Inspection on 10/11/08 for Southwell Court

This inspection was carried out on 10th November 2008.

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

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

Other inspections for this house

Southwell Court 27/11/07

Southwell Court 17/08/06

Southwell Court 17/01/06

Southwell Court 16/08/05

Southwell Court 01/03/05

Southwell Court 17/08/04

Southwell Court 27/02/04

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Paradise Lodge

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Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Southwell Court Hinkins Close Melbourn Near Royston Hertfordshire SG8 6JL     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Alison Hilton     Date: 1 0 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 26 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Southwell Court Hinkins Close Melbourn Near Royston Hertfordshire SG8 6JL 01763262121 01763262989 Southw@grantahousing.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Andrew Tilbrook Type of registration: Number of places registered: Granta Housing Society Limited care home 35 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability old age, not falling within any other category Additional conditions: One named individual in the category LD(E) for the duration of their residency only Date of last inspection Brief description of the care home Southwell Court is a home for older people. It is owned by Granta Housing Society and is situated on a modern housing estate in the village of Melbourn on the Cambridgeshire and Hertfordshire border. Accommodation is on two floors. People who live in the home are accommodated in 35 single bedrooms, all with en-suite toilet and washbasin. The home is divided into six flats, accommodating either five or six people. Each flat has a sitting/dining area, a kitchenette and an assisted bathroom. The ground floor bedrooms open onto a patio area. A shaft lift or stairs provide access to the first floor. All bedrooms on this floor have access to a covered balcony. There is a large lounge on the ground floor, an activities room and a hairdressing room. The home has Care Homes for Older People Page 4 of 26 Over 65 1 35 0 0 Brief description of the care home large attractive gardens with a pond and seating area. The inspection reports are available in the foyer of Southwell Court. The charges made are available from the home on request. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We, the Commission for Social Care Inspection (CSCI) carried out a key unannounced inspection of Southwell Court on Monday 10th November 2008, using the Commissions methodology described below. This report makes judgements about the service based on the evidence we have gathered. Staff, including night staff, people living in the home and the deputy manager were spoken to. An Annual Quality Assurance Assessment (AQAA) was completed and returned to the Commission prior to this inspection. An Expert by Experience spoke to five people living in the home and information she gathered is detailed in the report. A number of records were seen, together with three staff files and the files of two Care Homes for Older People Page 6 of 26 people living in the home. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 26 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information is provided to people so that they can decide if the home can meet their needs. Evidence: Details in the AQAA showed there had been improvements made to the new resident pack so that all the information needed to make a decision about moving to the home was provided. It also showed that people were encouraged to visit and stay for a meal so that they could get to know the home and other people living there. Some people said they had received information about the home before moving in. Visitors seen during the inspection said they had visited the home before the person had moved in as their relative had been unable to do so. People spoken to by the expert by experience said they had not had a choice about moving into the home and some were quite upset that this was where they were to Care Homes for Older People Page 10 of 26 Evidence: spend the rest of their days. These issues were discussed with the deputy manager who said she would talk to the relevant people. Appropriate assessments had been undertaken for these people by the local authority and the home prior to their admission. There was evidence that pre-admission assessments had been carried out by staff in the home, but on the two files seen there was little other information provided by the placing authorities. There were contracts on both the files seen. Care Homes for Older People Page 11 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans provide the necessary information for staff to meet the physical needs of those living in the home. Evidence: The care plans provide the information for staff to meet the needs of people living in the home as far as necessary tasks such as washing and dressing are concerned. There are some areas that need to be more explicit and where there are changes to areas such as mobility, then the care plan and risk assessments need to be updated to ensure the persons current needs are met. The files did not contain a pen picture of the person to give individuals a sense of identity. For example one person spoken to by the expert by experience said he had been a prisoner of war, boxer and RAF Police officer. None of this was detailed in his notes. Staff need to be aware of a persons past so that they can see the impact things like Remembrance Sunday, Armistice Day and Bonfire night can have on a persons behavior and well being. This also relates to a persons likes and dislikes in activities, which would give the co-ordinator a better understanding and further possibilities in the provision of activities. Care Homes for Older People Page 12 of 26 Evidence: The expert by experience spoke to five people in