and supervision about best practice and individual performance. The proprietors must ensure that persons appointed to manage and to work in the home have been subject to rigorous recruitment procedures so that service users are safe guarded by having people of the right calibre to care for them. The proprietors must take urgent action in respect of anyone working in the home who has not been open about their previous employment history. Personnel working in the home must be sufficiently trained and qualified. The organisation will need to introduce a training programme that has taken account of an analysis of the current training needs of the people working in the home. Such training must include basic induction, procedures to protect service users from abuse and care of those with dementia. Records of complaints, investigation of the same and response to the complainant must be maintained in the home. Service users must be consulted about the practice where members of staff assist them to change into their night attire before they are ready to go to bed. Service users must be provided with a comfortable and clean environment. Action must be taken on the few exceptions that were found to these standards to ensure that unpleasant odours are eliminated and that every service user’s bed in made properly each day. 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.V326081.R02.S.doc Version 5.2 Page 7 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.V326081.R02.S.doc Version 5.2 Page 8 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 1,3,4,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The pre admission process of service users to the home was seen to be undertaken for planned admission. However the process for the acceptance of admissions on an emergency basis resulted in inappropriate admissions and increased risk to service users EVIDENCE: The statement of purpose was available at the second visit to the home. Whilst it had been updated to indicate a change of manager, his training background and that of the staff working in the home were not included in the document. The document stated there was an attachment to identify the staffing structure for the home. The copy given to the inspector for filing with the CSCI did not include the attachment. Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 9 Three case files were assessed. Each showed that the home had received an assessment of need from the placing authority before the service user had been admitted to the home. In two cases the home had also carried out a pre-admission assessment of need to determine that the home was able to care for the service user. The assessment of need for a service user who had been admitted under emergency conditions showed that their primary assessed need was a dependence on alcohol. The home did not have the required expertise and was not registered to provide for service users’ with this identified need. It was the responsibility of the home manager to ensure that admissions to the home fell within the registration of the home. The case notes indicated that the service user had attempted to leave the home in the first few days following admission. There was no evidence that the service user lacked capacity to decide whether or not residence at the home was what they wished. Whilst acknowledging that the home took steps to safeguard the service user in an emergency situation the placement of this resident outside of the home’s registration category led to a situation which was difficult to contain. The home was not empowered under any legislation to detain anyone against his or her will over prolonged periods, as had happened in this case. Training records indicated that few staff, including the manager, had undertaken training in the best practice for the care of those with dementia. Given that all of the service users in the home were accommodated under this category, the training of personnel in this field of care is essential. Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 10 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 poor. This judgement has been made using available evidence including a visit to this service. On the whole service users’ every day needs had been met, but the detention of one service user against their will meant that there had been a serious contravention of their human rights. EVIDENCE: Care planning documentation provided clear guidance to service users’ needs and how these were to be met. However the arrangements for one person was inappropriate. The notes in one care file showed that action had been taken to prevent the service user from leaving the building. Whilst it was evident that this action had been taken in the service user’s best interest; the home was not legally empowered to detain them. It was explained to the inspector that there had been a lack of action by the placing authority when the problems of caring for this person had arisen. The organisation is advised to inform placing authorities about the home’s registered categories and its legal obligations in the delivery of care. Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 11 The overall guidance on care plans would benefit from more detail about personal preferences such as food likes and dislikes, although it was evident that permanent members of staff on duty were familiar with their choices. How agency staff, employed on a temporary basis, as happened over the Christmas period, would be able to identify personal preferences was not clear. The plans should show the contribution of service users or where appropriate their representatives so that the service user, as well as members of staff will be aware of how needs are to be met. Comments on a questionnaire stated “Contradictory instructions by different members of staff, as to whether she should be doing things on her own or accompanied i.e. visiting toilet, which leads to confusion in her mind.” Risk assessments seen were predominantly about the hazards associated with manual handling tasks. Assessments of the risk of falls had taken place, and interventions such as the introduction of pressure mats to alert staff when service users were moving around in their rooms were in place. Care notes indicated that service users had been referred to their doctors and other healthcare specialists as need be. There were records of regular chiropody treatment and an annual optical check. Service users had been taken to dentists for treatment and to the local hospital for appointments at specialist departments. There had also been contact with the Community Psychiatric Services and the District Nursing Services. Two district nurses were visiting the home at this inspection. They passed positive comments about the conduct of staff witnessed at frequent visits to the home. They also stated that the standard of care for service