Care Home: Southwood House

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What the care home does well Some of the areas that the service does well include: Management and staff make sure that people are made aware of their rights while living at the home. There is a very clear vision on how people have the right to privacy, dignity and respect and a contract is made with each person who decides to move into the home and this includes giving an explanation on how staff will treat them. An example of this was a staff member was observed asking a person if it was convenient to clean their flat, the person said no as they wished to speak to the inspector first. Then an agreement was made between them as to what time it would be appropriate for the member of staff to return. This showed that the person was treated in a considerate manner, and enabled to maintain an element of control in their own lives. Staff are also good at seeking the views of people, they make sure that there are opportunities for people to have their say in how the home is run. Although not everyone living at the home wishes to participate, for example to be part of a residents committee people do feel that they are listened to and the staff do act upon their views in most instances. What has improved since the last inspection? When we last inspected this home, we did not make any requirements. This would be when the manager and staff would have to change something to improve the standard of care. What the care home could do better: There are several areas that the owners and management needs to look at to make things better for the people living there. Some examples are as follows. Staff need to receive training in areas that will help them better understand the specific needs of the people living at the home. Although staff have undertaken training in other areas for example, health and safety, it would help to improve the standards of care if they could attend training about cerebral palsy, hydrocephalous and quadriplegia alongside the other specific needs of people living at the home. Some of the carpeting in the home needs to be replaced or to have a deep clean, including the room used as the television lounge. This is because they have a lot of stains and look worn in some places. One of the toilets had a very strong odour of damp. This does not provide a pleasant environment for the people to live in.People spoke of the recent changes to the menu. They feel that although there had been an increase in the choice available, the quality has declined. One person said, "I had quiche last week and they had actually put gravy over it, who has gravy on quiche?" A balanced diet using a range of ingredients must be available to people and served in a way that individual tastes are met. CARE HOME ADULTS 18-65 Southwood House Southwood House 44 - 45 Doddington Road Wellingborough Northamptonshire NN8 2JH Lead Inspector Katrina Derbyshire Unannounced Inspection 30th May 2008 10:10 Southwood House DS0000067510.V365545.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 Southwood House DS0000067510.V365545.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. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southwood House Address Southwood House 44 - 45 Doddington Road Wellingborough Northamptonshire NN8 2JH 01933 276473 01933 226969 patricia.garley@sanctuary-housing.co.uk www.sanctuary-care.co.uk Sanctuary Care Ltd 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) Mrs Patricia Ann Garley Care Home 15 Category(ies) of Physical disability (15) registration, with number of places Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2006 Brief Description of the Service: Sanctuary Care bought Southwood House in April 2006 from Ashley Homes. The home provides accommodation in single and shared flats in which people have access to a lounge, kitchen, bedroom and adapted bathrooms. The building also provides communal areas and a central kitchen that prepares a mid-day meal. The home is situated near to the town centre of Wellingborough with easy access to local facilities. Fees are calculated to meet the individual needs of each person and vary depending on complexity. The current fees are from £769.70 and include a set amount of personal care hours, with additional personal care hours when needed, charged at £15.00 per hour. The manager gave this information on the day of the inspection. In addition extra charges are made for services such as hairdressing, chiropody and newspapers. Any charges incurred for private dentistry or ophthalmic services are the responsibility of the individual. Southwood House DS0000067510.V365545.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. An Annual Service Review was undertaken about this home on 19th March 2008; we used written information that had been supplied by the home and feedback from people living there to help us when we did this. We changed our view about the service when we did this, so we decided to carryout a key inspection earlier than we had originally planned to. The Commission for Social Care Inspection also received an anonymous concern about the service in March 2008, this related to staffing levels and food. This unannounced visit took place on 30th May 2008. During the visit the communal areas of the home were seen alongside some of the individual accommodation. The inspector spent time with some of the people who live at the home in their rooms and the communal area. Management and staffing records were examined. The care of three people was looked at in detail. Tracking people’s care is the methodology we use to assess whether people who use social care services are receiving good quality care that meets their individual needs. Through discussion, surveys, observation and reading records, we track the experiences of a sample of people who use a service. Evidence used and judgements made within the main body of the report include information from this visit, feedback from people who live at the home and the management’s submission of documentation. Observations of care practice and communication between the people living at the home and staff was also made at the inspection. The focus of this inspection was to look at the key standards, to look into the concerns that had been raised. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There are several areas that the owners and management needs to look at to make things better for the people living there. Some examples are as follows. Staff need to receive training in areas that will help them better understand the specific needs of the people living at the home. Although staff have undertaken training in other areas for example, health and safety, it would help to improve the standards of care if they could attend training about cerebral palsy, hydrocephalous and quadriplegia alongside the other specific needs of people living at the home. Some of the carpeting in the home needs to be replaced or to have a deep clean, including the room used as the television lounge. This is because they have a lot of stains and look worn in some places. One of the toilets had a very strong odour of damp. This does not provide a pleasant environment for the people to live in. