Inspection on 16/08/05 for Southwell Court

This inspection was carried out on 16th August 2005.

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

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

Other inspections for this house

Southwell Court 10/11/08

Southwell Court 27/11/07

Southwell Court 17/08/06

Southwell Court 17/01/06

Southwell Court 01/03/05

Southwell Court 17/08/04

Southwell Court 27/02/04

Similar services:

Claremont House

Oak Ridge

Coopers Mill Ltd

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Paradise Lodge

Bilney Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Southwell Court Hinkins Close Melbourn, Near Royston Hertfordshire SG8 6JL Lead Inspector Janie Buchanan Announced 16 August 2005 @ 09:00 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 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. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Southwell Court Address Hinkins Close, Melbourn, Near Royston, Hertfordshire, SG8 6JL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01763 262121 01763 262989 Granta Housing Society Ltd Andrew Tilbrook Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number of places Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1 & 5 March 2005 Brief Description of the Service: 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. Service users are accommodated within 35 single rooms, all with ensuite toilet and washbasin. The home is divided into six flats, each accommodating either five or six people. Each flat has a sitting/dining area, a kitchenette and an assisted bathroom. There is a shaft lift to the first floor and 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 large attractive garden with a pond and seating area. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s first inspection for the year 2005/6. It was announced. The inspector spent seven hours at the home and interviewed three residents, two visiting district nurses, one visiting relative, four members of staff and the deputy manager. A brief tour of the home was undertaken, medication storage was checked and a range of documents were viewed. The inspector received 45 comment cards completed by residents and their relatives. The majority of respondents expressed satisfaction with the quality of care, staffing, activities and food provided at Southwell Court. However, five of these respondents raised concerns about staffing levels; two complained about the state of cleanliness in the home; one stated that some residents’ televisions were very loud and another requested that a more efficient method should be found to answer the front door of the home. These issues were discussed with the deputy manager. What the service does well: What has improved since the last inspection? What they could do better: Residents must be given more opportunity for stimulation through leisure and recreational activities outside the home and extra staff must be made available to ensure this happens. Although staff who administer medicines have Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 6 received training, a formal practical assessment of competence should be undertaken to ensure that they are doing it safely and correctly. Some areas of the home are in need of decoration and maintenance work. It was disappointing to note that many of these items were outstanding from the previous inspection and failure to comply with the regulations may result in enforcement action being taken. Domestic staff must be employed in sufficient numbers to ensure that standards of cleanliness do not fall. 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. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,5 The home’s Statement of Purpose and Service User Guide are good providing residents and prospective residents with details of the home’s services and enabling them to make an informed decision about where they live. Residents are fully assessed prior to moving into the home to ensure their needs can be met at there. EVIDENCE: The home has a very detailed statement of purpose and service user guide that gives residents good information about the home and the services on offer. However this information is mostly given to residents on arrival at Southwell Court and the inspector discussed with the deputy manager the importance of service users having this information before they are admitted, so they know what facilities to expect. Also discussed was the importance of making these documents available in a variety of formats suited to older people such as audiotape and large print. The details of the Commission for Social Care Inspection’s address should be updated in these documents. A copy of the home’s most recent inspection report was available for both residents and visitors to read in the main entrance. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 9 Residents are fully assessed prior to their admission either by the manager or his deputy and the inspector viewed completed pre-admission assessment on the three residents’ files that she viewed. All residents are encouraged to visit the home before they move and all spoken to confirmed that they, or their families had visited. One gentleman had visited several times in order to assess if the home was suitable for him. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The health care needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis. However, some medication practices need to be made more robust to ensure that they are administered safely to residents. EVIDENCE: Three residents’ care plans were viewed. The information they contained was detailed and gave the reader a good understanding of the resident’s health and personal care needs. There was evidence that residents had been involved in drawing up the plan, and also of regular review. Residents’ health care needs are met at the home. All residents were registered with one of three local GP practices; a chiropodist visits every six to eight weeks, a local dentist is able to come to the home on request and two residents currently have regular contact with a physiotherapist. Nutritional screening is undertaken monthly with all residents. Local health care professionals such as district nurses and physiotherapists have recently begun to attend staff meetings. This is practice is to be commended. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 11 Medication storage and a sample of residents’ medical administration records (MAR) were viewed. These were generally satisfactory but hand-written changes or additions to instructions did not indicate who made the change or when. There was separate storage for medicines that require refrigeration but there was no thermometer available in the fridge to monitor whether or not the medicines were being stored in acceptable environmental conditions. Staff do receive training in the administering medicines but no formal practical assessment of their competence is completed or documented. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Residents are helped to maintain their autonomy and exercise choice in their daily living. Meals are varied and well balanced and residents are offered good choice in what they eat. However, there appears to be few opportunities for residents to visit places and participate in leisure activities outside the home. EVIDENCE: The routines of daily living are flexible and there was much evidence that residents can choose what they do. One resident has a toaster and kettle in her bedroom because she prefers to make her own breakfast. This resident said that she collects her dinner from the kitchen and eats in her bedroom, as she prefers her own company. Another resident said that she likes to spend the day in her nightwear and will only get dressed if she is going out. The home employs an activities co-ordinator and there is a weekly activity schedule that includes games, exercise to music and a knitting group. However, it was disappointing to note that there had been little in the way of outings and activities organised for residents outside the home, despite the home having its own minibus. The inspector took lunch with the residents. This mealtime was relaxed and the food was plentiful and nutritious. Residents had a choice of three dishes: lamb Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 13 casserole, salad or cauliflower cheese and most commented favourably about the quality of the food. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Residents feel confident in making suggestions and complaints and staff have a good understanding of adult protection. EVIDENCE: Granta Housing Society has a comprehensive complaints procedure, a copy of which was available in the main entrance to the home. Details of how to complain are also included in the service user guide. Most residents, although not fully aware of the procedure, stated that they felt able to raise concerns with the manager directly if necessary. The Commission for Social Care Inspection has not received any complaints about the home in the last year. Many staff have undergone training in the protection of vulnerable adults and showed good knowledge of the different types of abuse and reporting procedures. The home also has its own policies in relation to adult protection and these cover, amongst other things, the different types of abuse, risk indicators and reporting requirements. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20,24,25,26, The environment of the home provides residents with an attractive and homely place in which to live. However, time taken to address repairs is slow and some areas of the home are in need of redecoration and maintenance work. EVIDENCE: There were a number of outstanding items of maintenance that had not been addressed since the last inspection. These included: • • • • • • • The paintwork and woodwork in the corridor in unit 1-6 is scuffed and marked The paintwork in communal areas in units 25-19 and 24-19 is badly scuffed and marked Some outside lights are not working Some outside guttering is leaking The wooden garden seat needs repainting There is water damage in room 17 and the hairdressing room The woodwork round the kitchen doorway in badly chipped and marked Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 16 The manager has experienced considerable difficulty in recruiting domestic staff and the cleanliness of the home has reportedly deteriorated as a result. Two relatives commented on this: one stated ‘my mother’s room is not kept as clean as I would like it, I clean myself when needed’ and ‘could do with more general cleaning staff for “under cleaning”. However, on the day of inspection the level of cleanliness on the home was satisfactory and the inspector interviewed a contract cleaner who had recently been employed to clean for seven hours a day. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Staffing levels are sufficient but should be kept under close review to ensure that residents’ needs are met, and they have the opportunity to engage in activities outside the home. The home’s recruitment and selections procedures are robust and ensure that residents are adequately protected. EVIDENCE: There are five care staff on duty between 7.30am and 3pm and four care staff on between 2.30pm and 10pm to support 35 residents. During the night there are two waking staff on duty, together with a member of the management staff, who sleeps on the premises. The duty rota was viewed on a randomly selected number of days: this confirmed the above staffing levels. Most residents interviewed felt that staffing levels were adequate to meet their needs, although one stated she often had to wait a long time to be taken to her room after breakfast. One member of staff felt that more staff were needed if residents were to be taken on trips and activities outside the home: another stated that he did not have much time for one to one work with residents. The home has had to rely heavily on agency staff in recent months, although this has recently improved with the recent recruitment of three new permanent members of staff. The home has a rigorous recruitment and selection procedure in place and all staff interviewed by the inspector reported that they had been thoroughly interviewed and that references and CRB checks had been taken up. However, the manager was unable to confirm if the contract cleaner had undergone a CRB check. Staff personnel files viewed further confirmed this. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 18 Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,38 The manager is experienced and competent for his role and the home has detailed policies and procedures in place to guide staff. The home regularly reviews its performance by actively seeking the views of residents. EVIDENCE: Feedback from both staff and residents about the home’s registered manager was very positive and the management approach of the home creates an open and supportive atmosphere to live and work in. The home is run in the best interests of residents and systems for consulting them are good. There are monthly individual meetings with each resident and additional formal consultation exercises. Communication systems within the home are generally satisfactory and there are several handovers throughout the day to keep staff informed of what is going on. Records viewed were well maintained, up to date and accurate and Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 20 the home’s policies and procedures were regularly reviewed. No major health and safety hazards were seen during the inspection. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 x 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 2 3 x x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 x 3 Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 22 Yes Are there any outstanding requirements from the last inspection? 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 9 Regulation 13 (2) Requirement Monitor and record the temperature of the medicines storage facilities to ensure a suitable environment exists. Residents must have more opportunity to participate in outings and activities outside the home. Hand written additions to the MAR sheets must be signed and dated All items of maintenance listed under standard 19 of this report must be be addressed. Many of these are outstanding from the last inspection. Timescale for action Immediate and ongoing 1 November 2005 Immediate and on going 1 November 2005 2. 12 16 (2) (m) 13 (2) 23 (2)(b) 3. 4. 9 19 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. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 23 Refer to Standard 1 Good Practice Recommendations The homes Statement of Purpose and Service User Guide should be devloped into suitable formats for residents such as audiotape or large print. 3. 9 An assessment of competence of staff to administer medicines safely must be documented and retained on file. Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 24 Commission for Social Care Inspection CPC1, Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Southwell Court I53 I03 15167 SOUTHWELL COURT V234894 160805 STAGE 4.doc Version 1.30 Page 25 - 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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