Inspection on 16/01/07 for Southwold House

This inspection was carried out on 16th January 2007.

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 no outstanding requirements from the previous inspection report, but made 5 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 13/11/05

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 Key Unannounced Inspection 16th January 2007 09:30 Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 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.V317815.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 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.V317815.R01.S.doc Version 5.2 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) kingston@consensushealthcare.org Consensus Support Services Limited Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 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. 13th November 2005 (unannounced inspection 25/4/06) 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 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 bedrooms, all with ensuite facilities. There is a good-sized garden/patio area to the rear of the home, and to the front there are limited car parking facilities. The range of fees was provided by the manager as being £1339.78 - £2082.34 per week. Additional charges are specified within the Statement of Purpose and should be discussed directly with the home or with the registered provider. A current copy of the home’s Statement of Purpose is available upon request from the home. All residents (clients) are provided with a ‘user friendly’ Service User’s Guide, and additional copies are again available from the home. Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection site visit. The inspection was undertaken over a seven hour period. At this inspection, all the key standards (plus others as appropriate) were assessed, as was the progress the home had made since the last inspection. A partial tour of the home took place. Staff on duty were spoken with. The vast majority of residents (clients) within the home have complex care needs and associated challenging behaviour patterns. There with the exception of 2 clients, it was not possible to engage in meaningful conversation. However, care practices and staff/client interaction was observed. The majority of clients living in the home were around for part, if not all the day. A random selection of records was selected and viewed. In preparation for the visit, the Commission had sent out questionnaires to health/social care professional and families. Unfortunately the response was not very positive and these matters were taken up with the registered provider. However, since those questionnaires were received, there has been a change of local management within the home and the Commission has received no further concerns. This matter is referred to again within the body of the report. On the day of inspection the home was warm, friendly and comfortable. Local management and staff were hospitable. The inspection process was carried out with ease and the cooperation of all those involved was appreciated. What the service does well: What has improved since the last inspection? There have been a number of significant improvements within the home since spring/summer 2006, and particularly in the last 5 months. Areas of improvement include management style and direction, the management and provision of client care, recording systems, staffing related issues, involving health/social care agencies more, exploring and developing more social networking and creating a more ‘healthier’ core staffing group. Southwold House DS0000061634.V317815.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. The summary of this inspection report can be made available in other formats on request. Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 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.V317815.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home was readily available and the Service User’s Guide was in a ‘user friendly’ format’. Clients, families and all other interested parties are fully involved in the admission process and appropriate assessments had been carried out. EVIDENCE: A current Statement of Purpose was available and all families (and clients where appropriate) are provided with a ‘user friendly’ Service User’s Guide. Copies of both documents are freely available upon request. The case record of the most recent admission to the home was viewed. Full admission assessments were evident and the client had visited and stayed overnight in the home several times before admission had taken place. As/when appropriate, the clients views, opinions and expectations had been noted and were clearly referred to in the subsequent support care plan. Records were in good order. The acting manager explained that historically a copy of the client’s individual Terms & Conditions has always been given to the family without a copy being Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 9 retained in the client’s file. The home realises that this is not good practice and is addressing the matter. Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning process within the home was comprehensive, current, inclusive of all interested parties and provided a sound basis for the provision of good care. EVIDENCE: Since the last announced inspection, the home has made good progress on this element of care. Two sets of care plan documentation and associated records were selected and viewed. The recording system itself was comprehensive and information was current. The home is currently in the process of reviewing documentation within files and hopes to archive non-current documentation. This will indeed be beneficial as some files were noted to be very full. Clients’ views, opinions and expectations were clearly recorded as well as those of relatives and other associated professionals. Documentation demonstrated that clients (accordingly to ability) fully participate in the planning of their own care. Indeed where clients were able to express their views about their care to the inspector, this was clearly mirrored within their respective file. Those risk assessments viewed had improved and were current and appropriate. Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 11 Staff spoken with had a good understanding of individual clients care needs and care was being delivered in a sensitive, dignified manner. Regular care package reviews were seen to have taken place, although the home expressed their frustration that sometimes funding authority’s need reminding of due dates. The home has an established key worker system in place. Records relating to clients personal monies being held by the home were viewed at random and found to be in good order. The home was asked to seek advice from their head office about their policy concerning how much should be held by the home before it is placed in a deposit account where interest can be accrued. As part of the inspection process the Commission the views of families and health/social care professionals about the care given at the home. This exercise was carried out early autumn last year. At that time the home was experiencing a difficult time and this was reflected with the surveys received. These findings were discussed with the registered provider at the time. Since then, the management style has changed and the inspection outcome demonstrated that things have improved. The home provides care for young adults with very complex care needs and therefore to obtain individual views and opinions about the care provided would not have been possible. However, where communication was possible, clients expressed contentment and pleasure. In addition the inspector observed good practices within the home during the course of the day. Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients are actively encouraged and enabled to lead a full and meaningful lifestyle. The home has a good understanding of individual client’s food preferences and appropriate records are kept. EVIDENCE: Each client (as appropriate according to ability) participates in the planning of their own daily activity programme. Due to the very complex care needs many clients have 1:1 designated care during the day. Since taking up her post in September the acting manager has explored further opportunities for clients to participated in adult education centres, community projects, work experience etc. In addition, community based projects now come into the home and clients enjoy this interaction. The home has an established programme of community social and recreation activities which clients enjoy. On the evening of the inspection, clients were Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 13 talking excitably about attending their ‘Tuesday night social club’. The acting and deputy manager spoke enthusiastically about a number of thoughts and ideas they have for the future in connection with social and leisure activities. It was reassuring and encouraging to see that even those clients with the most complex and challenging care needs have opportunities to lead a meaningful and fulfilling lifestyle. The home organises group and individual summer holidays and has it’s own transport. During the course of the day, clients were ‘going and coming’ and when spoken to about their respective activity expressed pleasure about what they had been occupied in or where they had been. The ‘talents’ of individual clients are recognised and encouraged by staff. A picture drawn by a client and given to the acting manager on her first day in post is proudly displayed in the office. The acting manager explained that all clients have contact with their respective family to varying degrees. The home has established links with a local advocacy service and has a designated area where clients can see their visitors in private if they wish. Records demonstrated that clients are fully involved in the planning of daily meals. In addition, clients assist with the weekly shopping and in the preparation of food. Records were available demonstrating that clients are provided with a varied and nutritional diet. The home respects clients’ cultural preferences. Clients have recently realised that the deputy manager has undiscovered culinary skills and his ‘home cooked’ meals have become very popular in the home. Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home demonstrated a good understanding of individual clients personal and health care needs. The homes current practice of administering medication via an invasive procedure must be brought in line with current guidance for the wellbeing of clients. EVIDENCE: Records show that clients’ individual preferences, likes and dislikes are actively sought, recorded and respected. These views are then incorporated within individual care plan documentation. Individual clients care plan documentation, details the personal and health care support required. Many clients have very complex care needs and challenging behavioural patterns, but documentation seen was comprehensive and current. The home has recently changed the clients designated GP. This was carried out with consultation with all appropriate agencies. This change has proved to very beneficial, and the home is pleased that it has opened up more and better working relationships with other health care professionals. The GP has now carried out a full review of each client’s medication profile and some clients are Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 15 now taken less medication than before. The home felt that clients were now benefiting from this and were able to give examples of how this had impacted on individuals. The use of ‘as/when’ medication has been subject to a full review and the home felt that this practice was being better managed for the wellbeing of clients. The storage of medication was clean, tidy as were the associated records. However, one ‘as/when’ medication is administered using an invasive procedure. The home could not demonstrate that the competence of staff had been assessed to carry out this procedure, there was no designated name health care professional taking ultimate responsibility and the practice was not in line with the home’s own stated policy and procedure. The acting manager realised that the current practice placed the client at potential risk and was taking immediate action to address the matter. Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place and clients have a ‘user friendly’ version. The home must ensure that all staff have an adequate understanding of adult abuse reporting procedures to safe guard clients. EVIDENCE: The home has a complaints procedure in place, whilst all clients are provided with a ‘user friendly’ version. Not all clients would have the ability to formally raise a complaint or concern, but all have a designated key worker, regular access to external health/social care professions, attend independent clubs/leisure/adult education facilities, families and with assistance, can access the established advocacy service connected to the home. Those clients able to discuss this aspect of care said that they would happily speak to the acting or deputy manager. Since the last inspection, the Commission received some concerns from family members, police and social care processionals about a number of practices within the home. These were raised with the registered provider at the time. It was thought that the concerns had come about because of the management style within the home at that time. Since then, local management in the home has changed and the Commission is not in receipt of any further concerns or complaints. During the course of the inspection, it was clear that the home must review the competency of senior staff who may find themselves in a position of needing to report any suspected adult abuse incident. Full details about how this Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 17 assessment was made, are known to the acting and deputy manager, and assurances were given that the matter would be addressed. Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients live in a comfortable environment that meets their needs. All clients have their own rooms and there is sufficient communal space. EVIDENCE: The ‘main’ house accommodates 10 clients. There is a self-contained flat for 2 rather more independent clients on the 3rd floor. The accommodation on the 3rd floor has designated named staff on duty when it is occupied. Each client has his or her own bedroom and ensuite facilities. Not all bedrooms were seen; those viewed were homely, comfortable, clean and very personalised. The home had adequate communal facilities. There had recently been a problem with a broken under floor waste water pipe. Repair work has been carried out, but the home should ensure that adequate ventilation measures continue to be taken as a very unpleasant odour still Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 19 lingers in part of the home and the windows in the room had not been opened. There were no obvious safety hazards around the home, but the inspector did point out that there were boxes of latex gloves around the home left within easy reach of clients. Due to the very complex care needs of some clients, this practice was questioned, but the acting manager said that there was no risk to clients’ safety. The acting manager was reminded of a fatality where a young adult with a learning disability had swallowed a latex glove. The acting manager acknowledged that much of the décor and furnishing around the home requires attention due to wear and tear. This was already in hand. In addition, the garden in its current state is not ‘user friendly’. The acting manager has plans in hand to address this in time for the summer period. The kitchen was clean and tidy. The washing machine had been out of order for several weeks, but a new one was on order and expected any day. Adequate contingency plans were in operation. Arrangements were in hand to improve the ventilation within the laundry area, as when the tumble dyer is in operation, the current ventilation is inadequate. The home felt relaxed, warm and the atmosphere was comfortable. Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Since the last inspection, there has been a change in corporate and local management style and direction, and this has had a positive effect. EVIDENCE: The rota was current and reflected the staff on duty at the time of inspection. The home runs on a minimum of 6 staff on duty during the day and 3 at night. Local management and staff members felt that these levels were adequate to meet current assessed care needs. A number of clients require 1:1 care because of their complex care needs and challenging behaviour patterns. Staff spoken with were very clear about their designated tasks and responsibilities. All expressed a pleasure and satisfaction in the work that they do. The records of the most recently recruited members of staff were viewed. Staff recruitment processes are managed by the ‘parent’ company (Caring Homes Ltd). Those records seen in the home were in good order. The acting manager has recently reviewed and revised the home’s induction schedule and has arranged for a visit by ‘Skills for Care’ to help further in establishing an effective programme which meets all the criteria Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 21 The acting manager is also addressing the shortfalls in staff training. A matrix had already been sent to the home’s head office/training section