the home. People said there was too much sitting and not a lot to do. Some of those spoken to were afraid of falling and consequently did not move about much and would have found organised exercise useful. The possibility of some exercise was discussed with the deputy manager, as the home does have a part time activities co-ordinator. This is also discussed in daily life and social activities. Another person spoken to, who has to wear pads, said that his/her family has to supplement those provided in the home with their own purchases. This was discussed with the deputy manager who said that the number of pads used are allocated by the continence team (health) and any extras had to be purchased privately. This has a financial implication for the person living in the home and is also a dignity issue. This is not an issue that the manager has any say over and is to do with the health authority but was brought up by people who live in the home. People in the home have informal meetings with their key worker every two months and the details of these are recorded so that individual needs and any concerns are noted and dealt with. Where an area of risk is noted there must be details of how this is minimised. For example one entry was X has a history of falls. Goal: Make sure X is safe at all times. Action: Nothing was written. This was discussed with the deputy manager after the inspection. There were details in the Accident/incident file of 9 occasions when X was found on the floor between 5/8/08 and 11/9/08 but no indication as to whether X had seen the falls coordinator although the physiotherapist had visited on 17/10/08. The deputy manager said that X was now hoisted and this was no longer an issue, but the overall issue would be discussed with the manager. Of the five people spoken to by the expert by experience two asked her to get them a drink as there was nothing available in their room. We spoke to the deputy manager and she said that there should be water and/or squash available in each persons room and that she would look into it. There was an entry in the staff meeting minutes for 10/9/08 that said The residents are still to be offered a cup of tea after lunch but it was agreed by all present that sometimes there isnt enough time to offer them a drink. This depends on what kind of shift you have. This makes it even more imperative that people have drinks in their rooms. The deputy manager agreed that this would be done immediately and so no requirement was made. The medication administration charts for three people were seen and with one minor error were correct. The controlled drugs register was also checked and found to be Care Homes for Older People Page 13 of 26 Evidence: correct. Care Homes for Older People Page 14 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are asked what activities they would like to do, so they can be included on the list, to make their lives more interesting. Evidence: Details in the AQAA showed that there are activities that take place in and outside the home. People can take part as they wish and records are kept of participants. The hairdressing salon has been redecorated and this was commented on by people in the home when speaking to the expert by experience. There were visitors in the home during the inspection and it was evident they were able to came and go as they wished. Several people spoken to by the expert by experience confirmed that they regularly had visits from family and friends and there was no restriction on this. People are encouraged to take part in activities and during the inspection there was a game of dominoes taking place in the large lounge downstairs. Other activities advertised for the week were bingo, video and sherry, board games and reminiscence. We spoke to the activities co-ordinator who said she has three hours per day for Care Homes for Older People Page 15 of 26 Evidence: activities. She has not completed any specialist training but does meet with other Granta activities co-ordinators regularly. She said there have been trips out to the local garden centre and to Duxford and that she is arranging for people to go out for a Christmas lunch locally if they wish. People who spoke to the expert by experience said they had enjoyed a firework display earlier in the week. They also said they would like some light physical exercise as they sit too much. They also said they were bored, although details in the AQAA showed that people are asked on a regular basis if there are any activities they would like in the home. It was discussed with the deputy manager that extra training may help the co-ordinator provide exercises and ensure that reminiscence work is appropriate. One person said they read a lot and they visited the mobile library. Another lady had had her nails painted. The maintenance person was spoken to and he said the home had purchased a polytunnel and people living in the home would be encouraged to help with growing seedlings in the spring. The home has Friends of Southwell Court who fund raise and sometimes accompany people living in the home so that less staff are needed. Main meals are served in the dining areas in each flat, but people do have a choice of eating in their room if they wish. People who spoke to the expert by experience and the inspector said that on the whole they found the meals OK or good. There was a choice of meals and an alternative could be provided if necessary. Staff were aware of those with special dietary requirements and said that special meals were provided. One person said the meals to be on time would be an improvement as it was sometimes half an hour after the due time that they were served in the flat. Care Homes for Older People Page 16 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a satisfactory complaints system with evidence that people feel their views are listened to and acted upon. Evidence: Details in the AQAA showed that everyone who comes to live in the home is given a copy of the complaints procedure