Care Home: Southlands

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What the care home does well The service makes sure all information is recorded, cross-referenced and communicated. These methods also provide a continually updated record of any needs or changes to service users mental or physical health that may be used in conjunction with any ongoing health care professionals input. The home will listen to the people who live in the home and make efforts to provide what they request. For example, the service users wanted an animal and after discussion decided on a parrot. This has been obtained and is now a family pet for the home. What has improved since the last inspection? No requirements or recommendations were made at the last inspection. Since the last inspection, the home has converted the disused garage and a storeroom into a `snoezolem` (a room for relaxation with different lights, soft music and relaxing areas, also where the visiting reflexologist can work with service users) and a dedicated art room. These are now much used facilities. What the care home could do better: The registered manager has informed the company about several maintenance issues over the past year. But there have been long delays in these being completed: 1. An upstairs bathroom has a w.c. that has been out of order since December 2007. Although there are other toilets available, service users are affected by not having access to the w.c. 2. The oven has been out of order for six weeks. Until a new cooker is supplied they are having meals cooked on a variety of small appliances. 3. A request for a fence and gate to partition part of the very large garden and grounds to make a garden area secure for the service users has not yet been responded to. Service users cannot access the garden without support due to their particular needs unless a suitable fence and gate sections off the grounds. The medication storage along with confidential information is held in a very small electrical cupboard. This may at times have to be visited by another source. This could compromise confidentiality as well as medication security. The registered manager has identified another area that would be a better setting for the medication and agreed to speak to the company about the possibility of organising this. CARE HOME ADULTS 18-65 Southlands East Street Harrietsham Maidstone Kent ME17 1HH Lead Inspector Wendy Gabriel Unannounced Inspection 31st July 2008 09:50 Southlands DS0000023871.V367690.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 Southlands DS0000023871.V367690.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. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlands Address East Street Harrietsham Maidstone Kent ME17 1HH 01622 858713 01622 858713 southlands@counticare.co.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) Counticare Ltd Ms Kirsti Griffin Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - (PC) to service users of the following gender: Either. Whose primary care needs on admission to the home are within the following category: Learning disability, maximum number of service users: 6 The maximum number of service users to be accommodated is 6. 2. Date of last inspection 24th July 2006 Brief Description of the Service: Southlands residential home provides care and support for up to 6 adults with learning disabilities. Some may also have mental health difficulties. The current resident group are all female. Each service user has a single bedroom two of which have an en-suite facility. There is access to public transport on the main A20 Ashford to Maidstone Road nearby. Shops and other amenities are within a short walking distance. A patio and large garden to the rear backs on to open farmland. There is car parking available at the front of the premises. The service has its own vehicle. Weekly fees are in the range of £1344.45 -£1778.00. For further up to date information please contact the provider. Southlands DS0000023871.V367690.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 3 star. This means the people who use this service experience excellent quality outcomes. During the inspection we looked at some documents and recording and spoke to staff and the person in charge. Some limited conversation took place with service users. An accompanied tour of the premises was undertaken. We also looked at the annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. There were no requirements made at the last inspection. One service user was in hospital at the time. The registered manager, with staff support, has provided an excellent recording system for all aspects of the service users daily lives. All documents can be cross-referenced to gain a detailed and up to date picture of current needs and of any changes. There is good evidence of the home accessing health care professionals to meet physical and mental health needs and we received a completed survey from a medical practitioner with positive responses to questions about how the service responds to and deals with healthcare matters. The home has identified changes to service users needs that necessitated a move from the home to another service. Service users were seen accessing different parts of the home and being occupied with favourite activities. There is a range of community and in-house activities for people living in the home. The registered manager and staff have carefully considered what person centred plans are for and have been inventive in providing the means to remind individual service users of their preferences and choices. What the service does well: The service makes sure all information is recorded, cross-referenced and communicated. These methods also provide a continually updated record of any needs or changes to service users mental or physical health that may be used in conjunction with any ongoing health care professionals input. The home will listen to the people who live in the home and make efforts to provide what they request. For example, the service users wanted an animal Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 6 and after discussion decided on a parrot. This has been obtained and is now a family pet for the home. 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. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 7 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. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 8 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 Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 9 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): 2. 