Inspection on 04/07/05 for Southwold House

This inspection was carried out on 4th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

Other inspections for this house

Southwold House 17/02/09

Southwold House 04/12/07

Southwold House 16/01/07

Southwold House 13/11/05

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 1HL Lead Inspector Ann Davey Announced Monday 4 July 2005 th 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 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 Stationary 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 I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Southwold House Address 16-18 Cliff Road Leigh-on-Sea Essex SS9 1HL 01702 715240 01702 715270 gemma.tevlin@achuk.com Aitch Care Homes Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Miss Gemma Tevlin CRH Care Home 10 Category(ies) of LD Learning Disability (10) registration, with number of places Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care and accommodation to be provided to 10 persons between the age 18 and 65 with a learning disability. Date of last inspection 8th November 2005 Brief Description of the Service: Southwold House is a 10 bedded establishment which provides personal care for 10 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 2 floors and provides 10 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. Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of 5 hours and focused mainly on the progress the home had made since the last inspection and also the new facilities on the 2nd floor that were ready for registration. The home has made application to increase their registered numbers by 2 clients to total 12. The 2nd floor accommodation will be independent of the facilities and staffing on the ground/1st floor and maintain it’s own recording systems The Commission has recommend that this increase takes place and the process is being completed. A partial tour of the ground/1st floor and a full tour of the 2nd floor took place. Staff and clients were spoken with. Records were selected at random and inspected. 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 current registered manager has been in post since November 2004.The manager requested that for the purpose of this report, the term ‘client’ instead of ‘resident’ is used throughout. The inspector gave a full and detailed ‘feedback’ to the manager with opportunity for clarification and/or further discussion. Assurances were given that the most critical shortfall identified concerning the staff recruitment procedure(s) in respect of Criminal Record Bureau checks would be addressed without delay. What the service does well: The home is furnished, fitted and decorated to a good standard. Clients are actively involved in the daily routines of the home. Care plans identify individual care needs and requirements, and the home is proactive in meeting them. Staff are positive in their outlook and actively seek ways to meet the different challenges that they face on a daily basis. The home has established links with the community. The manager has effective management skills and abilities, and is committed to providing a good standard of service. Staff were knowledgeable about clients needs. Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 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 standard(s) 1,2,3 & 4 The Statement of Purpose and Service User’s Guide provides clients, prospective clients, families and funding agencies with details of the services available, enabling an informed choice and decision about admission to the home. EVIDENCE: The home has amended their Statement of Purpose and Service Users Guide to reflect the increase in registration numbers. It is clear within the documentation, that the service to be provided on the 2nd floor will be independent in terms of facilities and staffing arrangements to the main home. Pre and post admission assessment documentation were in place and pre admission visits/stays are arranged. Documentation included clients’ aspirations and wishes where appropriate. The manager expressed concern that on some occasions, information provided by the funding and/or external agencies as part of the pre assessment process has not always been as detailed as they home would have liked. Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 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 standard(s) 6,7,8,9 & 10 Documentation systems in place identified clients assessed needs. The current system demonstrates that clients are consulted and participate in individual goal planning and corporate lifestyle decisions within the home. EVIDENCE: Individual care planning documentation was indexed and well ordered. Files were ‘sectioned’ which allowed easy access to specific documentation. It was evident that clients are involved in the care planning process, as their handwritten comments, signatures and record of discussions etc were seen. Risk assessments were on files, but the format used by the home was not always fully completed, as the ‘risk rating’ was not being routinely recorded (see recommendations). All other aspects and elements of documentation associated with an effective care planning system were evident. Staff were observed to be assisting clients in a sensitive and appropriate manner and demonstrated a good understanding of individual clients needs. Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 10 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 standard(s) 11,12,13,14,15 & 16 Established systems are in place to offer, provide and/or facilitate an appropriate and meaningful lifestyle for clients in the home EVIDENCE: Care plan documentation demonstrated that clients are consulted about all aspects of their personal development, social/leisure/occupational/educational aspirations and daily routines within the home. Clients’ limitations are appropriately considered. Clients confirmed that they are involved in regular ‘house meetings’ which might include discussions on food provision, outings etc. Clients spoke about, and are involved in a wide range of activities such as day centres, adult education, work experience, community projects, horse riding, swimming, local church events and well as ‘in house’ activities/events. Records evidenced that where appropriate, client’s families are involved with care planning. The home is currently working on a number of ideas to further develop ways of better and a more efficient communication system for some clients using an IT Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 11 ‘ sign and symbol’ system. The system is well on the way to being fully functional and will greatly benefit those clients with limited verbal communication, although the home relatively effective communication systems already in place. Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 20 Medication training/monitoring/supervision procedures must be reviewed to ensure compliance with current guidance. This is to minimise the risk of potential harm to clients because of inadequate/poor practice. EVIDENCE: Medication PRN (as/when necessary) protocols were in individual clients records. Medication was stored appropriately. The current practice of individual members of staff manually transcribing medication administration instructions without signature(s) does not comply with the guidance within the Royal Pharmaceutical Society of Great Britain (2003) section 3.2.2 (page 6). The document states’ there is no legal impediment to a care home constructing a hand written MAR sheet but there is potential for error when charts a regularly re-written by staff’ and ‘in the case of handwritten charts not checked by the GP, it is strongly recommended that these be checked by a second person and referenced back to the original prescription’. Five unsigned entries were noted on the records of one resident. Current identified practice places clients potentially at risk, as should an error be detected at a later stage, there would be no clear identifiable trail to follow. In addition, the Commission has received reports of two recent incidents within the home whereby medication practices have been the subject of ‘in house’ (ACH) management investigations. As a result of the home’s reports to the Commission and the inspector’s findings, a full review of medication practices/training/supervision must take Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 13 place to ensure that good and safe practice is promoted and monitored by management to safeguard clients. Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 14 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 standard(s) EVIDENCE: Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 24,25,26,27,28 & 30 The overall quality of furnishings, fitments and décor was of a good standard. EVIDENCE: Clients’ bedrooms were comfortable, homely and reflected individual taste and preference. Communal areas were functional, practical, well furnished and pleasantly decorated. A full ‘make over’ is planned for the rear garden/patio area, which will make the outside facilities more practical and functional. The home was clean and well maintained. The proposed 2nd floor accommodation provides a self-contained unit for 2 clients. It has 2 bedrooms ( ensuites), study room, laundry facilities, staff sleeping-in facilities and a well equipped/furnished lounge, dining and kitchen area. The 2nd floor is furnished, decorated and equipped to a high standard. The 2nd floor is accessed via a separate front door. Building Control and Fire and Rescue Department have no objection to the registration of this area taking place. Clients accommodated on the 2nd floor will need to have full mobility as there is no passenger lift facility. Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34 & 35 Clients benefit from an established core group of trained staff. Elements of the home’s current recruitment process could place clients potentially at risk. EVIDENCE: Only 6 clients are accommodated at present. Current staffing levels are adequate to meet their individual and corporate needs. The home has stated that no further clients will be admitted until they are able to increase staffing levels through the current recruitment process. Staff undertaking induction spoke positively of the support received. Staff induction records were not signed and dated by the person who had given the instruction, as per the home’s own expectation. The home has submitted an independent rota showing how the 2nd floor accommodation is to be staffed. Staff spoken with were knowledgeable about individual clients care needs. Good verbal interaction between staff and clients was observed. Three staff recruitment files were viewed. They did not contain current POVA 1st and Criminal Records Bureau checks. Employment records related to start dates in the home within the current year, and the CRB records on file related to previous posts with different employers. These staff were working in the Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 17 home unsupervised. The manager confirmed that the Criminal Records Bureau check requests were at the company’s head office but had not been dispatched to CRB. The manager agreed to take immediate action in order that clients are protected from any potential risk. Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41,42 & 43 Some current management and administration systems require urgent review to ensure that clients are protected and their wellbeing is promoted. EVIDENCE: A full review must take place regarding staff recruitment and medication procedures. Staff were in post and working unsupervised without cleared Criminal Records Bureau checks. This practice is not good and places clients potentially at risk. Even if this shortfall had been identified by the registered person (through Regulation 26 visits) and was being addressed, the findings at the inspection were as stated. There was no evidence that contingency plans had been put in place to safeguard clients whilst the matter was being dealt with. In addition, a full review of the home’s medication policy and procedures must take place together with a review of associated training and supervision procedures. Current practice could potentially place clients at risk. Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 19 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 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x x 3 1 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Southwold House Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x 1 1 2 I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 20 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 20 Regulation 13 Requirement The registered person must ensure that appropriate staff training, monitoring and supervision arrangements are in place to promote the safe recording and administraion of medication be in accordance with laid down current guidance. The previous set timescale of 8/12/04 to meet this standard, has not been acheived. The registered person must ensure that robust recruitment procedures are in place. This is with reference to current guidance concerning POVA 1st checks and Criminal Record Bureau checks. The previous set timescale of 8/12/05 to meet this standard, has not been achieved. Timescale for action 18/8/05 2. 34,41 & 42 13,18 & 19 18/8/05 Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 9 43 Good Practice Recommendations The registered person should ensure that all clients risk assessement documentation is fully completed. The registered person should review the manner in which the monthly Regulation 26 visits are carried out and reported on in order that the above shortfalls are addressed and monitored for future compliance. This is with particular reference to POVA 1st & CRB checks whereby the shortfall had reportably been identified, but no apparent measures put in place to minimise risk whilst checks were being processed. Southwold House I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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 I56-I06 S61634 Southwold V235946 040705 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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