Inspection on 13/11/05 for Southwold House

This inspection was carried out on 13th November 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southwold House 17/02/09

Southwold House 04/12/07

Southwold House 16/01/07

Southwold House 04/07/05

Southwold House 08/11/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Southwold House 16-18 Cliff Road Leigh-on-Sea Essex SS9 1HJ Lead Inspector Ann Davey Unannounced Inspection 13th November 2005 10:30 Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 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 Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 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 Adults 18-65. 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. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Southwold House Address 16-18 Cliff Road Leigh-on-Sea Essex SS9 1HJ 01702 715240 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) Aitch Care Homes (London) Limited Miss Gemma Tevlin Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care and accommodation to be provided to persons between the age of 18 and 65 with a learning disability. 4/7/05 Date of last inspection Brief Description of the Service: Southwold House is a 12-bedded establishment, which provides personal care for 12 young adults with a learning disability. The main body of the home accommodates 10 clients, whilst 2 clients are accommodated on the 2nd floor which is independent in terms facilities and staffing. The home is situated within a residential area of Leigh on Sea and is within walking distance of local shops and public transport links. The home has 3 floors and provides 12 single bedrooms, all with ensuite facilities. There are adequate communal rooms and there is a good sized garden/patio area to the rear of the home. To the front of the property there are limited car parking facilities. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Sunday morning over a period of 2.5 hours. It focused mainly on the progress the home had made since the last inspection, but other standards were also considered. A partial tour of the home took place. Staff and clients (residents) were spoken with. Records were selected at random and various elements assessed. A notice was displayed in the main entrance advising all visitors to the home that an inspection was taking place with an open invitation to speak with the inspector. The inspector gave a full and detailed ‘feedback’ to the assistant manager with opportunity for clarification and/or further discussion. The fax number for the home is 01702 715270. The home is now owned and managed by Consensus Healthcare Ltd. Both these details will be reflected within the ‘service information’ section in the next report. What the service does well: What has improved since the last inspection? What they could do better: It was disappointing to note that the specific shortfalls identified within the medication administration recording system at the previous 2 inspections remain outstanding. This practice as described within the ‘personal & healthcare’ section of this report, continues to place clients at potential risk. The staff rota was not clear and the inspector could not understand some of Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 6 the information recorded. Specific training needs were identified. These are described within the ‘staffing’ section of the report. The home accommodates clients with complex care needs, a number have challenging behavioural patterns. It is important for the safety and wellbeing of clients and staff that the home continues to focus on good risk assessment procedures. It is important that there is dialogue between the local authority and the home if/when any client is injured as a result of such an incident. 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. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 & 4 Pre admission assessments had carried out to ensure that the home can meet assessed care needs. EVIDENCE: Pre admission assessment documentation was in place. Documentation evidenced that all parties associated with the placement and when ever possible considering limitations the client, are consulted (also see standard 6). Clients are invited to visit the home prior to admission. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9 Documentation systems identified clients assessed needs. Clients are consulted and participate both in individual goal planning and corporate lifestyle routines/decisions within the home. EVIDENCE: Those plans of care assessed were orderly and current. Files were ‘sectioned’ which allowed easy access to specific documentation. Many clients have complex care needs and the home continues to develop strategies to manage and deal with consequential challenging behaviour patterns. The home must continue to ensure that adequate risk assessments are in place for both staff and clients. The Commission is aware that injuries have occurred to both staff and clients as a result of identified clients physical ‘outbursts’. Any injury to client as a direct result of another client’s behaviour should routinely be referred to the local authority for assessment under the local Protection of Vulnerable Adults procedure. One identified client has very specific care needs that were discussed with the assistant manager. Although the placing authority and the advocate has provided valuable input concerning how the home should meet these specific needs, there was no evidence that staff have received any identified training on the issue. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 10 Staff on duty were observed to be caring for clients in a positive, friendly manner. Staff interaction with clients was natural yet sensitive. Staff spoken with had a good understanding of individual clients care needs. It was evident that clients have a good rapport with staff. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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 & 17 Systems are in place to offer, provide and/or facilitate an appropriate and meaningful lifestyle for clients. EVIDENCE: Not all aspects of these standards were assessed. Care plan documentation demonstrated that clients are consulted as appropriate and according to their respective limitations on all aspects of their personal development, social, leisure. occupational, educational aspirations and also the daily routines within the home. The home has it’s own transport. On the day of inspection, all clients were involved in appropriate and meaningful activities. Some were at church, others were out with staff, one was enjoying their particular gardening interests, whilst others were with staff in the home. It was clear that a number of individual and corporate activities had been arranged for the afternoon. The routine of the day was relaxed and it was evident that that staff were very positive and committed to meeting individual clients social/recreational needs. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 12 It was evident that clients are involved as much as possible with the planning of food provision. It was positive to note that individual clients cultural/religious preferences are observed and met in a sensitive manner. Although available documentation would suggest that clients are provided with a balanced nutritional diet, there was an absence of any consistent approach to record keeping showing what had been provided by the home during the past week. This was discussed with the assistant manager who agreed with the inspector’s findings. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Clients receive appropriate personal care from the home and health care support from outside agencies. The home could not evidence that it is following current guidance concerning some identified medication and health care issues/procedures. EVIDENCE: Not all aspects of these standards were assessed. Records evidenced that clients receive appropriate personal care from the home and the assistant manager spoke of a good working relationship with outside health care agencies. The continuing practice of individual member(s) of staff manually transcribing medication administration instructions without signature(s) is not consistent with the guidance within The Royal Pharmaceutical Society of Great Britain (2003) section 3.2.2 remains. A number of examples were noted within a random selection of records. This is the 3rd occasion when this shortfall has been identified and potentially puts clients at risk of receiving incorrect medication dosages. The home was unable to locate a copy of the said documentation. The inspector retained copies of sample medication records. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 14 Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Clients’ views and considerations are recorded. Staff were clear about adult abuse protection procedures. EVIDENCE: Clients’ views and opinions on matters were clearly recorded within their respective documentation. The rapport overheard between clients and staff during the inspection was natural and considerate. The complaints recording system was not viewed on this occasion, but from aspects of different conversations with staff and clients, complaints would be dealt with sensitively. Staff on duty were aware of the correct adult abuse reporting procedures in accordance with their individual working status within the home. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The environment was homely, comfortable and clean EVIDENCE: A member of staff and a client showed the inspector around different areas of the home. Those bedrooms seen were comfortable, homely and reflected individual taste and preference. Communal areas were functional, practical, well furnished and pleasantly decorated. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34 & 35 The home has an established core group of staff. The current staff rota was not clear and specific training needs were identified. EVIDENCE: On the day of inspection, staff on duty were working well together as a team. Staff were very pleasant and helpful. Those spoken with had a good understanding of individual clients care needs. The rapport between staff and clients was warm, friendly and supportive. A random selection of staff recruitment files evidenced that appropriate CRB and/POVA documentation was now in place. This had been addressed since the last inspection. Three areas of staff training were identified: Medication administration recording (see standard 20) A specific identified care need (this specific care need is known to the home and referred to in standard 2 & 6) On the day of inspection, the home had 3 rotas all recording variable and different information. The inspector obtained copies. The ‘working’ rota was not conducive to clarity. The information recorded on this particular document was Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 18 confusing and some handwritten entries could not be read and/or understood by the inspector. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,41 & 42 The home is generally managed in a competent, professional manner. However, as a result of the inspection, specific training issues have been identified and must be addressed for the continuing safety and wellbeing of clients. EVIDENCE: Not all aspects of these standards were assessed. Clients are clearly involved and fully considered in the daily routines of the home. Routines are ‘client centred’ and the individual and corporate views and opinions of clients underpin the home’s daily activities. There are 3 identified training needs which the home must address for the welfare, wellbeing and safety of clients. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 3 2 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Southwold House Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 2 X DS0000061634.V264060.R01.S.doc Version 5.0 Page 21 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 YA17 Regulation 16 Requirement Timescale for action 31/12/05 2 YA20 13 The home must review its current nutrition recording system as the registered person(s) must be able to evidence that the home provides adequate quantities of suitable, wholesome and nutritious food. The registered person(s) must 31/12/05 ensure that appropriate staff training, monitoring and supervision arrangements are in place to promote the safe recording and subsequent administration of medication and is in accordance with laid down guidance. The previous timescales of 8/12/05 and 18/8/05 have not been achieved. This is a 3rd repeat requirement. The manner and style in 31/12/05 which the current staff rota had been maintained was not conducive to clarity and was open to interpretation. The registered person must be able to demonstrate that adequate numbers of staff are DS0000061634.V264060.R01.S.doc Version 5.0 3 YA33 18 Southwold House Page 22 4 YA42YA41YA35 18 on duty at all times to meet the needs of clients. Reference should be made to the said regulation to ensure full compliance. The registered person(s) must 31/12/05 ensure that all staff are appropriately trained to perform their allocated duties. Full details are within the ‘staffing’ section of the report. 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 YA9 Good Practice Recommendations The registered person(s) should ensure that adequate risk assessments are in place at all times. There should be an established system in place whereby the local authority (and funding authority) are consulted about any potential POVA issue which may occur as a result of client being injured in connection with challenging behaviour. Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Southwold House DS0000061634.V264060.R01.S.doc Version 5.0 Page 24 - 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. 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