Inspection on 04/12/07 for Southwold House

This inspection was carried out on 4th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 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 16/01/07

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 Bernadette Little Unannounced Inspection 4th December 2007 10:10 Southwold House DS0000061634.V349322.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.V349322.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.V349322.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) southwold@consensushealthcare.org www.concensusupport.com Consensus Support Services Ltd Jennifer Dixon Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Southwold House DS0000061634.V349322.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. 16th January 2007 Date of last inspection Brief Description of the Service: Southwold House is a 12-bedded establishment that 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 the seafront, 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 advised as being £1300.00 - £2123.99 per week. Additional charges are specified within the Statement of Purpose and should be discussed directly with the home or with the registered provider. Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine Key unannounced inspection. The site visit took place on over a six and a half hour period. Prior to this, the manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to the commission. Information from this document was taken in account and is included in the report. A tour of some parts of the building took place, random records and policies were inspected and time was spent with the residents and staff, observing care practice and seeking their views. The manager was not available at the site visit and access to information and records was limited in some areas. The deputy manager and the senior support worker on duty endeavoured to provide all assistance, while needing to provide planned support to residents and meet other commitments. Feedback was given to them as their time allowed. A random selection of relatives, staff, service users and professionals were contacted to seek their views on the home via surveys and the outcomes are included in the report. The assistance of all those who participated in this inspection process is appreciated. What the service does well: What has improved since the last inspection? There has been some redecoration of the home and work on the garden to make it a more pleasant for the people who live there. Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 6 New arrangements mean that staff no longer undertake invasive procedures for which they were not fully trained and competent. Staff have been given more training on other areas that are important, like safe moving and handling and listening to service users and knowing how to report any concerns to safeguard service users. 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.V349322.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.V349322.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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment system helps to ensure that the team at the home can meet the needs of the residents they admit and the information available would allow people to make an informed decision about the home. EVIDENCE: A statement of purpose and service user guide was available. The service user guide is available in written and picture format. Surveys indicated that relatives and a care manager were satisfied with the information made available to help them make decisions about the home. There have been recent admissions to Southwold. The AQQA advises of an improved system of assessing the needs of all residents prior to admission by the manager and a peripatetic manager to ensure they are relevant. Visits to Southwold are part of the assessment/transition process. The file sampled had a detailed assessment relevant to the person’s specific needs. A review of the placement had taken place after six weeks, which evidenced that the service user had been consulted and involved in the decision to live at Southwold. The last inspection noted that while a statement of the terms and conditions applied to the person’s residence at Southwold was said to be given to the relatives, a copy was not available to service users in their individual files. This Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 9 was still not available on the files sampled. Service users should have their own copy, in a format that supports them, so they know what their rights and responsibilities are. Southwold House DS0000061634.V349322.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are well supported to make decisions about their lives and to take risks within their individual abilities as part of an independent lifestyle, however there are some shortfalls in relation to care planning provision that could adversely affect them. Residents may not be sure that their information will be kept confidential. EVIDENCE: The care planning system in the home was reviewed. The deputy manager advised that all care plans are in the process of being rewritten in a person centred way. Many of the documents that make up the plans of care sampled are well written and use person centred language to emphasise the individual and their choices in daily living. However, they did not include service users’ signatures to show they had been fully involved or informed of the plan for their care. The manager advised in the AQAA the hope to produce care plans on disc to introduce more accessibility for service users. Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 11 Some aspects of the care plans would benefit from having more detail for staff to follow to ensure consistency, for example how often a resident is supported to visit their family and what that support involves for that person. Care plans should also be reviewed regularly and kept up to date to show changes, for example where a person has decided they currently do not wish to participate in an employment opportunity. Care plans document individuals’ actions and refer to positive reinforcement and recognitions of triggers to behaviour as ways of managing challenging behaviours to support residents. There was evidence that the staff team access other professional support for service users, for example the behaviour support team and this was confirmed by a professional surveyed. Service users are supported make decisions and choices in risks taking, for example going out alone on some occasions. The individual risk assessments sampled are appropriate and support service users’ rights to have risk as part of their lives and also include issues such as smoking, management of aggression, bathing, travelling in the home’s vehicle or management of finances. Surveys received from a relative and a social worker identified that a concern had been raised with the registered provider/organisation that they had used photographs and personal information on residents of Southwold in their promotional business publications. A response was still awaited as to if, and how, residents’ informed agreement to this was sought or if their right to privacy and informed choice was fully respected. Southwold House DS0000061634.V349322.