Care Home: Southlands

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What the care home does well Residents spoken with said that they found the move into the home a supportive experience, and were please that they were able to bring some of their personal possessions for their bedrooms. Most of the residents had previously visited the home or had a period of respite, which they said, "helped them make the decision about moving in". Residents spoke positively about the support and care they received from the staff team who they described as "very attentive", "they work very hard", "they are friendly and caring". Residents said their needs were met to a good standard even though the staff are "so busy". Residents said that staff members supported them "with dignity and respect at all times". Feedback provided in the surveys also supported that residents were supported in accordance with their needs, and comments made included "the staff do a good job, they give us fun, and are very helpful"; Residents were happy with the environment, which they said was homely, and all of those spoken with liked their bedrooms. There are systems in place to enable residents to provide feedback about the home and make suggestions for improvements. Visitors spoken to said the staff made them feel welcome and keep them informed of their relatives well being. They said that generally there were satisfactory staffing levels but at times there was staff shortages. The staff team reported that they work well together and have access to training opportunities to enable them to have the skills and knowledge to fulfil their roles. What has improved since the last inspection? The service did not have any requirements made in the previous inspection report. What the care home could do better: The information obtained and recorded about each individual would benefit from being in more detail so that person centred care can be delivered and underpinned by written records. This includes information about people`s history and background which would enable the staff team to gain more knowledge about individuals. The documentation in place would benefit from being reviewed to include the six strands of diversity, which are: race, gender identity, disability, sexual orientation, age, religion and belief. This will make it inclusive to all people. The staffing levels at the home need to be kept under review and information provided to the corporate provider about short staffing. It would be beneficial ifan assessment of the dependency needs of the residents currently living in this service is undertaken to ensure that the staffing levels are in accordance with their needs. The staff team would benefit from having training about the mental capacity act so that they are aware of the new legal rights people have who live in this service. This will enable the staff team to promote these rights. CARE HOMES FOR OLDER PEOPLE Southlands 21 Main Street Off Greenside Close Long Eaton Nottingham NG10 1GU Lead Inspector Claire Williams Unannounced Inspection 21st April 2008 09:30 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 Southlands DS0000035734.V362915.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. Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlands Address 21 Main Street Off Greenside Close Long Eaton Nottingham NG10 1GU 01629 531869 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) yvonnefowkes@derbyshire.gov.uk www.derbyshire.gov.uk Derbyshire County Council Yvonne Kristine Fowkes Care Home 23 Category(ies) of Dementia (3), Learning disability (1), Mental registration, with number disorder, excluding learning disability or of places dementia (3), Physical disability (2), Sensory impairment (3) Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2007 Brief Description of the Service: Southlands is a detached house in a residential area of Long Eaton, within walking distance of the town centre. The home provides social and personal care for 23 people aged 65 years and over. The home currently provides 4 day care places. The facilities are on 2 floors. All accommodation is in single rooms; bedrooms do not have en suite facilities. Access to the first floor is by stairs and a passenger lift. The home has two large lounge and dining areas, a quiet room/library, and a lounge where residents can smoke. Residents have access to well maintained garden areas. The fees for the home range between £98.60 and £325.05 per week. Items not covered by the fees include: toiletries, hairdressing, and transport. Southlands DS0000035734.V362915.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 the service is two star. This means the people who use the service experience good quality outcomes The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place over a period of 7 hours. In order to prepare for this visit we looked at all the information that we have received, or asked for, since the last key inspection on the 10th May 2007 This included: • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection report. • The annual quality assurance assessment (AQAA). This is a selfassessment that focuses on how well outcomes are being met for people using the service. • We sent out surveys to residents and staff team for their feedback. –6 staff surveys were received before the visit to the service and 7 from the people that use this service. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of three residents representing a cross section of the care needs of individuals within the home. Discussions were held with those residents as able, together with a number of others about the care and services the home provides. Their care planning and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their care and also for staffs’ recruitment, induction, deployment, training and supervision. We also spoke with two visitors who were in the home at the time of this visit. Following discussions it was agreed that the people who live in this service would be referred to as ‘residents’ for the purpose of this report. What the service does well: Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 6 Residents spoken with said that they found the move into the home a supportive experience, and were please that they were able to bring some of their personal possessions for their bedrooms. Most of the residents had previously visited the home or had a period of respite, which they said, “helped them make the decision about moving in”. Residents spoke positively about the support and care they received from the staff team who they described as “very attentive”, “they work very hard”, “they are friendly and caring”. Residents said their needs were met to a good standard even though the staff are “so busy”. Residents said that staff members supported them “with dignity and respect at all times”. Feedback provided in the surveys also supported that residents were supported in accordance with their needs, and comments made included “the staff do a good job, they give us fun, and are very helpful”; Residents were happy with the environment, which they said was homely, and all of those spoken with liked their bedrooms. There are systems in place to enable residents to provide feedback about the home