CARE HOMES FOR OLDER PEOPLE
Southwell Court Hinkins Close Melbourn, Near Royston Hertfordshire SG8 6JL Lead Inspector
Janie Buchanan Unannounced Inspection 17th January 2006 09:30 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.V276363.R01.S.doc Version 5.1 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.V276363.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Southwell Court Address Hinkins Close Melbourn, Near Royston Hertfordshire SG8 6JL 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) 01763 262121 01763 262989 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.V276363.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th August 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 DS0000015167.V276363.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year 2005/6 and was unannounced. The inspectors talked with five residents, two visiting relatives, two members of staff and the deputy manager. A brief tour of the home was undertaken and a number of documents, including residents’ financial records, were viewed. What the service does well: What has improved since the last inspection? What they could do better:
Opportunities for residents for stimulation through leisure and recreational activities outside the home must be improved. This was a requirement made at the last inspection and failure to comply with the regulations may result in legal action being taken against the home. End of life planning with residents should be introduced so that their physical, emotional and spiritual needs at the time of their death are discussed and honoured. The time taken to respond to repairs and decoration requests remains slow and, although work is to be undertaken soon to address the outstanding maintenance items, the home has failed to meet the required timescales yet again. Southwell Court DS0000015167.V276363.R01.S.doc Version 5.1 Page 6 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.V276363.R01.S.doc Version 5.1 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.V276363.R01.S.doc Version 5.1 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 Information available about the home is good and helps prospective residents decide whether or not the home is where they want to live. Residents’ needs are thoroughly assessed before they move in, so they can be assured they will be met at the home. EVIDENCE: The home has a statement of purpose and service user guide that contain all the information required by the standards. These documents have been updated since the last inspection and contain the correct contact details of the Commission for Social Care Inspection. The documents are now available in large print to make them more accessible to older people. The manager, or his deputy, assesses all prospective residents and evidence of pre-admission assessments were viewed on the files checked by the inspector. Residents spoken to confirmed that they had visited the home prior to their admission. One resident told the inspector that although she had not been able
Southwell Court DS0000015167.V276363.R01.S.doc Version 5.1 Page 9 to visit, both her daughters had, and had been given good information about the home. All residents are issued with a contract that clearly states the terms and conditions of their stay. Southwell Court DS0000015167.V276363.R01.S.doc Version 5.1 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): 7,9,10 Information in residents’ care plans is good, providing a consistent basis for the care to be delivered. Residents’ privacy and dignity are respected. EVIDENCE: Care plans were good and clearly set out each residents needs, and the action to be taken by staff in order to meet those needs. The plans had been reviewed regularly. Staff have undergone training in administering medicines and medical administration records checked by the inspector in flat 24-29 were satisfactory. District nurses have been working closely with the home’s management to team to assess their competency in administering medication, with a view to the management team then assessing the care staff’s competency. There is a culture of respect for residents in the home. One resident told the inspector ‘the staff always wait outside when I’m in the bathroom, they never intrude’; a relative commented ‘my mother wasn’t very happy about having male carers, and the problem was sorted quickly’. Staff interviewed by the inspector gave many good practical examples of how they maintain residents’ dignity and privacy when helping them with their personal care.
