Care Home: Southernwood Promoting Independence Centre

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What the care home does well Service users are supported well by an experienced caring staff team. Many positive comments were received from service users and their visitors. Some said the staff are very good and some respite clients stated they are happy to return over again. Visitors said they are very happy with the staff and can feel comfortable that their relatives are well cared for. The Expert said she met with an excellent staff team who were able to quickly identify the needs of short-term residents and provide a good service. She also said the centre is well decorated, warm, light and airy.A good system of self-monitoring is in place to continue improving the service provided. Complaints are taken seriously and residents feel safe in the centre. A good standard of meals are provided and mealtimes are an enjoyable affair. Sufficient staff are at hand to support those people who require it. What has improved since the last inspection? The centre`s management have reviewed requirements made at the last inspection in January 2007 and made the necessary changes to promote the comfort and wellbeing of those people who use the service. What the care home could do better: Review the medication system to ensure it meets current pharmacy guidance. Also review the timing of medicine rounds to ensure those residents who require medication for pain relief or to be taken before meals have their needs met. At mealtimes, ensure courses are served individually. This is important when a hot pudding is requested. Continue with the review of training requirements to maintain a balanced welltrained staff team. Ensure a system is in place to provide and record fire training at the appropriate intervals to maintain a safe environment for service users. CARE HOMES FOR OLDER PEOPLE Southernwood Promoting Independence Centre Southernwood Trafford Allerdene Estate Low Fell Gateshead NE9 6LH Lead Inspector Allan Helmrich Unannounced Inspection 24th and 26th November 2008 9:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Southernwood Promoting Independence Centre DS0000066639.V372883.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southernwood Promoting Independence Centre Address Southernwood Trafford Allerdene Estate Low Fell Gateshead NE9 6LH 0191 433 6467 0191 4914828 cbssouthernwood@gateshead.gov.uk 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) Gateshead Council Acting Manager Janet Regan (Not Registered) Care Home 23 Category(ies) of Dementia - over 65 years of age (7), Learning registration, with number disability (1), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2), Old age, not falling within any other category (23), Physical disability (5), Physical disability over 65 years of age (6) Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2006 Brief Description of the Service: Southernwood Promoting Independence Centre is a modern, purpose-built service designed to provide short-term care and accommodation for older people, some of whom may have physical disabilities. The building is on the site of the former Southernwood residential home for older people, in a housing estate. The new building was completed in June 2006, when it began operating as an intermediate care service. The service is operated and managed by Gateshead Social Services Department, with input from health services, including Occupational Therapists and Physiotherapists. Southernwood aims to provide 3 distinct services, that is: intermediate care for people who are receiving rehabilitative therapy; short-term ‘assessment’ care for those people being assessed for further services; and short breaks (respite care) for people who will return to their own homes. The building provides 23 good-sized single rooms, all with en-suite shower and toilets facilities. There are also 2 communal bathrooms, which are fitted with appropriate adaptations to support people with a physical disability. There is a communal lounge and small dining room on the ground floor, a separate smokers’ lounge and small kitchenettes on both floors. There is good car parking at the side of the building, with 2 disabled parking bays at the entrance. There is level access into building through electronic doors into the reception area. Southernwood is a short walking distance from local shops, and a short bus or car ride from shops on both the Team Valley and Low Fell. There is access to local transport directly outside the building. There is no fee for the first 6 weeks of the rehabilitative service. The weekly fees for assessment and short breaks are £79.92 - £882.80. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. This key unannounced inspection was carried out by an inspector for The Commission and an Expert by Experience provided by Age Concern, on 24th November. A further visit was made by the inspector on 26th November. The inspection lasted over 11 hours. Information received since the last inspection on 14th December 2007 was reviewed. This included information requested from the provider prior to the inspection. During the inspection we talked with people who use the service, staff, and the acting manager. Looked at information about the people who use the service and how well their needs are met. Looked at other records that must be kept. Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the building to make sure it was clean, safe and comfortable. Checked what improvements had been made since the last visit. What the service does well: Service users are supported well by an experienced caring staff team. Many positive comments were received from service users and their visitors. Some said the staff are very good and some respite clients stated they are happy to return over again. Visitors said they are very happy with the staff and can feel comfortable that their relatives are well cared for. The Expert said she met with an excellent staff team who were able to quickly identify the needs of short-term residents and provide a good service. She also said the centre is well decorated, warm, light and airy. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 6 A good system of self-monitoring is in place to continue improving the service provided. Complaints are taken seriously and residents feel safe in the centre. A good standard of meals are provided and mealtimes are an enjoyable affair. Sufficient staff are at hand to support those people who require it. 