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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Southwold are well supported to participate in activities and to access facilities in the local community that are appropriate to their needs. They are also well supported to maintain relationships with their families. Residents benefit from a well balanced, nutritional and varied diet. EVIDENCE: Service users at Southwold attend a range of activities dependant on individual abilities and behaviour challenges. The funding of some residents allows for higher one to one staffing levels and enables some residents to go out of the home on a more regular basis. Staff surveys express a desire for additional funding to further their commitment to supporting residents to enjoy more experiences. The home has a vehicle to support community access and care plans, records, discussion with service users and observation of practice shows that service users are also encouraged and supported to walk for exercise through choice, and as part of their plan of care to promote a healthy lifestyle. Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 13 Service users spoken with advised of attending college courses, playing snooker with staff, going swimming or shopping and also of meeting friends at an evening club or visiting their families. Care plans showed that service users are encouraged to participate in meaningful activities depending on their abilities, from assisting with everyday household tasks to employment opportunities. Surveys from relatives advise the home is proactive is supporting service users to access new experiences in the community and in maintaining contact. Service users were seen to receive telephone calls and support in arranging contact with relatives and visits home. Service users were confident to approach staff with queries and to express views. Staff responded to service users in a respectful way, explaining agreed plans and boundaries, offering service users opportunity to make choices and seeking service users for agreement for proposed actions. Where limitations on residents choice were in place following risk assessment, for example residents have to ask staff to open their bedroom doors or residents’ have no, or restricted, access to the kitchen, there was no acknowledgement in the care management documentation that the staff team understood that this limited the person’s rights. Residents spoken with were satisfied with the food served at the home and some explained that they sometimes help with cooking. Some residents are able to make drinks for themselves under supervised access to the kitchen and clearly feel comfortable to ask staff for this. Two residents said that the food was really nice. One confirmed that their specific dietary preference is accommodated and records show that cultural and religious diversity is also respected. The menu shows that a variety of foods are available reflecting the varied cultural experiences of service users and staff and a record of food served is maintained. Southwold House DS0000061634.V349322.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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ healthcare needs are generally met but improvements could be made, particularly to medication management systems and records to ensure positive outcomes for service users. EVIDENCE: Residents have named key workers from the staff group but receive personal support from all the staff. The deputy manager advised that all service users are mobile and able to undertake their own personal care, with varying levels of prompts and/or supervision. Staff are allocated residents to support during each shift as well as tasks that need to be achieved. Where there was to be a change, however brief, staff were heard to discuss and negotiate this with service users in a positive way. This respected service users and assisted people to remain feeling secure in their need for routine and structure. Care documents showed that plans were in place to monitor some aspects of residents’ healthcare needs such as diet and fluid where this was relevant. The care file did not have a detailed plan on if/when the service user needed to visit the dentist, optician, chiropodist etc., so that their healthcare needs are Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 15 known to those who support them. There was no record on one file that any of these appointments had occurred. The deputy manager stated however that the service user had seen the dentist and that all service users receive chiropody services. The deputy manager also advised that service users would see their consultant psychiatrist six monthly as appropriate and would have their medication reviewed at this time. The care files sampled do not include a plan on how each person is to be supported with their medication, or where this links to relevant healthcare issues. A medication profile is maintained on the care files. The team uses a monitored dosage system to manage service users’ medication. The systems were reviewed and records were found, in some cases, to be poorly maintained. There was no record of the staff deemed as competent to administer medication or sample signatures to assist with audits. Some medication administration records (MAR) did not have a photograph of the service user to support correct identity, nor a medication profile to check the MAR against. Some hand transcribed records/changes did not have two signatures to ensure accuracy and some medications were not signed for as checked and received. Where a service user’s medication was not yet part of the monitored dosage system, records showed that their medication had not been available for two days. A senior staff member explained this was because the prescription was not available to them in time to have it filled. The staff team have a policy that two staff sign for each medication administration. The MAR showed this as being done in a sporadic manner, which gave the administration records a confusing appearance and showed that all staff were not following safe systems. A senior staff member advised that staff are no longer involved in the use of invasive procedures and that staff are now to call for an emergency ambulance in this situation. Southwold House DS0000061634.V349322.