Southwell Court DS0000015167.V276363.R01.S.doc Version 5.1 Page 11 Policies and procedures are in place for handling death and dying (March 2002) and a number of staff have attended training in this matter. The inspector discussed with the deputy manager the importance of pro-active end of life planning with residents to ensure that their terminal care needs and wishes are known, clearly documented and carried out. Southwell Court DS0000015167.V276363.R01.S.doc Version 5.1 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 Staff at the home are friendly and welcoming and there are daily activities to provide entertainment for residents. However, there is little opportunity for residents to undertake enjoyable activities outside the home. EVIDENCE: The home employs a specific activities co-ordinator and there is a weekly schedule of events for residents. However, there is little opportunity for residents to participate in outings and leisure trips outside the home, despite the home having its own minibus. One resident told the inspector: ‘It would be nice to get out more, to a garden centre, Duxford or even just to Tescos for a coffee’. This issue was raised at the last inspection and it was disappointing to note that there has been little improvement. Residents are able to have visitors at any time and relatives stated that they were made to feel very welcome at the home. One commented: ‘staff always acknowledge me when I visit mum, I know them all, I always get offered a cup of tea’. The manager is currently setting up a ‘Friends Committee’ to encourage relatives to take a more active part in the life of the home. Southwell Court DS0000015167.V276363.R01.S.doc Version 5.1 Page 13 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 Residents’ complaints are listened to, and taken seriously EVIDENCE: The home has a detailed complaints procedure, a copy of which is available in the main entrance to the home. Details of how to complain are also included in the service user guide. The inspector suggested that the complaints procedure is further advertised in each flat, and also explained to residents at the next residents meeting. Residents interviewed by the inspector appeared confident about complaining, stating that they would talk to the manager if necessary. One relative commented ‘the management are very receptive, and any problems are taken seriously and sorted’. A record of complaints is kept that clearly states the nature of the complaint and any action taken in its light. Southwell Court DS0000015167.V276363.R01.S.doc Version 5.1 Page 14 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): 19,20,25,26 The environment of the home provides residents with an attractive and homely place in which to live. However, time taken to address repairs and redecoration continues to be slow. EVIDENCE: Southwell Court was purpose built and is suitable to meet the needs of older people. There are pleasant views out of the windows onto the garden and plants, pictures and books enhance the environment. One resident commented ‘I liked the home straight away, it is light and airy and the toilet wasn’t down some long corridor’. The home was generally clean, tidy and free from offensive odours on the day of inspection. New furniture has recently been purchased for the main lounge and a Parker bath is currently being installed. A number of maintenance items remained outstanding from the previous two inspections, and although these were due to be addressed on the Monday following this inspection, the home had failed to meet its deadline of 1 November 2005.
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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, 29 Staffing levels are adequate and residents are looked after by well-trained and caring staff. EVIDENCE: There are five care staff on duty between 7.30am and 3pm, and four care staff on duty between 3pm and 10pm to support 35 residents. During the night there are two waking staff, together with a member of the management team, who sleeps on the premises. Scrutiny of the duty rota showed these staffing levels to be maintained. The home continues to rely on agency care staff with about 23 shifts in the last two weeks being covered by these staff. There are a number of vacancies that are currently being advertised. Residents reported that staff were available when needed and only occasionally waited a long time for help. The inspector received many positive comments from both residents and relatives about the staff including ‘ the staff are very good and helpful’; ‘mum has a good relationship with her key worker’ and ‘little things get done that you ask’. Staff training is good and both training records viewed and staff interviewed confirmed that they had received all required training, in addition to training in the specific needs of older people. Eight staff have completed an NVQ level 2 in care, and 3 are currently undertaking it. Southwell Court DS0000015167.V276363.R01.S.doc Version 5.1 Page 17 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): 34,36 Residents’ monies are safeguarded by the home’s financial procedures. Staff receive good support to do their job. EVIDENCE: Secure facilities are provided for the safekeeping of money and valuables on behalf of residents. The inspector checked a random sample of residents’ cash sheets: these were in good order and audited regularly by a senior management member of Granta Housing Society. One resident told the inspector that she had given the manager a £100 to look after, that she had received a receipt for it, and could easily access the money when she wanted. Staff are regularly supervised and reported that they felt supported in their work. Records required by regulation for the protection of residents were up to date and accurate.
Southwell Court DS0000015167.V276363.R01.S.doc Version 5.1 Page 18 Southwell Court DS0000015167.V276363.R01.S.doc Version 5.1 Page 19 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 3 x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x 3 x 3 x x Southwell Court DS0000015167.V276363.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? yes 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 OP12 Regulation 16 (2) (m) Requirement Timescale for action 01/03/06 2. OP19 23 (2)(b) Residents must have more opportunity to participate in outings and activities outside the home. Time scale of 01/11/04 not met. A plan detailing activities and outings planned for the next 3 months must be submitted to the CSCI. All items of maintenance listed 01/03/06 under standard 19 of the previous report must be addressed. Time scale of 1/11/05 not met. 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. 3 Refer to Standard OP11 OP9 OP16 Good Practice Recommendations Residents should be given the opportunity to discuss their wishes in relation to the end of their lives. An assessment of competence of staff to administer medicines safely must be documented and retained on file. Staff should explain the complaints procedure to residents
DS0000015167.V276363.R01.S.doc Version 5.1 Page 21 Southwell Court and it should be more widely on display around the home. Southwell Court DS0000015167.V276363.R01.S.doc Version 5.1 Page 22 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
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