identifying what training has been completed. The home is expecting a response identifying the ‘gaps’ and providing a new training programme to meet current criteria. In the meantime, if any training is identified as being urgent, records demonstrate that the home is proactive and sessions are arranged. It was noted that no staff have completed a moving and handing course, and the acting manager was to address this as part of the exercise. The importance of this training was reinforced. Staff confirmed that there are regular staff meetings and both formal and informal supervision sessions take place. Staff were open in their views about the recent change in local and corporate management and felt that the changes had been positive and things were going well for the home. Staff impressed as being relaxed, open and comfortable with their work. A number of work related issues such as personal security, work patterns and working relationships with each other were discussed. There was a sense of working together as a team and morale seemed good. Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients benefit from the leadership and management approach of the home. The home carries out appropriate safety and maintenance checks. The registered provider is in the process of establishing an effective quality assurance package. EVIDENCE: Since the last inspection, the home seems to have found itself again and now presents as a well managed orderly establishment. The acting manager took up her post in September 2006, and has clearly been busy reviewing practices within the home and making changes where appropriate. The impact of the acting manager appointment has been a positive experience for the home. The acting manager is fortunate in that the deputy manager has good skills and Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 23 expertise, and together they have formed a sound local management team. Staff recognise these changes. The home has been without a registered manager for 5 months now and the Commission is not in receipt of any application. The acting manager is currently undertaking a Registered Manager’s Award and NVQ level 4 training course. She hopes to complete the course by June 2007. The registered provider regularly fulfils the Regulation 26 requirements and the home spoke positively of these visits. In addition, it was understood from the acting manager that arrangements are well underway in connection with the registered provider undertaken a Quality Assurance/Annual Development Plan in accordance with Regulation 24. Clients are actively encouraged to be involved as far as possible all aspects of the way the home is managed and run. This includes documented weekly client house meetings. A random selection of safety and maintenance records were viewed and found to be in good order. These included emergency lighting checks, fire evacuation drills, fire risk assessment documentation and the passenger lift maintenance check. The acting manager agreed that the safe working practice risk assessments were not current and required attention. Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 3 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X X 3 X Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 25 No 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 YA5 Regulation 5(a)(b) Requirement The registered person(s) must ensure that all residents are in receipt (have on file) a current copy of their respective Terms & Conditions of Residence. The registered person(s) must make arrangements for the safe administration of drugs. This is with specific reference to the practice identified at the time of the inspection whereby a PRN (as/when necessary) drug was being administered using an invasive technique without adequate arrangements being in place. The practice was not in line with laid down medication guidance or in accordance with the home’s practices and procedures. The home took immediate action to address this matter and this is reflected in the timescale given. 3 YA23 13 The registered person(s) must ensure that all staff are adequately trained and assessed as being competent to manage DS0000061634.V317815.R01.S.doc Timescale for action 28/02/07 2 YA20 13 16/01/07 28/02/07 Southwold House Version 5.2 Page 26 laid down adult abuse reporting procedures. This is with particular reference to senior staff that may take responsibility for shifts. 4 YA24 23 The registered person(s) must ensure that: 1) furnishings and décor are maintained to a satisfactory standard, and 2) the external grounds are suitable and safe for residents It is acknowledged that these matters are in hand. 5 YA35 18 The registered person(s) must ensure that all staff are adequately trained and assessed as being competent to perform their allocated duties. The home has already identified training ‘gaps’ and is addressing them. Other training such as medication, adult abuse reporting procedures and moving and handing training needs were identified at this inspection. 28/02/07 30/06/07 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 YA24 Good Practice Recommendations The registered person(s) should risk assess the practice of leaving unsupervised latex gloves around in the home. Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 27 2 YA30 The registered person(s) should ensure that the rooms affected by the recent plumbing issue are adequately ventilated. The registered person(s) should update the safe working practice assessment documentation to ensure that it complies with current legislation and guidance. 2 YA42 Southwold House DS0000061634.V317815.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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.V317815.R01.S.doc Version 5.2 Page 29 - 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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