3. 4. Quality in this outcome area is good. Prospective service users know they will have their needs and aspirations assessed and will be able to visit the service before making a decision about where to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The company has a bed co-ordinator who is closely involved with seeking suitable candidates for vacancies. The service has a detailed format for making an assessment. The first assessment will be between the registered manager, care manager and other involved people such as psychiatrist to discuss recognised needs. There is evidence of contact with health care professionals before a person moves into the home. The second assessment is with the prospective service user to give them the opportunity to express their wishes and talk about themselves. Each service user has their own copy of the service users guide and statement of purpose. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 10 Visits to the home including a few weeks stay can be undertaken prior to becoming permanent. Staff has previously spent two weeks with a prospective service user in a specialist unit getting to know them before they came into the home. The service has also identified if the home is no longer suitable for a service user and has had meetings with health care professionals as well as the company before making a decision to give the individual notice. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is excellent Service users know that their changing needs are taken into account. Risks and decisions they make will be regularly assessed and supported. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are detailed with management of behaviours and risks. Risk assessments are reviewed twice a month. All information is cross-referenced to other records the service maintains for each individual. This could be anything from outcomes of health care appointments to stated choices of meals. The home has health action plans that detail all about the individual and are updated at least monthly. Records had been prepared for an appointment that morning, indicating all that the health care professional being visited would want to know about the individual. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 12 Service users records contain all information for their needs and aspirations including detailed guidelines for staff. Information, including risk assessments is regularly reviewed and formal reviews with care managers and other parties are held annually. Person centred plans were discussed and the registered manager said that due to complex needs of the service users she believed that written person centred plans would not benefit individuals. Therefore, she has with the assistance of staff, devised different sources of information that are innovative and meaningful to individuals and are to help remind them of their own life choices. There is written guidance on ‘consistent approaches’ by staff towards each person. A survey received from a general practitioner had positive responses of ‘always’ to all questions regarding how well the service responds to and deals with healthcare matters. The AQAA states that one person is a member of the local learning disability group in the village and of the Prader-Willi syndrome association that provides her with monthly letters and support on coping with the syndrome. There was written evidence of regular service users meetings. Each service user has identified ‘talk time’ and key workers write end of month reviews. This, with all the other monthly information provides an up to date picture of ongoing health or psychological needs. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16,17. Quality in this outcome area is excellent. Service users know they will be supported to take part in work and leisure activities of their choice. Appropriate relationships are supported and service users rights are recognised. Diets are healthy and meet the diverse needs of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One service user wanted to show her room and talk about what she liked in there and about her hobbies including artwork and embroidery. She spoke about how proud she was to have got a job working in a canteen once a week. The registered manager helped her explain that this is such a wonderful achievement for her because of her particular needs. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 14 The staff said they were disappointed not to be able to get any college places for service users’ this coming term, as there were limited vacancies. However, they were courses that people attended at the company day centre. A local assessment intervention service offers numeracy and literacy. Other activities include golf, canoeing, swimming and rambling, one person said she and others liked going to the pub. The Butterfly Club and the Martello Club is sourced. The people who live in the home have a particular fondness for animals and wildlife and this was seen from their choices of pictures and decorations especially in the art room. Since the last inspection the home has converted the disused garage and a storeroom into a ‘snoezolem’ and an art room. Staff had decorated and furnished the snoezolem with appropriate lights, tactile objects and relaxing areas. The reflexologist uses this room on her visits. The art room was full of projects and the people who live in the home had decorated the walls, again including lots of wildlife themes and pictures. Service users help run a weekly disco and the funds go towards their trips. One person said she liked this. Staff said people locally were friendly and that people in the pub knew them. Families are involved where possible with the home. Service users receive health education classes monthly with the community nurse as appropriate for each person. The registered manager had a very good awareness of the mental capacity act and how it could be used purposefully for intervening on behalf of the service users. Holidays are taken and this year they went to the New Forest where staff had rented a cottage. This was very successful staff said; because it offered the wildlife that the service users enjoy so much. One service user spoke about this and that she had enjoyed the holiday. The registered manager spent time encouraging her to use the right words for where they had gone to