and make suggestions for improvements. Visitors spoken to said the staff made them feel welcome and keep them informed of their relatives well being. They said that generally there were satisfactory staffing levels but at times there was staff shortages. The staff team reported that they work well together and have access to training opportunities to enable them to have the skills and knowledge to fulfil their roles. What has improved since the last inspection? What they could do better: The information obtained and recorded about each individual would benefit from being in more detail so that person centred care can be delivered and underpinned by written records. This includes information about people’s history and background which would enable the staff team to gain more knowledge about individuals. The documentation in place would benefit from being reviewed to include the six strands of diversity, which are: race, gender identity, disability, sexual orientation, age, religion and belief. This will make it inclusive to all people. The staffing levels at the home need to be kept under review and information provided to the corporate provider about short staffing. It would be beneficial if Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 7 an assessment of the dependency needs of the residents currently living in this service is undertaken to ensure that the staffing levels are in accordance with their needs. The staff team would benefit from having training about the mental capacity act so that they are aware of the new legal rights people have who live in this service. This will enable the staff team to promote these rights. 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. Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 8 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 Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 9 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): National Minimum Standards 1, 2, 3, and 5 (6 not applicable in this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed and have access to information to enable them, to make an informed decision about moving into this home EVIDENCE: In the self-assessment that we received they said they would ensure all individuals would be assessed before they are offered a place within this home. They encourage trail visits to enable individuals to judge the home and its atmosphere. They said information about the home is readily available to residents and that a review would be undertaken following admission to ensure the care plan is accurate. We spoke to many residents and feedback from the surveys confirmed they have access to information about what the home offers and what the terms and conditions are. Copies of the Statement of purpose and Service user guide are available in the communal areas. The date on the Statement of purpose Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 10 indicated that it had not been updated since 2006, so therefore it would benefit from being updated to ensure residents have access to accurate information. The residents we spoke to confirmed they had been assessed before they moved into the home, and this was supported by the assessments in the 3 files that we examined. Residents spoke of varying reasons as to why they chose this home, and these included: “I wanted to be near my family”, “I have lived in this area all my life and did not want to move elsewhere”, “I came to visit and stayed for respite, I liked it so decided to stay”. One Individuals spoke about their admission and said: “the staff were very supportive, nice and patient”. The home does not provide intermediate care and there were no residents accommodated at the time of the site visit with diverse cultural or religious needs. It would be beneficial however for all documentation to be reviewed considering the six areas of diversity, so that is it inclusive to all people. Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 11 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): National Minimum Standards 7, 8, 9, and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that residents receive is based on their individual needs. The principles of respect, dignity, and privacy are put into practice. EVIDENCE: In the self-assessment that we received they said all individuals would have their health care needs appropriately catered for and have access to relevant professionals. They said care plans would be completed for everyone and reviewed regularly. Systems are in place to ensure medication is administered safely and they said all individuals are treated with dignity and respect. The three care files that we examined did contain a care plan, which clearly identified each resident’s needs and how these should be met. The care plans are completed electronically on a standard format. The care plans were written in a person centred way and contained some information about individuals likes, dislikes, preferences and abilities, but these could be expanded and more detail provided to give more direction to the staff team on how individuals would like to receive their care. Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 12 The files did not contain information about resident’s 24 hour routine, or about their social history and background. This information would benefit the staff team as it would enable them to gain more knowledge about the person and assist them in supporting individuals in accordance with their preferred routine. Each file contained risk assessments and risk management plans to help staff support residents in a way that will minimise any risks, and to monitor any key health needs. Residents who we spoke with said they have access to healthcare professionals, when they need them. Some residents were observed visiting the chiropodist who was present in the home at the time of this visit. The files contained evidence of reviews that have been held with residents in order to discuss their care and life in the home. In discussion with the staff team it was clear they had a good understanding of the residents needs. A key worker system is in operation and staff members said they enjoyed this role as it meant working closely with residents. Residents told us they receive their medication in accordance with their wishes. There were records to support that medication was stored and administered as prescribed. It was reported that the senior staff members are currently undertaking training to ensure they are competent to undertake medication tasks. Due to a change in the law the storing of controlled drugs must now be in accordance with the legal specifications. All residents spoken with said that support is provided in a “safe, respectful and dignified manner”. They spoke positively about the staff team who they said: “work very hard to help everyone”, “are kind and considerate”, “friendly and caring”, “provide excellent care.” From the observations made and the feedback all residents felt there needs were met. However people with high dependent needs had limited staff interaction other than when they undertake personal care tasks due to the staffing levels and duties they have to fulfil. Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 13 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): National Minimum Standards 12, 13, 14, and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about their lifestyle and have access to social, cultural, and recreational activities that meet their expectations. EVIDENCE: In the self-assessment that we received they said all individuals would be encouraged to retain their skills and learn new ones, and residents will be encouraged to sign documentation. They said daily life and activities will match individual preferences, and residents will be encouraged to exercise choice and control over their lives. Residents we spoke to said they spend their days doing what they want to do, and confirmed that a variety of activities was available to them four days a week and on some evenings. Individuals were proud to show me the pictures they had painted and certain individuals told us about the “little jobs” they did around the home. One individual who is a keen gardener showed me the plants that have been prepared for the outside garden area. In the files that was examined there was little information available about individual’s interest and hobbies. This could mean that if people cannot Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 14 verbalise staff would not know what activities certain residents would benefit from. Staff members did state that in these cases they would ask relatives for the information. A board is displayed in a communal area detailing the activities for the month of April in additional to other information such as the days the hairdresser will visit, and the books available from the library. A staff member who assists with breakfast also has the role of facilitating activities in the week. She said that she makes sure she spends time doing one to one activities with individuals who do not like group activities and those with high dependency needs. These individuals receive limited interaction with activities from the care staff due to only 2 staff members being on duty, so therefore they spent their time sitting in the lounge and not engaged in any activities. Feedback from the more able residents spoken to and from the surveys supported that they felt they “had enough to do in the home” and liked the activities available. Two visitors, who spoke to us, confirmed there were no restrictions on when they could visit. They said they felt welcomed by the staff team who they described as “friendly, and caring”. They said they were kept informed of their relative’s well being and thought the ‘staff worked very hard’. We joined the residents for their lunchtime meal, and the atmosphere was relaxed. Residents told us that they have “lots of choices”, and this was evident from the variety of the meals that were provided. A notice was displayed to state that the home was awarded 4 fours stars following an Environment health inspection, which means good standards, are maintained. There was a copy of the minutes taken from a residents meeting that was held to review the menus and obtain feedback from residents about the food. Following this meeting certain meals were amended and replaced by the options put forward by the residents. The feedback from the surveys indicated that residents did like the food provided, and comments were made about how it can be improved and these included: “the mash potato has no taste to it”, “I would like more kippers to be provided” Southlands DS0000035734.V362915.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): National Minimum Standards 16, and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to express their concerns and have access to effective complaints procedures. They are safeguarded from harm by the procedures and training provided to staff. EVIDENCE: In the self-assessment that we received they said policies and procedures are in place to inform residents on how to make a complaint and to keep them safe from harm. They said they had received 6 complaints since the last inspection, and all but one had been responded to. The complaints records were examined and all of the issues raised had been dealt with in accordance with the procedures in place. Residents who spoke to us and feedback from the surveys supported that they knew how to complain and one comment made included, “ I would speak to a member of staff or one of the managers”. The complaints procedure was displayed in several areas. Visitors spoken to said they would raise any issues or practices that they felt “was affecting their relatives well being”. The staff members that were spoken to had a good understanding of what action to take if they witnessed a potential abusive situation. They confirmed they had undertaken refresher training, but there was no records in place to support this as all training information is now stored electronically and managed by the training section. Information provided in the self assessments supported that staff had received the required training. There have been no Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 16 notifications since the last inspection, and residents spoken to said they felt safe living in this home. Southlands DS0000035734.V362915.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): National Minimum Standards 19, 24, and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy living in a homely, and safe building that meets their needs and assists them to be independent. EVIDENCE: In the self-assessment that we received they said the grounds were safe and well maintained. Systems are in place to control the spread of infection, and odours. A programme of renewal is in place, and equipment is available to encourage independence. Residents who were spoken to said they liked the communal areas and in particular their bedrooms which they had personalised with their belongings. There are several areas, which residents can make use of and small clusters of residents were observed to be using different areas. Residents liked certain lounge areas and said, “they have character as they have all of the old features”. Residents said they have access to various aids and equipment in Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 18 order to assist them in their mobility and to get around the home. The feedback from the surveys was also positive about the building and they said it meets there needs. Residents commented on how much they liked the garden and many comments were made by individuals about how much they were looking forward to using it in the warmer weather. The public are able to access the garden area and some use it to access the main road, this means that the garden area is not secure and could have potential implications for residents. It was reported that wander guard has been visited to all external doors as a measure to alert staff if any residents leave the building. This is also a form of restraint as it affects resident’s freedom of movement. Information was provided about this to enable the current policy and procedures to be reviewed in light of this new guidance. Southlands DS0000035734.V362915.