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. The summary of this inspection report can be made available in other formats on request. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. Quality in this outcome area is good. Southernwood provides good written information about its services and all service users have their needs assessed before coming to stay here, so the centre can make sure their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Southernwood has a written Statement of Purpose that provides clear information about the different services that it aims to provide and it can be made available in different formats. Currently this document is being rewritten to include recent personnel changes. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 9 Southernwood also provides a written Service Users Guide for the people who might use this service. This explains in plain English what the service is like, what the building is like and what people can do during their stay. The Service Users Guide is part of an information pack that is kept in each bedroom for easy reference by the people who are staying here. The manager confirmed that, on request, this information can be made available in other languages and formats. There are three distinct services provided at the centre: rehabilitation; an assessment period, perhaps to arrange other services; and a short-break holiday stay. Only people whose needs have first been assessed by a health or social care professional are referred to the centre. No–one is admitted without the centre receiving a written assessment, including emergency placements. The registered manager can then make a decision about whether the centre can meet their specific needs. For referrals to the rehabilitation places, the manager also takes advice from the occupational therapists and physiotherapists to ensure that the prospective service user has the potential to achieve rehabilitation. Some people are admitted in an emergency and a system is in place to ensure a planning meeting is arranged within 72 hours. There is a further assessment within 5 days and then after 2 weeks. This ensures the individuals care needs are met. The plans reviewed each contained a local authority care plan, terms and conditions of residency and a record of the pre admission visit conducted to ensure the persons needs could be met before a place was offered. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. Service users health & personal care needs are well supported by good care planning, regular involvement from other professionals and clear recording. However, the medication system could be improved to ensure the welfare of service users is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Shortly after admission a range of assessments are conducted to ensure the support provided to the service user both meets their health and personal care needs but also promotes their independence. The plans of care are discussed with the service user and signed by them and support staff to show agreement of the care to be delivered. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 11 The care plan for an emergency admission contained physiotherapy and occupational therapy input to ensure the persons mobility was assessed and a plan developed for improvement. Other care plans included an admission checklist, a brief social history, a photograph and personal and medical contact details. Other details recorded to ensure a good standard of support is provided include; a medical summary, personal likes and dislikes and a daily living and needs assessment. Key staff regularly review each of the plans. Records demonstrated that service users regularly see healthcare professionals to promote their good health with details of health checks, visits to their GP and hospital appointments being recorded in the individual files. Each service user is weighed regularly to monitor their health. Three residents spoken to all stated the home provides a good standard of support and staff were observed throughout the inspection checking peoples comfort levels. The Expert by Experience had many positive things to say about the caring staff team. She felt the staff did their best to ensure each service users stay at Southernwood was an enjoyable experience. She was also very impressed by the way staff provided care and empathy to one distressed service user. All senior staff that dispense medicines have had training in the safe handling of medication. Medicines are safely stored either in lockable units within service users bedrooms where they have been assessed as able to self medicate or in a central dedicated store. The following issues were identified for improvement to promote good medication practice and to ensure the wellbeing of service users; Leave medicines, that is medicines given to people leaving the service to visit day services or other events, should be recorded. The maximum and minimum temperature of the medication fridge should be recorded to ensure medicines are appropriately stored. Limited life medicines should be dated as opened. The medical reference book should be renewed. The timing of medicine rounds should be reviewed. Morning medicines were still being dispensed past 11:00am. However it is accepted that the inspectors may have taken senior staffs time. All bedroom doors are lockable by service users and they have private shower/toilet facilities. Each bedroom has a telephone. This means that service users can make and receive calls in the privacy of their own rooms whenever they wish during their stay. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. Service users are able to maintain there regular lifestyle and can take part in some in-house activities if they choose. Visitors are made welcome. A good standard of healthy food is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service users expectations and lifestyle choices are identifies shortly after entering the service. During the inspection one service user was seen leaving the building to go to a day service and another went out with a relative. Other than a weekly exercise class all activities are ad hoc. There is a TV lounge where most people socialise during the day. There is good freedom of movement for service users around the building, and many people spend some time in the privacy of their own rooms. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 13 Any pre arranged events are detailed on the home’s notice board. Otherwise staff simply go around the home informing service users of any activities being arranged. Staff were seen throughout the inspection involving service users in conversation and encouraging activity. Staff spoken to said they had recently taken people out to local shops on foot and for other places of interest further away taxis are used. Service users records contain details of social interaction and this is used to determine if specific individualised support is needed. The records showed that people were involved in sing a longs, had family visitors, used the hairdresser and played bingo and quizzes. A game of bingo took place during the inspection and one person spoken to said he had been asked but chose not to be involved. Most people seem to prefer spending time in the main lounge talking with each other, watching the television or listening to music. There are also small lounges where groups of people were seen in conversation without staff support. The Expert commented the home contained plenty of small lounges where people could be alone if they wanted to. Also the main lounge was a bright happy place where residents were involved in a quiz. She also found books to read and CD’s to listen to but felt mostly people were content to sit and chat. There were a number of visitors during the inspection. All had many positive comments to make about the centre and the service that their relatives were receiving. One visiting couple commented that they were more than happy with the care their relative was getting. There are kitchenettes on each floor where service users can make themselves drinks and snacks if they are able. Some people receiving a rehabilitation service also use these, with support, to regain confidence in their kitchen skills before returning home. There are dining facilities in a small lounge, within the larger TV lounge and in a small kitchenette on the first floor. Main meals are prepared in the main kitchen by catering staff and transported to the small kitchenettes. The meals are then plated and served by support staff. The Expert who had lunch in the main dining area said meals were served hot with not too much on the plates. People were then asked if they wanted more. One person did not want the menued choices so was offered homemade soup. Staff were in attendance all through lunch to encourage service users to eat, but not rushing those who took a little longer. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 14 One service user who chose to eat lunch alone in an upstairs kitchen had both his main meal and hot pudding served together. This is not good practice. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. People using this service can be sure their complaints will be taken seriously and that they will be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is clear written information about how to make a complaint in the Service Users Guide, which are in each bedroom. At the front entrance there is a copy of how to complain written in Braille and an audio version on tape. The centre actively encourages complaints as a way to improve the service and several complaints and expressions of dissatisfaction were recorded with the detail of how they were resolved. One complaint was forwarded to The Council for resolution. In discussions service users and their visitors said that they would feel comfortable about approaching senior staff if they had any concerns, and were confident that these would be dealt with. All care staff have had training in Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 16 customer care so that they would know how to recognise and acknowledge any dissatisfaction people might have with the service. Service users have good access to advocacy services provided by Age Concern during their stay if they need such support. Details of this service is posted on notice boards in the home. As with all adult services in the Gateshead area, Southernwood uses the local authority Safeguarding policy. This includes robust procedures for reporting and investigating suspected abuse. All staff at the centre have had updated training in the POVA procedures. Discussions with the manager and senior team indicated that they are very clear about their roles and responsibilities under the procedures. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is good. The centre is bright, modern and well maintained. The accommodation is comfortable and clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Southernwood was specifically designed and then built in 2006 to provide short-term accommodation for older people with a range of needs, including physical disabilities. It is a bright, modern building that is furnished and decorated to a good standard. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 18 There is a large lounge/diner and two other small sitting rooms one of which is used by smokers. Outside there is a large patio with seating for use in better weather. Bedrooms are well equipped with wardrobes, drawers, writing table, digital TV and large-button telephone. All bedroom doors are fitted with approved fire authority devices so that they can be held back to support a service user’s easy access, without compromising fire safety within the building. All bedroom doors are lockable from the inside by a service user. Service users are asked if they want a key to their bedroom. Each of the bedrooms has en-suite showers/toilets. Several of the bedrooms were personalised with small items of memorabilia. There are 2 communal bathrooms that are fitted with adapted baths for those people who either choose or cannot use the en-suite facility provided. The needs of people with dementia, visual impairments and physical disabilities have been taken into account when designing the sizes, equipment, décor and colour schemes within the centre. There is good signage and distinct colour contrasting around the building to support service users to find their way around. One bedroom has been equipped with pressure mattresses and pressure pads to unobtrusively monitor the safety of a service user who needs additional support during the night. The Expert commented, ‘ the home was well decorated, warm, light and airy with plenty of little lounges where you could be alone if you wanted to. The bedrooms are adequate for short stay residents and even then they had a lot of personal things around. Overall service users were very satisfied with the good quality of accommodation. One person said, “It’s a comfortable place to be whilst waiting to get better.” Service users who commented were very happy with their accommodation and felt the home was clean and comfortable. The laundry is well equipped and in a service area away from service users’ accommodation. All parts of the building that were examined were clean and hygienic. