Inspection on 17/08/06 for Southwell Court

This inspection was carried out on 17th August 2006.

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 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

Southwell Court 10/11/08

Southwell Court 27/11/07

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

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 Alison Hilton Key Unannounced Inspection 17th August 2006 07:50 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southwell Court Address Hinkins Close Melbourn Near Royston Hertfordshire SG8 6JL 01763 262121 01763 262989 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) Granta Housing Society Limited Andrew Tilbrook Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 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. Residents 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 large attractive gardens with a pond and seating area. The inspection reports are available in the foyer of Southwell Court. The cost is between £361.00 and £430.00 per week. Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Thursday 17 August 2006 between the hours of 07:50 and 16:30. The manager was in the home. 12 residents, 5 staff and 1 relative were spoken to during the inspection. Staff and resident files together with other paperwork and records were inspected and a tour of the building was made. Questionnaires were sent out to residents and relatives. 18 resident and 15 relative questionnaires were returned prior to the inspection. Some comments made on the questionnaires included “ the staff are kind and friendly”, “residents are well cared for which gives peace of mind”, “ the home has an extremely welcoming atmosphere”, and “ issues are dealt with quickly”. What the service does well: What has improved since the last inspection? The repairs commented on in the last inspection report have been completed. This meets the requirement from the last inspection. The home has an activities schedule, which was displayed in each of the dining areas. There are still few outings arranged as there are only two staff able to drive the minibus. The home has re-initiated the Friends of Southwell Court, which is made up of relatives who will assist and help organise trips and activities, and ensure the best interests of the residents are met. The manager is building end of life discussions with residents into their annual review. This meets the recommendation from the last inspection. All staff who administer medication have the appropriate training. This meets the recommendation from the last inspection. Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 6 What they could do better: 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 DS0000015167.V308239.R01.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 Southwell Court DS0000015167.V308239.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home ensures that prospective residents needs are assessed prior to their admission to the home to make certain it can provide the necessary care. EVIDENCE: Southwell Court does not provide intermediate care. Talking to residents and information provided in the pre-inspection questionnaire, showed that the prospective resident or their relatives had visited the home prior to admission. Information provided in the resident questionnaires showed that they (or their relatives) had received appropriate information, which allowed them to make a decision as to the suitability of the home. Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 9 The staff team are qualified and experienced to meet the needs of the residents. Documents and staff files showed that training in specialist areas of work has been provided. On the residents files inspected there was evidence of pre-admission assessments completed by the home as well as other professionals. A copy of the homes statement of purpose and inspection reports on the home are kept in the entrance hall. Southwell Court DS0000015167.V308239.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The arrangements to meet the health and social care needs of residents are appropriate. The principles of respect and privacy are put into practice. EVIDENCE: All residents have care plans and those seen during the inspection were detailed to enable staff to provide the necessary care. Staff were clear about the needs of residents and how they should deal with specific issues. The home has effective systems in place to ensure all care plans are reviewed and updated monthly or whenever changes occur in the residents’ level of need. Residents and their families are encouraged to attend reviews to ensure the care plan reflects their views. The manager is building end of life discussions with residents into their annual review. This will ensure the necessary information is placed on a residents file. This meets the recommendation from the last inspection. The manager said that the home intends to provide staff with palliative care training from Arthur Rank homes, which will include provision of information and the necessary documentation. The home Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 11 has a room that could provide overnight accommodation for a relative if necessary. Staff provide personal care in private and were seen to treat residents with respect. There was evidence that where there had been an issue over the gender of the carer providing personal care; this had been dealt with by the manager to the satisfaction of the resident and her family. The manager said that the home had tried to find an advocate group to act on behalf of residents but had been unable to and the home still relied on relatives and other visitors. All current residents have family members who visit. Boots Chemist provides medication training for managers and care staff. This meets the recommendation from the last inspection. The home uses the monitored dosage system (blister packs) and Medication Administration Record sheets are completed. Those seen during the inspection were adequate. The District Nurses are involved with the home and there was evidence of this on the files seen during the inspection. Southwell Court DS0000015167.V308239.