users’ skin was good as they were rarely called upon to treat pressure sores or similar. A senior member of the team was observed as she administered medicines. The practice observed and the systems for the storage and recording of medicines were in accordance with good practice guidelines. Staff with the responsibility for administering medicines had undertaken distance-learning courses in safe procedures. Oral and written feedback from service users and their representatives about the conduct of the home confirmed that service users had been treated with courtesy and their dignity had been respected. However, the practice of dressing service users in their night attire before they were ready for bed had compromised service users’ rights to dignity in public places around the home. It was explained that this practice took place mostly as service users wished but it was expected that service users who required the assistance of two members of staff to change their clothes would have been changed into their night attire before the night shift commenced. Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 12 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 12,12,14,15. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The daily lifestyle in the home, whilst relaxed and informal, did not provide sufficient opportunities for service users to take part in stimulating activities. Bedtime routines had not been carried out in the best interests of service users at all times. EVIDENCE: Activities for recreation and stimulation were mostly dependant on the input from a part time activity organiser who arranged activities for communal participation. Lists were displayed in the units. Whilst these showed daily activities, staff on duty acknowledged that it was rare for the advertised activity to take place in the units. There was no systematic approach to engage service users in meaningful activities other than those arranged by the activity organiser. Service users and their representatives were at pains to comment favourably on the care delivered to service users. Comments however did include reference to the lack of activities for recreation and entertainment. Those on Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 13 questionnaires included, “Activities could be more suitable for adult stimulation within the unit. Only ever observed watching TV and crayoning colouring book. (Outside entertainment excluded). “Could do with more (activities) but I understand the limitations on staff and money. She used to enjoy keep fit. It would be nice if this could be arranged.” “Not sure how many activities are provided. Lists don’t seem to change or get updated. Have asked staff but been told activities change/cancelled and not regular.” It must also be acknowledged that other responses ticked the box to indicate that they were satisfied with activities. One had commented that the service user “enjoyed get togethers, sing alongs, church services and painting exercises.” As detailed in the previous section, routines for bed times were in place for those service users who had high dependency needs to suit staff working patterns rather than for service users’ individual needs and preferences. Service users’ visitors had been encouraged to visit. Questionnaires returned by service users’ representatives commented favourably about systems to keep them updated about their relatives’ needs, “Visit three or more times a week and always made welcome and always addressed by name”, “Staff usually available to discuss with ourselves or our father anything we wish to discuss. Named nurse sometimes unavailable on account of shift work but will contact by telephone regarding any concerns we have.” Service users’ representatives held responsibility for financial affairs. The home was in receipt of personal allowances from the local authority or sums of money from service users’ families in order to make small purchases. Bedrooms seen showed that service users had been able to bring personal possessions into the home. Arrangements for service users nutrition were of a good standard. Service users stated that they liked their meals. “The food is good.” “Nice.” “There is lots to eat.” A visitor commented about the quality about the food especially the meal served for the Christmas lunch, which was described as “wonderful.” Nutritional needs assessments were seen on case files. Menus seen offered a satisfactory choice. A meal was seen in progress. It was eaten in an unhurried atmosphere. The meal was sampled. It was well cooked and tasty. Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 14 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 poor. This judgement has been made using available evidence including a visit to this service. Whilst there was a clear complaints procedure there were few records on file to show that complaints had been acknowledged, investigated and complainants informed of the outcome of enquiries. Recruitment procedures are disjointed and carried out both in the home and centrally therefore these had not been sufficiently robust to protect service users. EVIDENCE: Previous inspection of the home had established there was a detailed complaints procedure in place. Service users confirmed that they felt confident to raise concerns, “ I can talk to the staff if I am worried.” I would tell my key worker, who could tell the manager”. Visitors to the home also confirmed that they felt able to speak to staff or the manager. The central complaints register contained few references to complaints. The file contained a monthly return to HQ in relation to complaints. This did not contain any detail about individual complaints. The inspector was aware of a series of complaints made by a relative since the last inspection relating to the transfer of a service user to nursing care, this relative and staff at the home Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 15 had been in contact with CSCI regarding her concerns. There was no reference to this complaint in this file. Staff spoken to at the inspection showed an awareness of protection procedures. These personnel had however all been employed in the home for sometime and had undertaken induction training that had included briefing in protection procedures. Records showed that more recent employees had not undertaken any induction training. There were few records to show that members of staff had undertaken comprehensive training in adult protection procedures. The organisation had failed to take up relevant references for a recent employee, including a reference from a senior manager at the previous place of employment. Information received by this inspector after the visit to the home showed that the employee had been dismissed for poor practice from their previous position in a care home. Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 16 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 19,24,26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The layout and adaptations to the building were suitable for the care of the service users. There had been difficulties however in maintaining a pleasant odour in all areas of the building. EVIDENCE: As detailed previously the layout of the building had enabled effective working with service users in a homely environment. The homelike décor and soft 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 signs of wear and tear in some of the communal areas, which was a pity after all the efforts to create this attractive environment. Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 17 A staff member raised with the inspector concerns over the working practices of other staff in relation to making beds. The staff member told the inspector these issues had been raised with members of the management team and no action had been taken. This information was passed on to the manager at the inspection. Bedrooms seen also looked attractive and comfortable with the exception of two bedrooms where the beds had been poorly made. There was an unpleasant odour in the corridor to one of the units and a bedroom with an extremely pungent unpleasant odour. The manager reported that another bedroom also needed to have the carpet replaced because it had been soiled with urine. Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 18 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 poor. This judgement has been made using available evidence including a visit to this service. Whilst feedback on the conduct of staff had been positive, the failure to provide induction and ongoing training for staff in the best practice for key areas of their responsibilities meant that there was a risk that service users would not receive the service to which there are entitled. EVIDENCE: Whilst the overall judgement in this section is poor, this is not a reflection on individual members of the team seen at the inspection who presented as caring and committed to service users’ welfare. A good level of rapport was noted between service users and the staff on duty. Service users described members of staff as, “Very good.” “Marvellous.” “Kind.” Visitors to the home were similarly confident about the abilities of the staff and raised no concerns about their conduct. “Staff are very good.” “I am happy with the care and I wouldn’t want my relative to live anywhere else.” However, it must be acknowledged that the standard of training and recruitment fell below legal requirements and the National Minimum Standards for the operation of care service for older persons. Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 19 Although feedback had been positive, the organisation had placed service users at risk and themselves open to liability by not ensuring that all personnel received instruction in health and safety requirements and the best practice for the care of service users. The central training record for 38 members of the care team and the personnel files for three recent employees were assessed. These records were concerning in that they showed a low level of professional qualification and inconsistent training throughout. Only six members of staff held a National Vocational Qualification (NVQ) award in care practice at level 2. None had been achieved at level 3. Files indicated that personnel employed for more than a year had received on going training. There were few records to show that personnel employed during the last year had received any induction training. Given there had been 8 new starters during this period, this was concerning. The inspector was told that there were probably records of induction on individual files. Three were assessed. The file for a domestic assistant showed that a basic induction had commenced. The other two files were for care assistants who had worked in the home since March and May 2006. Neither file held any evidence of induction training. The training provision recorded to date was manual handling for both and emergency first aid for one. Records indicated that only 11 personnel had received training in dementia care. It was explained that dementia care was usually covered during induction. As the content of this training had not been recorded and given the level of dementia care the home was providing, there was an evident need for a specific training programme in this aspect of care. Rotas indicated that basic care staffing numbers had been rostered. There was a good level of support via the ancillary team that comprised a chef manager, chef, kitchen assistants, house keeping assistants, laundry assistant and handy person. The administrator was experienced and capable, having worked in the home for a number of years. A questionnaire referred to her input as “most helpful.” It was reported that there had been staffing difficulties because of staff sickness over the Christmas period. This had included senior team attendance, the staff having had to contact another home for assistance. Agency personnel had been employed to cover these shortages. Recruitment procedures as noted in section 4 were inadequate. References must be sought from the manager or equivalent at the current or last employer. Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 20 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): Standard 31,32,33,36,38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of the home had not been carried out in line with expected levels of professionalism for a home of this size. There were inadequate strategies to consult with service users or their representatives and to consult, inform, supervise and train personnel. EVIDENCE: Previous reports had shown that the home had been well managed. There had been a period when the home had operated without a manager before the current manager’s appointment. This may have contributed to the decline in the management of the home identified at this inspection. Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 21 The current manager was appointed in August 2006. He had been tardy in submitting an application for registration to the CSCI. He was advised at this inspection to commence this procedure by applying for a CRB check through the CSCI. Although the manager had previous experience in the management of care homes, he had not attained the minimum level of qualification expected for his post. His Curriculum Vitae was seen at this inspection and showed that he had been appointed to manage at three other care homes. All of these had been for relatively brief periods and he had not been registered in any of these posts. He had undertaken various training courses in relation to the care of service users and also personnel management. He had not, however, undertaken any assessment of his knowledge/skills as is required to achieve a NVQ award in care at levels 2 and 3 or a management award at level 4, which is the minimum standard of qualification for a manager’s position. Visitors to the home stated that they found the manager to be approachable. Members of staff had similar views. There was other evidence to show that personnel were discontent with the overall management of the home. Comments were passed about poor communication from the senior team and a lack of confidentiality when issues concerning others’ unsatisfactory practice had been raised. There were inadequate systems to consult and inform staff. Staff stated that they were kept up to date about changes in service users’ needs at the handovers at shift changes. There were few other methods of formal staff communication. Whilst there were records to show that the current manager had held 3 senior staff meetings there were none to show that there had been any general staff meeting for since his appointment. Supervision had evidently been abeyance for some personnel for a significant time. One spoken to stated that they had not had supervision for five years and another that they had not had supervision in the two years of their employment. Given the size of this team there must be formal management systems in place to ensure that staff receive proper guidance/ instruction about practice and individual performance. Service users and their representatives had the opportunity to air their views at individual reviews. No records in relation to general meetings with service users or their representatives were given to the inspector. The expected annual quality assurance process had not taken place since March 2005. A report of the audit and a précis of its outcomes were seen. There was no arising action plan to show how issues raised would be dealt with. Record keeping in relation to monies held on behalf of service users was of a good standard. Records seen showed that monies were held centrally but in separate accounts. The home held a central cash float for local cash purchases made on behalf of service users. These charges were then deducted from their Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 22 individual accounts. Purchases and charges on the records seen were commensurate with the usual expenditures for people living in care homes, such as chiropody and hairdressing costs. Health and safety arrangements for the environment seen at the visit to the home were satisfactory. Adaptations for safety such as window restrictors, low surface temperature radiators and controlled water supplies were standard throughout this purpose built home. Visual checks on equipment showed that regular maintenance checks had been carried out. Staff training records for more recent employees did not identify that they had been briefed about safety aspects of their role. It is accepted however that each employee had been issued with a comprehensive handbook that set out safety requirements within their role. It was agreed at the visit to the home that the Provider’s Information Questionnaire that details other aspects of safety arrangements would be returned to the CSCI by an agreed date. This had not happened at the time of finalising this report. The scoring for this standard is therefore made in relation to the information made available to the CSCI. Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 2 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 1 2 x x x x 2 x 2 STAFFING Standard No Score 27 3 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 x 3 1 x 3 Southway DS0000014971.V326081.R02.S.doc Version 5.2 Page 24 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 OP1 Regulation 4 Requirement The registered person must revise the statement of purpose to include details of the staffing structure and the training background of the manager and the staff. The registered person must not admit/ accommodate persons whose primary assessed need is not within the home’s registered categories. The registered person must provide personnel with training in the care of those with dementia. Care plans/risk assessments must not set out strategies designed to detain service users against their will. The routine of dressing service users in their night attire when they are not ready to go to bed must only take place at the expressed wish of the service user and not for the convenience of staff. The registered person must maintain records of complaints to include acknowledgement, DS0000014971.V326081.R02.S.doc Timescale for action 30/05/07 2 OP3 12(1)(a) 14 14/02/07 3 OP4 12(1)(a) 18(1)(c) (i) 12(1)(a) 15 12(1)(a) 15(1) 31/08/07 4 OP7 30/05/07 5 OP12 14/05/07 6 OP16 12(1)(a) 22(3)(4) 14/05/07 Southway Version 5.2 Page 25 7 OP18 12(1)(a) 13(6) 8 OP26 12(1)(a) 16(2)(k) 12(1)(a) 18(1)(c) (i) 12(1)(a) 9(2)(b)(i) 9 10 OP30 OP31 11 OP33 12(1)(a) 24 investigation, any actions arising and a response to the complainant. The registered person must protect service users by following robust recruitment procedures that include the obtaining of a reference from the current or immediate past employer and provide personnel with training in adult protection procedures. The registered person must ensure that service users are provided with bedrooms that are free from offensive odours. The registered person must provide personnel with induction training. The registered person must ensure that the person appointed to manage the home is sufficiently experienced and qualified to meet the aims stated in its statement of purpose. This must include specific training in the management of a residential care service for those who have dementia. The registered person must carry out at least an annual quality review of the service and make the resulting report and action plan available to service users and their representatives. 14/05/07 30/05/07 14/05/07 14/05/07 31/08/07 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 Southway Refer to Standard OP12 Good Practice Recommendations Service users should be offered opportunities to take part DS0000014971.V326081.R02.S.doc Version 5.2 Page 26 2 3 4 5 6 7 OP24 OP28 OP30 OP32 OP36 OP38 in activities for stimulation and recreation on a more frequent basis. Beds should be made properly to ensure the comfort of service users. 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 manager should introduce systems to inform and consult personnel through regular staff meetings. In order to meet the National Minimum Standard regarding supervision of staff this should be carried out at least six times in each year. The pre-inspection questionnaire documentation requested by the commission should be returned prior to the inspection taking place. Southway DS0000014971.V326081.R02.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.V326081.R02.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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