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): National Minimum Standards 27, 28, 29, and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team are trained, skilled and recruited to safeguard residents from harm. However the staffing levels have the potential to affect residents well being. EVIDENCE: In the self-assessment that we received they said they have sufficient number of staff with suitable skills and experience. There is a good skill mix and staff training needs are met. There are 2 members of staff on duty on each shift, supported in their role by a deputy manager. The staff have to support residents with their personal care needs, and also undertake laundry tasks. Residents told us that generally there are sufficient staff on duty but at times they are “very rushed and busy”. Residents said their needs are generally met and staff provided a good standard of care and support, comments made include: “they are marvellous and do a grand job”, “They work very hard, and I try not to bother them much”, they are excellent and brighten our day”. Relatives spoken with said that usually sufficient staff were on duty and they described the staff as being “caring, and kind”. The feedback provided by the staff from the discussions and surveys supported that generally sufficient levels were maintained, however comments were made that this depends upon Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 20 the dependency needs of the residents and at peak times an additional member of staff would be beneficial. Some of the residents have complex support needs and often this may require the assistance of two staff members. In these cases this means that no staff are available to support the remaining residents. Observations supported that residents with high dependency needs had little interaction with staff members during the morning and afternoon periods as they were undertaking essential duties, and supporting other residents. Feedback from the resident’s surveys indicated that 6 individuals felt that there was “always”, enough staff available when they needed them and 1 survey said that “usually”. The staff surveys indicated that “usually” there is enough staff to meet resident’s needs. Staff comments identified that at times they are rushing around and it would be beneficial to the residents if more staff were on duty at peak times so that residents are not “rushed”. Not all of the staff that completed the surveys felt that they had all of the required training to meet resident’s needs in particular around dementia and learning disabilities. They said they have received some training but this was on a basic level and they would benefit more in-depth training in these areas. Information concerning the staff members training records and recruitment information is now recorded centrally. The self-assessment indicated that all of the required checks have been undertaken and staff have completed the mandatory training. Southlands DS0000035734.V362915.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): National Minimum Standards 31, 33, 35, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is managed to promote and protect the health and safety of residents and staff and provide a safe environment. EVIDENCE: In the self-assessment that we received they said that the management team are qualified and experienced to manage the service effectively. They said the health and safety of residents and staff are promoted and protected. Quality assurance and quality monitoring systems are in place; and the home is managed to create an open, positive and inclusive atmosphere. The self –assessment contained clear relevant information to support how the home is managed to meet the needs of the residents who use this service. Information provided also identified that systems are in place to monitor the Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 22 standards and development of the service. It was reported that the staffing levels are monitored by the management team to ensure resident’s needs are met. Staff residents, and relatives spoken to said that the management team were experienced, supportive and approachable. Residents said they are consulted about aspects of the service through the provision of meetings, questionnaires and individual discussions. A report was seen of the findings from the recent quality assurance survey that was completed and this is displayed in the home for residents to see the outcome. The feedback from the resident’s surveys indicated that they felt the management team were approachable and supportive. Some of the comments in the staff surveys indicated that the communication between staff and management could be improved, and some staff indicated that they did not feel listened to by the management team, and at times were treated unfairly and id not always feel supported. Residents said they are able manage their finances if they wish, but many said they have given their consent for the management team to do this. Residents said they were happy with the systems in place, and confirmed they are encouraged to sign their transactions and receive a receipt. Southlands DS0000035734.V362915.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 3 3 3 x 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 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 3 X 3 X X 3 Southlands DS0000035734.V362915.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 OP7 Regulation 15 (1) Requirement Timescale for action 01/08/08 2 OP9 13 (2) 3. OP27 18 (1a) 4. OP30 18 (c) (i) In accordance with the new guidance the care plans must be completed in more detail so that they are person centred and reflect how the person would like their support to be provided. They must also include reference to the individual’s ability to make decisions under the requirements of the mental capacity Act. The storage for controlled drugs 01/10/08 must comply with the royal pharmaceutical requirements. This is to ensure medication is stored in accordance with the law. The deployment of staff must be 01/07/08 monitored and sufficient staff must be on duty to meet resident’s needs. All of the staff must attend 01/09/08 mental capacity training to ensure they work in accordance with this new legislation and promote individuals rights to make decisions about their lives. Southlands DS0000035734.V362915.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. Refer to Standard OP1 Good Practice Recommendations The Statement of purpose and Service user guide should be updated to reflect the changes to the inspection schedule, and to ensure all information is still valid. The wander guard system should also be included in this document. The admission records should be reviewed to incorporate the following areas of diversity: race, gender identity, disability, sexual orientation, age, religion and belief. These areas should be completed for each resident. Staff should have more in-depth training in relation to Dementia, mental health, and learning disabilities to enable them to gain the skills and knowledge to support residents with these support needs. A policy should be developed about the use of the wander guard system that has been fitted to all external doors. 2. OP2 3. OP30 4. OP33 Southlands DS0000035734.V362915.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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