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service can be assured that any concerns they may have will be listened to and acted upon and that satisfactory arrangements are in place to promote their protection from abuse. EVIDENCE: Southwold has a written complaints procedure which the AQAA stated was reviewed in August 2007 and is available in a pictorial format to make it more user friendly to service users. Information on the complaints procedure was not seen to be easily available in the home. Service users spoken with said they would be able to tell someone if they had any concerns/worries. Surveys received indicated that relatives/professionals would know how to make a complaint. Information from surveys and discussion with staff indicated that they would listen to service users and would support them to raise any concerns. The AQAA advised that one complaint had been received by the home in the past year. This related to a breach of confidentiality and appropriate records of investigation and response was on file. Staff surveys indicated that staff would know what to do if anyone raised any concerns about the home. Staff spoken with confirmed that had had training in safeguarding vulnerable people and were aware of appropriate actions to take in relation to whistleblowing to safeguard service users. The training matrix provided indicates that not all staff that work at Southwold have had training Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 17 on this issue. Since the last inspection, two referrals have been made under safeguarding procedures and are currently being assessed and monitored. They were appropriately reported by the manager and agreed actions taken to safeguard service users. Staff spoken with advised that they had had training on management of behaviour that challenges and they were also aware of the potential triggers and planned strategies to support residents. The training matrix indicates that the majority of staff had attended training on this issue and the deputy manager confirmed this included physical intervention and de-escalation strategies. Southwold House DS0000061634.V349322.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents of Southwold live in a home that meets their needs within a homely and welcoming environment that would benefit from more regular maintenance. EVIDENCE: The premises are clean and homely and offer a welcoming environment. The communal lounge and dining room are spacious and provide sufficient space for residents and staff to move around. There has been some redecorating but areas where making good damage and further decorating were noted as needing attention. One WC was recorded as out of use and another noted in the maintenance book as not working properly again. The AQAA advised that maintenance services provided two days each month but that the registered provider is to rectify this. One window was not fitting well, which the resident explained they had previously raised, but this had not been actioned. One window was not Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 19 safely restricted. The deputy manager confirmed the following day that the maintenance person had been called in and it had been made safe. The residents’ rooms seen were very personalised and all had their own ensuite. Residents confirmed that their rooms are comfortable and one resident said “I love it”. Residents were free to choose to spend time in communal areas or in their own room. Southwold House DS0000061634.V349322.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 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can expect to be supported by a competent and enthusiastic team that will work positively with them to promote good care outcomes. The records on staff recruitment, induction and training practices do not best safeguard service users. EVIDENCE: Rosters showed that minimum day staffing levels are seven support workers, with three awake staff at night. The deputy manager explained that the day staffing levels had been increased to reflect the increased number of residents at Southwold. Staff spoken with confirmed that the levels were adequate to meet the needs of the residents. The AQAA states that all bank staff and one third of the permanent staff have achieved NVQ at least to level 2 and that the remaining twelve permanent staff are currently undertaking this. There have been some staff leave and some new staff appointed, but there remains a core group of staff that are familiar to the residents. Additionally Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 21 some staff had transferred from another care home. Recruitment files requested for sampling did not contain all the required records to show that the registered provider had used a robust recruitment process to safeguard residents. One file had no photograph to confirm identity, there was only one reference, and a reference was provided from a care employer not mentioned on the person’s employment history. One file had no povafirst check and neither had a criminal record bureau check(CRB). The deputy manager subsequently advised that the CRBs had been available but filed separately. The files sampled showed evidence of a ten day induction period, confirmed by staff spoken with. This included looking at the care needs of each of the people living at the home with a permanent staff member to ensure the new staff was competent in supporting each resident with their specific care needs. There was no evidence of other induction/training on the files looked at. The training matrix provided by the home did not include all the training that staff advised that they had completed. No record of any training was available for some staff to show that they had had opportunity to learn about how to support residents with their particular needs and conditions. The deputy manager confirmed that the record was not up to date. Observations of staff practice and interactions showed that staff were skilled at communicating with residents and respectful in their approach. A comment from a professionals survey stated “ the member of staff was very skilled in supporting the client, defusing situations and promoting choice”. Staff were noted to remain calm and professional throughout the site visit, including times when they could have felt under pressure. Southwold House DS0000061634.V349322.