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Social activities are organised and provide some stimulation for residents. Meals are nutritious and balanced and offer a healthy and varied diet for residents. EVIDENCE: The home has an activities schedule, which was displayed in each of the dining areas. There are still few outings arranged as there are only two staff able to drive the minibus, which the manager said is old and cumbersome and difficult to drive. The local paths make it difficult to take residents, who have mobility problems and require wheelchairs, out to the local amenities such as the pub. Residents said they would like to go out more but only on short trips. The activities provided in the home were agreeable to some residents but others said they did not wish to join in and the staff accepted this. One resident was in his room painting a watercolour; another said she liked to look out at the fishpond. The home has an activities co-ordinator who works 9-12am. She keeps a record of who has participated in activities. Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 13 Between 10th July and 10th August the manager said that there had been 12 visits to hospital, GP or other health service where an escort had been required, and this took one member of staff from the building, sometimes for the whole day. There was evidence of this during the inspection where a resident had to be escorted to an appointment, leaving the building at 12md and returning at 4pm. The home has recently re-initiated the “Friends of Southwell Court”, which is made up of relatives who will assist and help organise trips and activities, and ensure the best interests of the residents are met. Each flat has a kitchenette where breakfast is prepared. Lunch is provided from the main kitchen. Several residents were seen having breakfast and they commented that they could have different cereals and drinks as well as toast. They said the meals were lovely and there was always a choice. Lunch was lamb stew or vegetable burger accompanied by vegetables and potatoes. One resident had a salad and another the lamb stew but with a different gravy because of a food intolerance. Banana in custard was the pudding, or fresh fruit and yoghurt if preferred. The menus provided in the pre-inspection information showed a varied diet was available to residents. Some residents have fridges in their rooms and one resident spoken to also had a toaster. Health and safety issues had been considered and she had a different type of fire detector in her room so that burning toast did not set it off. Staff said they received food hygiene training and records seen during the inspection confirmed this. Southwell Court DS0000015167.V308239.R01.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has an effective complaints procedure, details of which are available in the foyer. EVIDENCE: The manager stated that the complaints procedure is given to all residents as part of the homes information on admission. He has recently sent out the information to all residents again and has copies of the procedure in the foyer. This meets the recommendation from the last inspection. The procedure in relation to a new complaints form appears cumbersome and time consuming unless senior staff can use their discretion to decide what a complaint and what a comment is. To have to complete a form when a resident comments that the “cauliflower cheese does not taste too much of cheese” is not a good use of management time. Comments should be recorded, as they have been before, so that any patterns emerging can be seen, and any action needed can be detailed. Residents spoken to during the inspection said they knew who to speak to if they were unhappy with anything in the home. Relatives’ questionnaires showed that all were aware of the homes complaints procedure and some had used it in the past. One relative said that when she had made a compliant it had been dealt with quickly and to the satisfaction of her relative and herself. Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 15 Staff said they received Protection of Vulnerable Adult (POVA) training and training records confirmed this. Staff were clear about what they would do in the event of witnessing abuse and what the different areas of abuse were. Southwell Court DS0000015167.V308239.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements to some bedrooms had been made and repairs completed. Some areas may put residents at risk of harm and do not provide fully accessible surroundings in which to live. EVIDENCE: The repairs commented on in the last inspection report have been completed, although final snagging has to be undertaken. This meets the requirement from the last inspection. Generally the home is well maintained and provides a homely environment for residents. There are currently six unoccupied rooms and some of these were being decorated during the inspection. Each flat has areas of seating so that residents can sit in the sun or in the shade. Fruit is available in the kitchen area. All bedrooms have telephone lines available and all radiators have individual thermostatic radiator valves. All bedrooms have available outside Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 17 space although