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 7 People spoke of the recent changes to the menu. They feel that although there had been an increase in the choice available, the quality has declined. One person said, “I had quiche last week and they had actually put gravy over it, who has gravy on quiche?” A balanced diet using a range of ingredients must be available to people and served in a way that individual tastes are met. 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. Southwood House DS0000067510.V365545.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 Southwood House DS0000067510.V365545.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): 1&2 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Systems in place to assess the needs of prospective people and information about the home are good, ensuring the home has sufficient information to ascertain that they are able to meet the person’s needs. EVIDENCE: On examination it was shown that changes had been made to the Statement of Purpose and the Service Users Guide; this was in response to changes that had taken place in the home. Elements listed in Standard 1 of the National Minimum Standards and Requirement 5 of the Care Homes Regulation had been included. As previously assessed some of the information included had been produced using pictures to make it user friendly for some of the people living at the home. On speaking with a person who had recently moved into the home they confirmed that the information that they had received was sufficient, they said” me and my family had lots of stuff and yeah I think it did help because it’s a hard time when you move, so yeah it helped”. The homes policy regarding the admission of people showed that a planned approach to all admissions to the home should be undertaken. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 10 Two people through discussion confirmed that they had been involved in the decision to move into the home and had been given the opportunity to visit prior to making any decisions. One person said, “ they asked me lots of questions about me, what I liked”. Combined assessments by the home and placing authority are in place for more recent admissions to the home, these are comprehensive and make clear the needs that the home would need to meet. In addition one person through changing needs was being helped by management and staff to move on to alternative accommodation. Social and cultural needs are assessed alongside the physical and social needs of the person, documents were seen to support this as did staff through interview. The care plans in place were directly linked to the assessment of needs. Southwood House DS0000067510.V365545.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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Opportunities for people to make decisions about their lives are good and make people feel in control of their own lives, however inconsistencies in care planning are not sufficient to ensure all people receive continuity of care. EVIDENCE: Through examination of care plans kept within the individual folders for each person it showed that there were documents in place, which briefly indicated the needs of the person. In most entries there was sufficient direction to staff to state how the person should be supported. However one person had moved into the home recently, and many of the documents within their folder had no entries. These included physical dependency assessment, nutritional risk assessment and no clear care plan. Management advised that due to restructuring of the staff team, this must have been overlooked at this time however a requirement has been made. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 12 As reported at the previous key inspection there again was evidence that people made some choices; menus were one example and the purchase of a new flat screen television another. Where people were unable to communicate their choices, or not interested in the activity, the staff assist by choosing on their behalf, using their knowledge of the person and their likes and dislikes. It was also observed at this visit that one of the people living at the home participated in the organisation of the lunchtime meal, they were seen setting the table and working with the staff member who was preparing the meal. People living at the home through discussion stated that they were able to make many choices, one person said,” I choose to stay in my flat, its what I want to do, what I do is up to me not the staff”. Risk assessments were in place within the individual care files examined. Risks that had been assessed included diet, moving and handling and risks when leaving the home. Staff through interviewing confirmed that they had received training in this area; in addition they demonstrated a good level of understanding in the possible risks to people living at the home. One member of staff said, “we have to read the risk assessments especially for moving and handling, its stops us and residents getting hurt”. Southwood House DS0000067510.V365545.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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home do have some access to local facilities so benefit from being part of the community and are supported in maintaining personal relationships. Although delivery and quality of food needs to improve to meet every ones individual tastes. EVIDENCE: People living at the home had contact with their families and some went to their home for regular weekend visits. All people spoken with stated that they never had restrictions for receiving visitors or in turn visiting friends or family members themselves. At the time of the inspection some of the people living at the home had an advocate acting on their behalf, documentary evidence to show this was seen. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 14 Examination of care documents and through discussion with staff it was confirmed that efforts were made to access courses and other development opportunities for people at the home. Letters were seen to show that efforts had been made for one person to start attending a course at a local college. Another person seen had a computer with internet access available to them within their own flat. Staff and records also showed that there were activities available in the home including a film club. Three people spoken with however did indicate that there was not enough opportunities to go out, they felt that this was because there were not enough staff on duty. These reflected the comments received by the Commission for Social Care Inspection earlier in the year through returned cards. Menus were in place to show that a mixture of protein, carbohydrates, dairy and fruit and vegetables were offered throughout the week. Staff were observed talking with the people who live at the home, providing guidance and support throughout their meal. Comments on the standard of food were mixed, some people felt that the food was “very nice” others felt that “not very good sometimes”. One person described having been given quiche the previous week and gravy had been poured over it, they found this “unacceptable”. One staff member also commented that although the amount of choices at mealtimes had increased, they felt that the standard had deteriorated they said, “its cheaper food, they changed the supplier and it just doesn’t taste the same”. The Borough council had inspected the kitchen in March 2007 and had awarded the home 3 stars, the certificate of this was on display in the home. Minor food safety matters raised at that time had been addressed by the staff at the home. Southwood House DS0000067510.V365545.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The systems in place for the ordering, administration and storage of the medication are good so people receive their prescribed medication when needed. Staff are good at supporting people to access health care support so that their health needs are met. EVIDENCE: Care records examined contained documents from a variety of medical specialists. These documents for example hospital letters, showed that people received regular support from Doctors and Nurses. Staff confirmed that they assisted people to attend hospital appointments and the outcome of any medical intervention and subsequent guidance was recorded. Feedback through returned comment cards to the Commission for Social Care Inspection showed that people felt they received the medical that they needed. The storage, receipt and administration of medication was examined. The medication administration sheets were noted to be satisfactory. The storage of medicines were seen to be in a locked facility. Records were seen to show Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 16 returns of unused medication. Staff confirmed that they did receive regular updates in the administration of medicines and observations were made of medication and noted to be appropriate and follow safe practice guidelines. Through observation and confirmation by returned comment cards it was confirmed that clothes and hairstyle reflected peoples individual personalities. Guidance and support regarding personal hygiene was offered and the level offered by staff was reflected in the care plans examined on this inspection. However several comment cards returned to the Commission for Social Care Inspection from both people living at the home and staff felt that staffing had been reduced in the home. This was also reflected in people’s comments at this inspection, although the manager disputed this. The effect people felt was that they now needed to wait longer for assistance, or that staff no longer had the same amount of time to spend with them. This area will be addressed within the staffing section. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 17 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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The complaints procedure in the home is satisfactory and results in people being listened to and their concerns acted upon. EVIDENCE: The homes policy on the safeguarding of adults included the referral guidance in accordance with the local Safeguarding of Vulnerable Adults policy. It includes varying types of abuse and examples including, physical, financial and sexual abuse. The home uses the local protection of vulnerable adults policy and this contains guidance to staff on how to report any allegation of abuse. Staff also confirmed that they had received training in this area. In addition the home also had in place a very clear complaints procedure. Reference is also made within the homes statement of purpose on how anyone may complain about the services in the home. One staff member said “ its not a bad thing getting a complaint, it just means we sometimes have to change and then things get better”. The policy was noted to meet with this standard and did inform the reader how they would be responded to and within what timescale. Documents of complaints received were examined and these were kept alongside the response to the complainant. The number demonstrated that the people living at the home used the complaints procedure often, and on speaking to them they confirmed that they felt comfortable in raising any concerns that they had. At times complaints had been upheld and changes had Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 18 then been made to try and improve standards although the manager acknowledged that at times this had not always happened. The Commission for Social Care Inspection had been contacted and given information on concerns about staffing levels and general deterioration in standards, this information was used as part of this inspection process. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 19 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 & 30 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements are needed to some of the décor and fittings to create a homely environment throughout the home for people to live in. EVIDENCE: The location was just on the outskirts of the town centre with all its amenities and the layout of the home provided space for people to move around the home freely. Furnishings and fittings were domestic and of a sufficient standard, however carpeting in some areas of the home including the television lounge was very stained. Several walls were noted to be scuffed and marked including along the main corridor. The communal areas in the home were clean and tidy and people’s individual accommodation contained personal items, which reflected their individual personalities. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 20 Within one toilet located at near the front entrance there was a strong smell of damp, staff confirmed that they had also detected this but were unsure of the cause. The grounds were well maintained providing grass areas and places to sit out for people who live at the home. The communal areas of the home were clean and free from offensive odours at the time of inspection as were individual flats of people’s seen by the inspector. Policies were in place regarding infection control. Hand washing facilities were sited in varying areas. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 21 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, 33, 34 & 35 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The number and/or deployment of staff and training is not sufficient for all people to feel that they receive the support that they require. EVIDENCE: Information received by the Commission for Social Care Inspection raised concerns on the number of staff on duty being insufficient. In addition comment cards submitted to the Commission for Social Care Inspection by both staff and people living at the home felt that there had been a reduction in staff. Through speaking with people at this visit, many supported this view. However on discussion with the manager, she advised that there had been no reduction. Work needs to be undertaken to review the deployment of staff so that people receive the support that they need. As previously outlined in this report people feel that opportunities to go out are limited by this, as is waiting for assistance when they require help with their personal care. A review of the number and deployment of staff must be carried out. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 22 Training records showed that staff had undertaken training in the statutory areas including fire safety and medication. However many staff had not undertaken training in the specific needs of the people who live at the home. Through discussion with staff this was confirmed and a requirement has been made. The homes recruitment policy and procedures as previously assessed are clear and comprehensive, documents submitted by the home to the Commission for Social Care Inspection show that no change has taken place to these policies. References are taken prior to staffs’ commencement and the relevant Criminal Records Bureau check is also carried out and evidence of this having been undertaken was seen. Certificates of qualifications are present within staff files. A manager, senior staff, administrator, support workers, catering and housekeeping staff are employed at the home. Several of the people living at the home made positive comments on the skills of the staff team, one person said “they always seem to know what they are doing”. Other people felt that not all staff had the same level of competency and they felt that they could not always meet their needs, one person said, “it worries me that it’s the same ones that get it wrong all the time I think they need more training or something”. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 23 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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Health and safety systems are sufficent to reduce the risks associated with this area for the people living at the home. EVIDENCE: Staff and training records showed that heath and safety training had taken place including fire safety and food hygiene. The most recent inspection by the Fire Service showed that the home met the required standards. In addition the most recent inspection by environmental health had awarded the home 3 stars. As assessed previously the policy on health and safety was noted to be clear in its guidance to staff and comprehensive. Records were seen that evidenced that required safety checks had been carried out relating to fire, gas and electrical equipment. Approved contractors had undertaken servicing of Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 24 equipment and site visit paperwork to evidence that theses had been carried out were seen. Regular checks relating to water temperature for example had been recorded on charts. Stocks of aprons and gloves were noted to be available for staff to use, in relation to infection control although staff did comment that the quality of these had reduced as the supplier had changed. No staff at this visit were seen to use these items inappropriately, their use was only seen to be made in the area where they were needed, for example at the lunchtime meal to reduce the risk of cross infection. The home carries out consultation with the people in different forms. Staff confirmed that on a day-to-day basis people are asked for their views and these decisions are then integrated into the care plans, examples included a certain type of diet. More formal methods such as residents meetings had taken place in the past and minutes were available for inspection, but the home recognised that the views of all residents could not be sought in this way and many did not wish to be involved. Everyone spoken with except one reported that they found the manager to be a very good listener and all felt that she was very easy to talk to and that they trusted her. Staff said that they found the manager to be both organised and approachable. People said that the manager was nice and their comments suggested that they felt confident in her abilities. The manager has the National Vocational Qualification in Management Level 4/Registered Managers Award. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement A plan of care must be in place to ensure all risks, measures and guidance is clear to staff to fully meet the individual needs of the people living at the home and ensure consistency of care. The provision of meals must be sufficient in quality and served in a manner that meets the individual tastes and preferences of people living in the home. Replacement or sufficient cleaning of stained carpets must take place to assist in creating a homely environment for people to live. Action must be taken to make good the areas of paintwork in the home that are scuffed and marked to assist in creating a homely environment for people to live in. The number of staff and their deployment within the home must be sufficient to meet the individual needs of the people living in the home in a timely manner. All staff must be trained for the specific conditions and needs of DS0000067510.V365545.R01.S.doc Timescale for action 31/08/08 2. YA17 12(4)(a) 16(2)(i) 31/08/08 3. YA24 13 & 23 30/09/08 4. YA24 13 & 23 30/09/08 5. YA33 12 & 18 31/08/08 6. YA35 18(1) 31/10/08 Southwood House Version 5.2 Page 27 people who live at the home to improve standards and ensure consistency of care. 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 YA24 Good Practice Recommendations The cause of the smell of damp should be sought and then action taken to remedy this. Southwood House DS0000067510.V365545.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Southwood House DS0000067510.V365545.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. 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