stay. This was warm and appropriate and the service users facial expressions indicated she was happy to be given this opportunity to express herself. The service has large grounds backing onto fields. A request was put to the company last year for a fence and gate to secure a smaller size area around the house where service users could access the garden unaccompanied. But this has not been responded to. The facility would benefit the service users and give them the opportunity to make freer use of the grounds. The registered manager said the home does not have a locked kitchen despite there being people with Prader Willi syndrome living in the home. Some service users help with choosing the menu, shopping and assisting to cook meals. The larder, fridge and freezer were full and there were plentiful fresh vegetables and fruit in the home. The menu was varied and the registered manager said that occasionally service users could choose a takeaway. The Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 15 registered manager said that this relaxed yet watchful ethos had assisted some service users to make good choices regarding their diet. The cooker door had been broken accidentally approximately 6 weeks earlier. Despite this being reported to the company at the time it had not been replaced. The home had however bought a selection of small appliances to be able to continue with cooking. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. Service users receive support in the way they want. Medication administration is suitable and service users are protected by policies and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We received a completed survey from a medical practitioner with positive responses to questions about how the service responds to healthcare matters. Care plans detail support to be given to service users and the service takes care to find out what preferences the service users express. Care plans also detail the varied physical and mental health support individuals require and these are cross-referenced with health care risk assessments. The home receives the support of general practitioners, community nurses, psychiatrist, diabetic nurses and other health care professionals. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 17 Staff were very clear about the mental health and emotional needs as well as physical needs of service users and spoke with empathy about support and recognising changing needs. Medication administration is robust and the home maintains records and polices about medication administration. Storage although secure with dedicated fixed steel cupboards, is held in a locked, small electrical cupboard. This would at times be accessed by other agencies such as an electrician and the secure and confidential information currently on view in the cupboard would be compromised. The registered manager pointed out another area that might be better placed for the storage and agreed to seek permission to source this. The registered manager pointed out that one medication is currently being counted by the home following a series of errors in amounts being sent from the pharmacy. She agreed to write a document for staff to follow to maintain security, cleanliness and infection control regarding this until the matter is resolved. The home undertakes a weekly audit of medication. The stock control book is also signed by the pharmacy. The registered manager and deputy manager has undertaken a six month training course regarding medication administration and this was assessed by the community nurse. The registered manager and deputy manager will regularly reassess staff to make sure of their competence and confidence. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. Service users are enabled and supported to have their views listened to and are protected by the homes policies and procedures regarding abuse, neglect and self harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service maintains suitable policies and procedures regarding making complaints and adult protection procedures. To encourage service users to make their concern known, regular one to one talk times are held between the individual service user and their key worker. Staff receives training in adult protection and understanding adult abuse and on non-violent crisis intervention. Staff were aware of the need to report issues they may have concerns about. One complaint had been received this year regarding the overgrown state of the gardens. The registered manager responded immediately to the complainant by telephone and reported the matter to the company. But it took the company several months to organise the garden issue. The company has organised service user forums whereby a representative for each service will be invited to join in with senior members of the company and discuss issues about the home. Although they will be escorted to the venue by Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 19 staff, staff from the home will not be in attendance at the forum so service users can feel free to discuss any matter they choose. An annual questionnaire is given to people and this is collated and responses made known. The service also gives feedback forms to visitors at any time for their comments and views on the home. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 20 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): 24,25,27,30. Quality in this outcome area is good. Service users live in a clean, safe and comfortable environment. Repair to the upstairs toilet and to the oven will improve the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean and tidy and is presented in a very homely and comfortable way. Service users bedrooms seen were very individual and one person showed her room with justifiable pride. The kitchen is open to service users with support and was seen to be clean and well organised. The service maintains detailed cleaning programmes for the home. The laundry room is clean and well organised. The washing machine is capable of reaching high temperatures for infection control. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 21 Two bedrooms have en-suite facilities and there are adequate bath, shower and toilet facilities for people. But one toilet has been out of order since December 2007 and despite being reported to the company has not been repaired yet. An accidentally broken oven door has not yet been repaired despite being reported six weeks prior to the inspection. In the meantime the home has purchased several small pieces of equipment to make sure service users receive cooked meals. This year, staff and service users have changed the disused garage and a large store into a well fitted out ‘snoezolem’ and a lively art room. The art room has evidence of service users participation in their own choice of murals for different walls. This is an excellent facility for service users and there was good visual evidence that it is used regularly. The extensive grounds are now well maintained. A request for a separate area of the garden around the house to be fenced off to provide a secure environment for service users to go unattended has not been responded to by the company. This means service users must wait for staff to be available to them if they want to access this area. Records for the maintenance of equipment were up to date and fire records are maintained. Following a request by the service users for a pet the service has narrowed down choices to one that all service users liked and have got a parrot that is now a family pet for the home. The parrot is well cared for and lives in suitable, clean conditions in the office. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 22 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): 32,34,35. Quality in this outcome area is good. Service users are supported by qualified and competent staff and are protected by the homes recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The recruitment process has begun for a new member of staff for a vacancy in the home. The company undertakes the major part of recruitment and confidential information is held at their head office. Induction includes the company induction format and the homes own induction. Service users may be involved in expressing their views on prospective members of staff. Training is usually undertaken or organised by the company but recent company changes means that external training is not available until October. A wide selection of training certificates were seen and these cover the mandatory courses as well as more specialised courses for the needs of the service users. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 23 NVQ is well underway and staff has or are undertaking level 2 or 3. Night staff receive training to meet their rota times. A member of staff confirmed that there is a range of training and added that she or any member of staff could request a training course if they felt it would benefit the service users. Staff were observed discussing particular needs for a service user with the registered manager and they had a clear awareness of ongoing issues and how to respond. Staff are aware of the ethos of the service to record and cross reference different areas of information. Supervision and annual reviews are undertaken. The staff group in this home is female to meet the complex needs of the current service users. The company employs male staff in other homes. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 24 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): 37,39,42. Quality in this outcome area is excellent. Service users benefit from the ethos and management approach of the home. Service users know their views are taken into consideration. Service users are protected by the homes health and safety practices and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has the Registered Managers Award and has been registered within the last year. She has five years experience and is currently completing NVQ4 in care. The registered manager undertakes quality assurance reviews including annual questionnaires and feedback forms that may be used at any time. There is currently a survey being compiled called ‘what you think of Southlands’. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 25 The registered manager has a very clear idea of how the home is to develop and her aims for the service users living there. Plans include more activities and greater choice for service users through enabling them to express their wishes. The registered manager has identified the changing needs of one service user. Reviews and action has been taken to find a different and more suitable environment for her. Another service user has been enabled to become more independent and the registered manager has discussed the possibility of her going to different home in the company that can suit her particular abilities. Very detailed records are maintained and regularly reviewed and a cross reference system is in place to follow the mental health as well as physical needs of service users. The registered manager discussed person centred plans and that many of the service users could not retain the information if it was recorded in a document. She has been very innovative and has devised with staff help, different person centred systems for service users in the home. The registered manager was observed encouraging one person to find and use the right words to express her opinion of her holiday and where she had visited. This was done in an enabling and warm manner. The staff team is now stable and consistent. The registered manager says she operates an ‘open door’ policy. A member of staff confirmed that she was approachable and people could discuss anything with her. Staff meetings are held. The registered manager and staff have a good understanding of risk management and risk assessments are regularly reviewed. The company makes regular monitoring visits and the home notifies us of adverse events. The AQAA states that new health and safety, COSHHE and generic risk assessments have all been implemented. Service users have their own savings books and are enabled to get their own money with staff support. Staff undertakes documentation of this and receipts are held. One service user is supported to write her own details in her book. The annual AQAA was completed by the registered manager and was clear and thorough. Records for the maintenance of equipment were up to date. Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 26 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 X 2 3 3 3 4 3 5 X 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 3 25 3 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 4 X X 3 X Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Southlands DS0000023871.V367690.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Southlands DS0000023871.V367690.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!