Care Home: Southlea Residential Care Home

What the care home does well Southlea is a small home providing comfortable, homely accommodation for people who live there. The owners ensure that the property is well maintained with redecoration and refurbishment carried out when necessary. Occupancy levels have increased with no vacancies at this time. This has provided people with stability. Two people spoken to during the visit were very happy, looked well and were welcoming. Communication between the team is good with both formal and informal opportunities for staff to discuss things with the manager. This ensures that everyone is kept informed and the day to day running of the home is good. What has improved since the last inspection? Action identified at our previous inspection had been addressed. Suitable arrangements are in place, which enabled relevant assessment information to be gathered prior to a new person moving into the home. This included contact with the funding authority as well as the person visiting the home prior to a decision being made ensuring people coming to live at the home can be supported in a way, which fully meets their needs. Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Care plans had been developed and reviewed providing up to date information about people and there specific needs. Where changes had occurred this too had been documented ensuring staff were fully aware of the persons needs and if there were changes in support to be provided. Risk assessments were in place covering areas of concern. These were specific to the individual needs of people and detailed the intervention required to minimize potential risk ensuring people were kept safe and not placed at risk of harm. Medication records had improved. Items are booked in when received from the supplying pharmacist and completed on administration. Staff have also received training ensuring they are competent in supporting people safely. More opportunities for social and leisure activities have been introduced providing people with variety in their daily routines and the ability to develop new life skills. A comprehensive induction is now undertaken by new staff ensuring they are aware of the policies and procedures within the home and what is expected of them whilst carrying out their duties. Staff supervision has been introduced and information is recorded. This shows that staff are receiving the support and direction they need to carry out their duties. The manager had ensured that new staff did not commence their employment until a satisfactory criminal record check and references had been received ensuring people were not placed at risk. What the care home could do better: Key inspection report CARE HOME ADULTS 18-65 Southlea Residential Care Home 23a Cross Lane Radcliffe Manchester M26 2QZ Lead Inspector Lucy Burgess Key Unannounced Inspection 18th August 2009 10:15a Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlea Residential Care Home Address 23a Cross Lane Radcliffe Manchester M26 2QZ 0161 280 9841 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) southleacarehome@supanet.com Southlea Limited Manager post vacant Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should at all times employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection 18th August 2008 Date of last inspection Brief Description of the Service: Southlea is a privately owned care home registered to provide care and support for up to 5 people with mental health needs. The fee charged by the service is £373.00 per week. The home is a large Victorian property situated on a main road in the Radcliffe area of Bury. It is close to several amenities and has good transport links. The metro-link is close by and Bury is a 5-minute bus/tram ride away. Accommodation is provided in single rooms with en-suite facilities. The home provides practical and emotional support 24 hours a day from staff with training in, and knowledge of, mental health needs. Staff work closely with other professionals to ensure that the needs of service users are met and reviewed. Southlea Residential Care Home DS0000061330.V377244.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 stars. This means the people who use this service experience good quality outcomes. This was a key inspection, which included a site visit and took place over one day for a period of 5½ hours. The service did not know that the inspector was going to visit. During the visit we spent time looking at care records as well as information about the staff and health and safety. We also looked at what progress had been made since we last visited the home in August 2008. As part of the inspection process the provider was asked to complete a selfassessment survey information document (Annual Quality Assurance Assessment). This was being completed by the manager and would be forwarded to us as agreed. Time was spent speaking with people living at the home and staff. Their comments have been added to the report. Discussion and feedback was held with the manager during the visit. What the service does well: What has improved since the last inspection? Action identified at our previous inspection had been addressed. Suitable arrangements are in place, which enabled relevant assessment information to be gathered prior to a new person moving into the home. This included contact with the funding authority as well as the person visiting the home prior to a decision being made ensuring people coming to live at the home can be supported in a way, which fully meets their needs. Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 6 Care plans had been developed and reviewed providing up to date information about people and there specific needs. Where changes had occurred this too had been documented ensuring staff were fully aware of the persons needs and if there were changes in support to be provided. Risk assessments were in place covering areas of concern. These were specific to the individual needs of people and detailed the intervention required to minimize potential risk ensuring people were kept safe and not placed at risk of harm. Medication records had improved. Items are booked in when received from the supplying pharmacist and completed on administration. Staff have also received training ensuring they are competent in supporting people safely. More opportunities for social and leisure activities have been introduced providing people with variety in their daily routines and the ability to develop new life skills. A comprehensive induction is now undertaken by new staff ensuring they are aware of the policies and procedures within the home and what is expected of them whilst carrying out their duties. Staff supervision has been introduced and information is recorded. This shows that staff are receiving the support and direction they need to carry out their duties. The manager had ensured that new staff did not commence their employment until a satisfactory criminal record check and references had been received ensuring people were not placed at risk. What they could do better: The home has been without a registered manager for some considerable time. This must be addressed without further delay. All staff should receive training in relation to the local authorities safeguarding adults training so that they are clear of the procedure to follow should an allegation be made. Confirmation of the recent POVA referral made by the provider should be forwarded to us. A plan of training for the forthcoming year should be developed and include areas in relation to mental health awareness so that the team, particularly those with no previous experience, are able to develop their knowledge in the specific needs of people they support. Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 7 The manager is asked to verify references received for new employees making sure that information provided is accurate ensuring people working at the home are suitable and fit to do so. Water temperatures were recorded as being high, these need to be regulated to around 43°C for the safety and comfort of people. Action identified on the fire safety certificate in relation to detectors must be addressed ensuring people are not placed at risk of harm or injury. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Southlea Residential Care Home DS0000061330.V377244.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 Southlea Residential Care Home DS0000061330.V377244.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The assessment process enables people to be involved in making the decision about where they want to live as well as sharing information about their needs and how they wish to be supported. EVIDENCE: A new person moved into the home in February 2009. Records showed that a referral had been received in January 2009 from the funding authority. Information had been provided by the social worker, which included Care Programme Plan (CPA) and STAR risk screening tool. A pre-admission assessment had also been completed by the manager of the home with further information being provided by the person’s family. The manager explained that opportunities had been made available for the person to visit the home for a meal and overnight stay so that they could familiarise themselves with the home and meet the people who already lived there. This enabled them to make a decision about whether they wanted to move into the home. Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 10 Whilst some of the information from the local authority was limited in relation to the person’s mental health background, this was said to be due to the person having little involvement from services until recent years. Visits had been made by the persons CPN once they had moved in to ensure that they had settled and review the suitability of the placement. Southlea Residential Care Home DS0000061330.V377244.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual plans reflect the current and changing needs of people and how they are to be supported ensuring their needs are met. EVIDENCE: The care file was also looked for the new person to see how the person’s assessment information had been developed into a plan. Information gathered at the assessment had been transferred to the care plan. Information was orderly and included personal information, assessment, care plan, risk assessment, diary notes, professional appointment, CPA review minutes, personal care charts, meal records and weight records. Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 12 The care plan examined showed what the persons is able to do and what they need support with. Plans had been signed by the person. Information included those areas, which had previously given cause for concern and required monitoring due to the potential risks. Risk assessments clearly showed the potential risks and the support required to minimise this. There was clear evidence of involvement from relevant health and social care professional ensuring this person was appropriately supported. Records showed that where there had been changes information had been updated to reflect this. Information had been signed by the person and the manager to evidence they were aware of what had been recorded on the plan. Each person has an identified key worker. The manager explained that 1-2-1 sessions have been introduced, which provides opportunities for each person and staff to spend time talking about the support they receive, if they have any issues or concerns and anything they would like to do. The manager said that these had been positive allowing people quality time to sit and talk with each other. As the team is small people have regular informal contact with staff on a daily basis. We observed people having an open relaxed rapport with each other and the staff and clearly enjoyed people’s company. It was also obvious that staff have a very good insight into the needs and behaviours of people and how they wish to be supported. Southlea Residential Care Home DS0000061330.V377244.