and there are copies available in the foyer. Two complaints were seen and showed that management in the home had dealt with them thoroughly and according to their procedures. Five people we spoke to knew who they would talk to if they were unhappy with anything. The contract cleaners have still not had PoVA training as required at the last inspection and this is disappointing. The manager said that he had spoken to the agency manager but had not ensured this had been done. Care Homes for Older People Page 17 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of decor in the home is good but there was an offensive odour that means the people who live there are sometimes not in pleasant surroundings. Evidence: Details provided in the AQAA showed that comments received from visitors were positive about the level of cleanliness in the home. The patio outside the lounge has been extended and a gazebo installed. More garden furniture and flower pots have been purchased. The carpets in the corridor have been cleaned and do look better, however some areas of the home still have an offensive smell and this did not dissipate during the inspection. The deputy manager said that the rooms are cleaned regularly but because of continence issues this is difficult to manage. Changing the flooring was discussed. We talked to District Nurses who were concerned that there were often no facilities to wash and dry their hands after looking after a patient. With no soap and paper towels in peoples bedrooms the nurses were unclear how staff were maintaining health and hygiene rules. We looked in a number of rooms during the inspection and all bathrooms had soap and paper towels available but not each persons en suite facility. The manager needs to ensure these are in each room so that hand washing is part of Care Homes for Older People Page 18 of 26 Evidence: health and hygiene and to stop cross contamination. Another concern was the lack of washbowls available to them when people were unable to get to the bathroom. It was suggested that the nurses and managers discuss the issues raised. Information received since the inspection shows this has taken place and the manager has ensured that there are gloves, soap, towels and disposable wipes in all en-suite rooms, and bowls are available where needed. Care Homes for Older People Page 19 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Progress has been made in addressing staff shortages and as a result people receive consistent care. Evidence: The AQAA showed that questionnaires completed by people in the home and their relatives indicated that the home meets their care and support needs. Staff have received further training about the importance of a prompt response to call bells after the last inspection and staff were seen to respond as quickly as possible during this inspection. The deputy manager stated that all vacancies had been filled and staff were due to start work once all the checks had been completed. The files of three staff were seen and they contained all the required information. Criminal Record Bureau (CRB) checks are kept at Granta Head Office and an e mail is sent to the manager to show a clear check has been received and there was evidence of these on the files. The deputy manager confirmed that there are four care staff and one manager working in the morning, three care staff and one manager in the afternoon and two care staff and manager (sleeping in) at night. The rota seen confirmed this and there were the correct number of staff on duty during the inspection. There is time allotted for handover from one shift to another and this was observed between the night shift to Care Homes for Older People Page 20 of 26 Evidence: the morning shift. The deputy manager said that although there has been a high use of agency and bank staff recently they have been the same staff thereby giving some consistency to people living in the home. Care Homes for Older People Page 21 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff receive supervision and appraisals to ensure a consistent approach to care and meeting the needs of people living in the home. Evidence: Details in the AQAA showed that the manager has been working in care for 21 years and holds the Registered Managers Award, NVQ Level 4 in Care Management, City and Guilds 325/3 in Advanced Care Management and is working towards NVQ Level 4 in Care. There was evidence that staff receive supervision and appraisals and those on duty confirmed this. The minutes of staff meetings were seen. Details in the AQAA showed that night staff are more involved in fire safety drills and in discussions relating to their knowledge and anticipated actions during a fire. Care Homes for Older People Page 22 of 26 Evidence: Inspections have been carried out by the Social Services Contract Monitoring Unit, Dietician (mealtime observation) and Environmental Health, the reports were not seen as part of this inspection. The maintenance person was spoken to and he confirmed that there were workmen in the building completing checks on the hard wiring and others looking at the loft. He said he completed all statutory checks for emergency lighting and fire alarms and completed the appropriate paperwork. Care Homes for Older People Page 23 of 26 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 18 15 (6) All staff (including contract 31/01/2008 workers) must have completed training to protect those who live in the home. The home must be pleasant and clean to ensure the well being of people living in the home. 01/03/2008 2 26 16 2(k) Care Homes for Older People Page 24 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 7 26 Information in the care plan should be as up to date as possible to ensure staff provide the necessary care. The home should be free from offensive odours so people live in pleasant surroundings. Care Homes for Older People Page 25 of 26 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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