this would be difficult for anyone with a mobility problem as access is via a step. A requirement has been made. Two kitchenettes have been upgraded but two are still awaiting refurbishment. There is a possibility that a resident could hurt themselves on broken drawers even though efforts have been made to show they are faulty. A requirement has been made. The stairs to the first floor could be a hazard for anyone who is partially sighted or has some other problem that would make it difficult for them to see where the stairs start. The need for a stair gate or something similar should be considered for the safety of residents. A requirement has been made. In relation to the two comments above, a phone call was received from the area manager to say that Granta are waiting for a start date for the work on the kitchenettes (the work was agreed Thursday 17 Aug); and the maintenance department from Granta were going to the home Friday 18th August to assess the work necessary for a stair gate. The carpet in the corridor will need to be replaced before it becomes a hazard. The garden had become overgrown whilst the handyman had been sick and the grass needed cutting and the weeds pulled up. The handyman said this would be done as soon as possible. A recommendation was made in relation to this standard. There were no unpleasant odours in the home. Southwell Court DS0000015167.V308239.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home makes appropriate checks on prospective staff and the recruitment procedure is followed ensuring the safety of residents. EVIDENCE: The home has one night staff vacancy and one weekend support worker post available. Although in the past the home has used agency staff to cover large numbers of shifts, there is now an increased number of bank staff and the staff rota for August and September shows there will be no agency staff used. Staff rotas show that there are 4 or 5 care staff on duty in the morning and 3 in the afternoon. This figure does not include managers who are on duty. There are 2 waking staff and one manager (sleeping on the premises) at night. The number of staff reflects that the home has six beds vacant at the moment. On speaking to residents there were many comments about the caring staff and how helpful they are. Staff spoken to felt there were enough staff on duty to ensure the needs of residents could be met. All like working at Southwell Court and felt the management team was approachable and plenty of training was on offer. Three staff files were inspected and some information held by the company’s human resources office was unavailable. There was evidence on file that Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 19 Criminal Record Bureau checks had been completed prior to commencement of employment. The home provides the TOPSS induction training, which includes all statutory courses. Details in the pre-inspection questionnaire show that staff will be receiving training in palliative care, and the manager said that dementia care had been requested in staff appraisals. Staff said they had received further training in equality and diversity, moving and handling refreshers; diabetes and some are completing NVQ Level 2. All 3 assistant managers are working on NVQ Level 3. The deputy manager has almost completed the Registered Managers Award. 11 care staff have NVQ Level 2. Southwell Court DS0000015167.V308239.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is being managed in an open and inclusive way with evidence of leadership and guidance from the management team, ensuring residents receive consistently good levels of care. EVIDENCE: Staff said that they were supervised on a regular basis and there was evidence of this on the files seen. The manager said that the home only looks after small amounts of cash for residents and relatives are responsible for all other finances. No member of staff manages or assists with resident’s personal bank accounts. The home has a regular audit of incoming and outgoing money for residents and there is Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 21 a further check by the person who completes the Regulation 26 visits. There was no inspection of individual accounts at this inspection. The manager has almost completed the Registered Managers Award and is then starting NVQ Level 4 in Care. Documentation required by the standards is in place and provides the necessary details. Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 23 (1) Requirement Timescale for action 31/10/06 2. OP19 13 (4) 3. OP20 23 (2) The registered person must ensure that all areas of the home are safe and well maintained. This is in relation to two kitchenettes that have yet to be refurbished. The registered person must 31/10/06 ensure that the stairs leading from the first floor have some way of restricting access to ensure residents safety. This is in relation to the possibility that residents who are confused or have visual problems may fall down the stairs. The registered person must 31/10/06 ensure that all areas are accessible to residents. This is in relation to all the bedrooms, which lead onto a patio or balcony via a step. This restricts access for anyone with a mobility problem. Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 24 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. Refer to Standard OP19 Good Practice Recommendations The registered person should ensure that the grounds are kept tidy even when the handyman/gardener is off sick. Southwell Court DS0000015167.V308239.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office 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 DS0000015167.V308239.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!