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. Staff get regular training and supervision to ensure the necessary skills are available to provide the people who use the service with good care and support. Recruitment procedures ensure people who use the service are safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided by the home manager showed that three staff are currently working towards an appropriate vocational qualification and all other staff have achieved the standard. The records showed that a regular training programme is in place to ensure staff receive the training they need to support people referred to this service. The manager is currently reviewing the training needed to maintain a balanced staff team. During the inspection sufficient staff were on duty to meet the needs of the service users. The staff rota demonstrated that the normal care staffing levels, in addition to the manager who works as part of the team, includes an assistant manager and four support staff from 7:30am until 9:30pm. From Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 20 9:15pm until 7:45am there are two support staff on duty and they have access to an on call assistant manager should they need further support. Other than the managers post, there are currently no staff vacancies. The acting manager stated the provider’s recruitment and selection processes. She also confirmed that all necessary checks and clearances are taken up on potential new staff prior to their employment. Most records are held centrally at the staffing section of the Social Services Department. The service retains some information about each staff member within the centre. A system is in place to ensure all new staff receive a comprehensive induction equivalent to the nationally agreed standards. Details of this is recorded in a workbook and signed by the manager on completion of a demonstration of competency. Staff are also now able to use e-learning on the authorities intranet site and if a competency is achieved a certificate is provided. Staff spoken to stated they feel well supported and that morale in the staff team is good. Service users stated that staff provide good support. The Expert commented she had met with an excellent staff team who were more than capable of dealing with short-term residents needs. They provided encouragement, care and empathy. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is good. Southernwood is a well-managed service run for the benefit of service users. Health, safety and welfare are promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A temporary manager is currently managing this service while a decision about a permanent manager is made. The service is well run and consistency is achieved with the support of four assistant managers. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 22 The acting manager is well qualified having worked in a senior capacity for over six years and having obtained the Registered Managers Award to demonstrate her abilities related to caring for vulnerable people. The standards in the service are regularly monitored by senior managers who provide a comprehensive assessment each month, concentrating on different aspects of the service. A quality assurance system is also in place to develop and monitor the standards of care provided. Self critical reports are produced and action plans necessary to improve standards are produced. Meetings are used to obtain and provide information within the service. There have been both service user and staff meetings held within recent weeks. Minutes are produced and made available. Supervision records are up to date. This provides staff with a regular opportunity to meet with management on a 1-1 basis for support. Staff spoken to stated that training and support are available and that concerns are listened to and addressed wherever possible. Service users are encouraged to control their own finances and a lockable unit is provided in bedrooms for this. However a service is available if requested where up to £20 can be deposited for safekeeping. All monies are accounted and receipts are kept for all purchases and two signatures evidence each transaction. Prior to the inspection a record of maintenance agreements and health and safety matters were provided by the home to demonstrate good care is taken to ensure residents are safe. The home’s gas service certificate was seen and annual small electrical appliance checks were reviewed and found to be in order. Senior staff carry out health & safety audits each month. A fire risk assessment of the building was in place and regular fire checks are conducted. But it could not be fully demonstrated that all staff have received appropriate fire instruction at the intervals suggested by the Fire Authority to ensure the safety and well being of service users. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 2 Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13(2) Requirement The manager must ensure the following issues regarding the safe handling of medicines are addressed; Medicines provided for people leaving the centre for short breaks or day services (Leave medicines) must be recorded. The maximum and minimum temperature that medicines are stored should be recorded each day. Medicines with a limited life should be dated when opened to ensure they are used within date. The medical reference book should be replaced with a more contemporary one. The manager must ensure that staff receive appropriate fire instruction at the following intervals; Day staff 6 monthly and Night staff 3 monthly. This should be recorded in a suitable log and signed by those staff obtaining the instruction. Timescale for action 28/02/09 2. OP38 23(4)(e) 28/02/09 Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP15 OP30 Good Practice Recommendations The manager should monitor the time taken to dispense morning medicines and take any appropriate action to ensure it is appropriate. Review the practice of providing a main course and hot dessert at the same time. Continue reviewing staff requirements related to training. Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Southernwood Promoting Independence Centre DS0000066639.V372883.R01.S.doc Version 5.2 Page 27 - 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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