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, 40 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and stakeholders can expect competent leadership from the manager, whose actions to develop quality assurance systems will support the home to develop taking the view of residents and other interested people into account. EVIDENCE: As stated, the manager was not available at the time of the inspection site visit. The manager has been in post for over a year and, since the last inspection, has made a successful application to the commission to be registered to manage this service. In the AQAA, the manager advised that she had recently undertaken training that would enable her to deliver training within the home, as well as completing NVQ Level 4/Registered Manager Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 23 Award. A survey from a relative advised that they have noted positive changes and that the resident has been more settled since the manager came into post. Staff spoken with said that the manager is approachable and very supportive. One staff survey particularly noted that the manager was very supportive during the induction process and also takes time to check out with the staff how they “are faring” with the job. A senior staff spoken with at the site visit was unaware of the home’s actions to monitor the quality of the service it provides. The manager states in the AQAA that Consensus Support Services have a quality network forum in conjunction with the British Institute of Learning Disabilities. Their plan for improvement for the coming year is to involve service users and staff in ensuring that quality is provided in all aspects of their service, and reporting clearly on recommendations identified. A relative survey advised that the manager had responded to their view that a resident needed more stimulation and had arranged access to additional services. Records showed that the registered provider had not regularly undertaken the required monthly visits to the home to check on how it was progressing. The deputy manager advised that the organisation’s head office manage resident finances, paying money as requested into the home’s account, with cash then put into service users’ wallets, which were securely stored for them. The deputy manager stated that the ‘house’ budget is used to fund for example, service user meals out or night at the pub. Records sampled of how and when money was paid to a service user concurred with the information recorded as agreed in the care plan, to support the service user to manage their money in a structured way. Records were supported by receipts where appropriate and were audited for additional security. Withdrawals were signed by one staff member and not by the service user. Guidance was provided on offering service users this right/responsibility where it can be safely assessed as appropriate or two staff signing as an additional safeguard. Health and safety records sampled mainly showed that safe practice and procedures were in place. Generic risk assessments, for example relating to security of the premises, had been updated this year. A report by the Fire Service in January 2007 stated a satisfactory level of fire safety in the home. Records were available to demonstrate regular fire drills. These should identify the time they occurred and who participated. Records showed that checks had been undertaken on fire doors, equipment and emergency lighting, but these had stopped recently. The gas safety and electrical fixed wiring inspection certificates were valid, but the available portable appliance testing certificate had expired. Southwold House DS0000061634.V349322.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 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 3 2 3 X 2 x Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 25 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 YA6 YA19 Regulation 15 (1) & (2) 12(1)a Requirement Where possible care plans must involve the service user and regular reviews must take place, including as changes happen. Care plans must be in place for all identified needs and must include clear plans for staff to follow to support service users’ healthcare needs. Where limitations are in place, for example on the service users freedom of movement, information on, and acknowledgement of, this must be clearly documented in each service user’s care file. A safe system of medication must be maintained and a record kept of medications received into the home. So that service users are safeguarded, a robust recruitment procedure must be used by the registered provider, and supporting records must be obtained. Timescale for action 01/01/08 2. YA16 17(1) Sch 3 01/01/08 3. YA20 13(2) 04/12/07 4. YA34 19(1) Sch 2 01/01/08 Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 26 5. YA35 18 17(2) Sch 4 So that service users needs are met and service users and staff are safeguarded, staff must be provided with training appropriate to the work they do and to the needs of service users. Records of all staff training, including induction training, must be available in the home. A system for reviewing and keeping under review the quality of service provision must be in place and include the views of service users. 01/01/08 6. YA39 24 01/03/08 7. YA39 26 8. YA42 23 The quality of the service 01/01/08 provided to residents must be monitored by the registered provider and monthly visits and reports undertaken as required, to ensure that a quality service is provided. The manager must have an up to 21/12/07 date certificate for portable appliances. 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 YA5 Good Practice Recommendations Each service user should be given a copy of the current statement of terms and conditions that contains information on their rights and responsibilities at Southwold, and in a format that supports best their individual needs. Service users’ right to privacy and confidentiality should be respected and the registered provider should obtain, and DS0000061634.V349322.R01.S.doc Version 5.2 Page 27 2. YA10 Southwold House be able to show, informed decisions from service users or their representative before using their photographs and names in business publications. 3. 4. YA20 YA20 A photograph of residents should be held with the medication records to enable correct identification. Hand-written changes or additions to instructions for prescribed medicines should be signed and dated by the person making the entry, and a second signature system used to support accuracy. A record of the staff deemed as competent to administer medication with sample signatures should be maintained to assist with audits. The current availability of routine maintenance hours/personnel should be reviewed so that the premises at Southwold are kept a well maintained and safe environment for service users. Routine safety audits should be undertaken and recorded regularly. 5. YA20 6. YA24 7. YA42 Southwold House DS0000061634.V349322.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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.V349322.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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