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): This is what people staying in this care home experience: 11, 12, 13, 14, 15, 16 and 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Routines within the home are flexible and enable people to follow a lifestyle of their choosing with opportunities provided both in and away from the home. EVIDENCE: Little has changed over the last year with regards to peoples daily routines. Each follow a lifestyle of their choosing and are able to rise and retire and come and go as they wish. One of the new members of the team has been actively involved in holding resident meetings to discuss activities and social events providing people with further opportunities both in and away from the home. Some of the discussion has included people accessing college courses, however at this time people Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 14 have expressed a wish not to. Other discussion has included accessing local leisure centres and day trips. Meetings appear to have been positive resulting in some people taking part in additional activities. Activities have included attending the Civic Centre, pub lunches, garden centres and shopping trips. Alternatively people enjoy spending time relaxing at home watching TV, reading the paper, playing dominoes, scrabble or helping staff with tasks within the home such as washing up, preparing meals and cleaning etc. They have also recently taken part in a car boot sale. The manager said that any money raised would be used to fund activities. The owners have recently purchased 2 new televisions for the communal rooms. Some people are very active and go out independently. One person spends a lot of time with a friend visiting places such as Chester and York. Another regularly attends the gym and visits family several times a week. Contact with family is encouraged and support is provided where necessary. Visitors are also welcome at the home. Two people spoken to during the visit were very happy, looked well and were welcoming. As previously identified people receive their mail unopened, however support is offered should this be needed or a response is required. People also have a front door key and keys for their bedrooms, however it is at their discretion whether they are used. Meal times are relaxed with no set times. This varies depending on individual routines and plans. Each person is encouraged to make their own choices and where able to prepare snacks and drinks. Where necessary support is provided and usually the main evening meal would be made by staff. Records are completed with regards to what meals people have had as well as regular weight monitoring. People are encouraged to follow a healthy diet. Where issues are identified a referral to the dietician would be made for further advice and support. Records in relation to Safer Food Better Business continue to be completed by staff in line with good practice guidance. Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported in way which ensures their health and well being is maintained. EVIDENCE: Support varies depending on the needs and wishes of people. Showering facilities are provided in each of the bedrooms. Where personal care is required this is detailed in the persons care plan. In the main people are offered prompts and encouragement to address their own needs. The health and well-being of people continues to be monitored. Records are held in relation to personal care, weight and health appointments. People have access to a variety of health care professionals including GP, consultants, chiropodist, dentist, occupational therapist, CPN and social workers. The manager explained that a referral was being made to the OT for one person to assess their skills and abilities in relation to independent living skills. Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 16 Mental health reviews are undertaken depending on the care plan in place. Support and advice is provided from the mental health team when needed so that people are able to maintain a good quality of health. There was clear evidence to show that action had been taken to address some of the concerns about the new resident, particularly around their diet and weight loss. A referral had been made to the dietician and an assessment undertaken. Staff had been providing a varied diet encouraging the person to take regular meals and drinks. Food and fluid charts had been completed and regular weight records had been made. The dietician had advised of a target weight for the person to reach. This had been achieved. This person had also been supported to access a service from the optician. A domiciliary visit had taken place so that their eyes could be tested and new glasses had been provided. Medication is held securely in the staff office in a wall mounted cupboard. Two of the residents self medicate. Items are held in their rooms and checks are carried out by staff ensuring this is safe and people are complying with their medication. Information was seen on the file for the new person to show that a support plan had been put in place on their admission, which enabled them to continue self medicating however enabled staff to monitor if this was safe. Medication administration records (MARs) are maintained for all items received and retuned to the supplying pharmacy. Individual records have an up to date photograph of the person with their date of birth and doctors details. Records are signed following administration of medication and identify when items are needed, if they are PRN (when required medication) or if they are held separately and the number in the blisters. A homely remedies document has also been signed by the individual doctors agreeing alternative medication that may be administered by the staff at the home. Stocks appeared to be well managed. Medication training at level 2 has been provided for staff. This has been through distance learning with Trafford College. It was noted that one of the new members of staff has yet to undertake the training. This was discussed with the manager as staff work alone on each shift. The manager explained that she had carried out some in-house training in relation to the system used and that the staff member is shadowed on each occasion to ensure that medication administration is safe. The manager and an experienced carer had recently completed training in ‘medication for managers’, which included how to assess staff competence in this area. The manager is asked to complete an assessment of the new member of staff. She was also advised of training available through the Partnership. The manager contacted the group during our visit and made arrangements for this member of staff to attend training at the beginning of September. Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 17 Two people are in receipt of medication, which needs to be closely monitored. Regular blood checks are carried out to ensure that they receive the correct level of medication. Records are amended accordingly so that staff know what is needed ensuring people are kept safe. Southlea Residential Care Home DS0000061330.V377244.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place ensuring people are listened to. Training for staff needs to be arranged so that they are clear about their responsibilities should an issue arise. EVIDENCE: Information is available within the home in relation to complaints and protection. The manager advised us that there have been no complaints or protection issues since our last visit. No concerns have been raised directly with us. The home is a member of Training Partnership Group. Staff training in relation to safeguarding has previously been undertaken however this has not been for some time. So that all staff, including new members of the team, are aware of the current Local Authority policy and procedure, further training should be provided. The manager explained that they were waiting for dates to be scheduled by the training group so that staff could be nominated to attend. This is an outstanding area. The manager is aware that this must be addressed ensuring staff are aware of the procedure to follow should an allegation be made. Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 19 We also discussed with the manager the arrangements in relation to people’s finances. People are in receipt of their personal allowances. This is provided each week and is generally managed by each person themselves. One person does ask for budgeting support from staff. A record is made of personal allowances being handed out and is signed by both parties. One person is supported by a family member. Southlea Residential Care Home DS0000061330.V377244.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Southlea provides clean, comfortable homely accommodation which is well maintained ensuring people live in a safe environment. EVIDENCE: The home is a small domestic property set in a residential area of Radcliffe. The home is situated on a main road and is easily accessible to local transport and shops and a short distance from the town centre. Accommodation comprises of 5 single bedrooms, one of which is on the ground floor. Each of the bedrooms have en-suite shower facilities. Bedrooms were comfortably furnished and had been personalised with the persons belonging including pictures, ornaments etc. There is a lounge, dining room, which is the designated smoking area and kitchen on the ground floor and an office, sleepSouthlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 21 in area and a separate toilet in the basement for staff. There is also a small rear yard, which people use to sit out during fine weather. The property is well maintained, clean and tidy. Any work or repairs needed are recorded in a maintenance book and addressed by the providers promptly. Following discussions with the people at the home the providers have purchased 2 new televisions for the communal areas. Suitable arrangements are in place with regards to domestic tasks. Generally these are completed by staff and adequate provisions are made available with regards to protective clothing and cleaning products. As previously identified, laundry facilities are sited in an enclosed area in the kitchen and do not cause any concern in relation to cross infection. Southlea Residential Care Home DS0000061330.V377244.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff recruitment, training and development has improved ensuring people working at the home are safe to do so and have the knowledge and skills needed to carry out their duties. EVIDENCE: The staff team comprises of the manager and 5 support staff. Single cover is provided throughout the day and night. Information detailed in the rota showed that there are 3 shifts each day. The manager was asked to amend the rotas so that the full names of staff are recorded and the times worked can be seen. This was done during our visit. The shifts are 8am till 2pm, 2pm till 8pm and a sleep-in night staff from 8pm till 9am. The manager explained that some of her hours are spent providing support. Further recruitment is to be made so that there are additional hours allowing for the manager to carryout additional office tasks as well as allowing some flexibility to release staff for training. Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 23 Since out last visit two new members of staff have joined the team. Recruitment information was examined. Information held included a photograph, application form, references, copies of identification, job description, terms and conditions and a criminal record check. The manager is advised to carry out checks on references ensuring the information received is accurate. A record of this should be made on file. Other documents included the skills for care induction which had been completed by the manager with new staff. There were also supervision records. Periodic team meetings are also held. As the team is very small opportunities to talk with the manager are available during handover. This ensures good communication between the team with information being shared regularly. The manager has completed a training matrix. This showed that some staff had completed training over the last year in health and safety, fire safety, record keeping, infection control and medication level 2. Some staff were awaiting dates for their training. One of the new members of staff had not completed medication training. The manager told us that she was observing administration. The manager was advised about training available. This was arranged during our visit. The manger was advised to develop a training plan covering areas of training needed by staff. This should also include courses in mental health awareness as information on the matrix showed that none of staff had received training in this area. It was noted that a new member of the team had no previous experience in care work. The manager needs to ensure staff have the knowledge and skills needed so that people are supported in a way which fully meets their needs and people are not placed at risk. Further training is provided with regard to NVQ. The manager has already completed levels 2, 3 and 4, one carer has achieved level 2 and 3, a third member of staff has completed level 2 and 2 further staff are currently completing the award. Southlea Residential Care Home DS0000061330.V377244.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst the manager has yet to complete her registration, outcomes for people are good ensuring they receive a quality service which meets their needs. EVIDENCE: The manager has worked at the home since 2007. An application to register with us has been completed however was returned due to information being incomplete. Discussion was held with the manager about what was required. This must be addressed without further delay so this does not compromise the service and people continue to receive a good quality service. The manager Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 25 has been a registered manager during her previous employment. She has previously completed the NVQ level 4 and registered manager’s award. Requirements and good practice recommendations identified during our previous visit had been addressed. Evidence seen has been detailed throughout this report. The owners of the home are actively involved with the service. The manager told us that they visited the home on a weekly basis and any support needed was provided. In relation to quality assurance, the provider has carried out the monthly monitoring visits in line with regulation. Systems are also in place to seek feedback from staff, people living at the home, relatives and health and social care professionals involved with the service. The manager is to send out surveys to interested parties to seek feedback about the service provided. Staff and resident meetings are held, as well as care reviews and staff training and development. We previously identified that in developing the homes annual development plan the manager should consider the feedback received from other parties in relation to how the service can continue to improve and develop. A copy of the report should be provided to those people using the service as well as other stakeholders, including the CQC. A sample of checks were looked at with regards to the annual safety check. Up to date servicing certificates were seen for gas safety, electric circuits, fire systems and small appliances. Action was identified on the fire safety certificate in relation to detectors needing to be replaced. This needs to be addressed ensuring the system is working effectively. Other in-house checks are carried out in relation to fire safety and fridge and freezer temperatures. Water temperature checks are also made, readings showed that temperatures were high. During our previous visit the manager told us that thermostatic valves had been fitted to outlets, these should regulated for the safety and comfort of people. Southlea Residential Care Home DS0000061330.V377244.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 X 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Version 5.2 Page 27 Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation 19 schedule 2 Requirement The manager must verify staff references ensuring the information provided is accurate and people are suitable to work at the home ensuring people are protected. Application must be made by the manager to CQC with regards to becoming the registered manager. This must be done without further delay. Action identified on the fire safety check with regards to detectors must be addressed ensuring peoples safety Timescale for action 30/10/09 2. YA37 Section 11 CSA 30/10/09 3. YA42 23 30/09/09 Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 28 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 YA20 Good Practice Recommendations Competency assessments in relation to the administration of medication should be completed on staff ensuring practice followed is safe. As dates become available the manager must ensure that all staff attend training in Safeguarding Adults so that they know what action to take in the event of an allegation or suspicion of abuse ensuring people are protected. A staff training plan must be developed ensuring staff have the knowledge and skills required to meet the specific needs of people living at the home. An annual business plan should be developed showing how they intend to develop the service whilst considering the views of those living at the home. A copy should be distributed to people using the service as well as other stakeholders including the CQC. Water temperatures should be regulated for the safety and comfort of people at the home. 2. YA23 3. YA35 4. YA39 5. YA42 Southlea Residential Care Home DS0000061330.V377244.R01.S.doc Version 5.2 Page 29 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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