Inspection on 31/05/05 for Sea View Lodge

This inspection was carried out on 31st May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sea View Lodge 04/08/09

Sea View Lodge 18/05/09

Sea View Lodge 19/06/08

Sea View Lodge 26/06/07

Sea View Lodge 22/11/06

Sea View Lodge 23/06/06

Sea View Lodge 02/03/06

Sea View Lodge 14/12/04

Sea View Lodge 30/03/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Sea View Lodge 116 Central Parade Herne Bay Kent CT6 5JN Lead Inspector Kim Rogers Unannounced 31 May 2005 13:00 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 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 Stationary 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. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sea View Lodge Address 116 Central Parade Herne Bay Kent CT6 5JN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01277 375253 Mr S Sheikh Mr S Sheikh Care Home 10 Category(ies) of Learning Disability (10) registration, with number of places Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No Service users should be admitted to the home under 30 years of age. Date of last inspection 14/12/04 Brief Description of the Service: Sea View Lodge is registered to provide personal care and support to ten people from 30 years upwards who have a learning disability. There are currently seven service users living at the home. The home is owned and run by Mr and Mrs Sheik. Mr Sheik is also the registered manager and is in day-today charge of the home. The premises is a three storey terraced house to which an extension has been added at the back. The extension provides two bedrooms for service users, and an office and sun lounge used by the registered providers. All service users have single rooms. One ground floor bedroom has en site facilities. All bedrooms have a wash hand basin. The home has a small garden to the front and rear and is situated opposite the sea front. The home is within easy reach of local shops and amenities. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out by two inspectors, Kim Rogers and Jenny McGookin. There was one care staff at the home with five service users when the inspectors arrived. Two service users were attending a day centre. A second member of staff arrived at 13.30. The manager was not at the home on the day of the visit. The Inspector chatted to service users and both members of staff, looked around the home and looked at some records. Service users told the inspectors about their forthcoming holiday to Blackpool in July. Service users said they are looking forward to their holiday. The home was clean and orderly and suitably fragranced. Service users had just finished their lunch and were relaxing in the lounge. One service user was knitting and another looking at magazines. The atmosphere was relaxed and service users appeared happy. Several inspections have been carried out at this home over recent months. Previous reports can be viewed on the CSCI website. The provider has now met most of the outstanding requirements made at previous inspections. Some requirements remain unmet relating to medication storage, staffing levels, recruitment and induction of new staff. The inspectors were unable to assess the progress towards other outstanding requirements, as care staff were unsure where staff files, induction and training records were. The Provider must ensure all records required by legislation accessible so they are available for inspection at any time. The Commission continue to be concerned about the number of staff at the home. There are three staff.: two care staff and the manager Mr. Sheikh, who also works as a carer on shift. Staff work twelve and six hour shifts. One care staff and the manager cover the sleep-in shifts between them. From the rota on display it was evident that the three staff are working an average of 68 hours a week. There are no bank staff to call on and agency staff are not used. The manager is on call for emergencies, but lives over one hour drive from the home. More staff are needed to ensure a good quality service, continuity of care for service users and to ensure all service users’ needs are fully met and their health and safety is protected. An immediate requirement was made following this visit. Products including bleach and disinfectant were stored in a bucket in a shower cubicle of a bathroom used by some service users. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 6 All products such as these must be stored securely in line with the C.O.S.H.H regulations. The Provider has updated parts of the home since the last inspection and has produced a development plan for the house. Service users lives would be enhanced with further investment to update and improve the environment and furniture and fittings. Some service users have lived at this home for several years. Mr. Sheikh took over the home approximately three years ago. Service Users said: ‘The food is good’ ‘Staff help me’ ‘My bed is comfy’ ‘I like to prepare the vegetables at weekends’ ‘We have nice dinners’ What the service does well: What has improved since the last inspection? What they could do better: Priority must be given to the recruitment of more staff. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 7 The environment could be improved to further enhance service user quality of life. Some furniture and fittings need repairing or replacing, including a broken window in one bathroom that has been made safe. Thought should be given to enhancing communal areas of the home. There are two rooms at the back of the home that are not used, as they are currently not registered. There is a lean-to type room to the side of the house at the back. The purpose of this room should be established to ensure standards relating to health and safety and hygiene are met. The room is currently used as a laundry, staff room, smoking room, treatment room and activity room. Confidentiality of service users may be compromised, as there is confidential information on display in this room on a notice board. 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. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 Prospective service users have some information they need to make a decision about the home. Service users know that staff can communicate with them. EVIDENCE: Following previous requirements the Manager has sent a copy of the Statement of Purpose and the Service User Guide to the Commission. Both documents contain the required information. The purpose of the Statement of Purpose and Service User Guide is to enable service users and significant others to make an informed choice about how their care needs are to be met. Both of these documents should be given to prospective and current service users. Both of these documents are produced in writing and may not be accessible to prospective service users i.e. in suitable formats. Thought should be given to this. Since the last inspection the manager has employed the services of a private occupational therapist. The occupational therapist toured the home, talked to service users and the manager and produced a report with some recommendations. The manager sent a copy of the report to the Commission. Facilities for people with mobility problems are available only on the ground floor, because there is no lift. Staff were observed communicating effectively with service users. No service user has moved into the home since the last inspection. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 10 Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,10 Service users are supported to make decisions about their lives. Service users’ confidentiality is not fully protected. EVIDENCE: Service users told the inspector about their forthcoming holiday to Blackpool. The holiday was booked while the inspectors were at the home. Service users said they discussed ideas between them and showed the inspector a shortlist. Staff had supported the decision-making by providing various holiday brochures. Service users said they are able to choose their meals and are offered alternatives to the planned meal. Service users were dressed in their own clothes and had individual styles. As mentioned in the summary of this report, there is a lean-to type extension to the side of the property at the back. At present the laundry is sited here. The room is also used as a staff room and smoking room. During the visit one Service user was using this room for activities such as listening to the radio while another service user received medical treatment in this room. There is no restriction on accessing this area, for example the door is not locked. Confidential information is displayed on a large notice board in this room Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 12 including a bath rota, the degree of support service users need, and ‘wash and bed change’ rota. Service users’ names are displayed. This could compromise their dignity and privacy. Service users should be consulted on this matter, and a confidential alternative record should be considered if necessary. The purpose of this room should be clearly established so that standards relating to hygiene, privacy and health needs can be fully met. The home has a cordless portable telephone. Two phone calls were received during the visit, which were taken by staff in the kitchen with staff talking and walking about. The inspectors in the ‘lean to’ room could overhear both conversations. Thought should be given to protecting the confidentiality of service users when phone calls about them are received. Not all bedroom doors have a suitable lock fitted. Service user plans and risk assessments were seen at the last inspection. It was noted that the manager had improved the care planning and risk assessment process. Care plans and risk assessments will be inspected further at the next inspection. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,17 Service users have opportunities to develop social, educational and life skills. Community access is limited. Participation in leisure activities is limited. The pace of life at the home is relaxed and unhurried which suits Service Users needs and expectations. EVIDENCE: Four service users attend a day centre from 2-5 days a week. One service user is currently choosing to stay at home and not attend the day centre. Two other service users attend an adult education class together and a club one day a week. One service user spends seven days a week at the home. One service user told the inspectors that they like to prepare vegetables at weekends and they enjoy doing their own ironing. Staff said that service users like to help around the kitchen. One service user goes with the Manager to do the weekly shop, usually on a Sunday. Staff said that other service users cannot go out as ‘they are too heavy for us to push in wheelchairs’. Service users confirmed this as the reason for not going to local shops, restaurants Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 14 etc. However, one service user uses a taxi to get to night school and umbrella club once a week. The home has no adapted vehicle. The manager must give thought to how to meet the mobility needs of all service users so that access to the community facilities is not restricted. The manager has used his car in the past for shopping and appointments or taxis are used. After 7.30pm there is only one member of staff on duty seven days a week. This means that community presence for service users could be limited Service users have various hobbies, which include knitting, crochet, and watching television and word searches. During the visit five service users were at home, all were engaged in one of the above in house activities. As mentioned in the summary of this report, service users have planned their holiday to Blackpool. They are travelling together as a group. As required the Provider must consult with service users about their preferences regarding evening activities and outings. This consultation, and any resulting activities, including staffing requirements should be recorded. Some service users have family and friends. Service users were happy to show the inspector photographs of their relatives, which are framed and displayed around the lounge. Staff said that relatives are welcome to visit at reasonable times and that service users keep in touch with their families by telephone. The home has no private visitors room for service users and their guests to use although there is potential for two rooms at the rear of the property to be adapted and registered. The atmosphere during the visit was relaxed and unhurried. The pace of life seemed to suit service users’ needs. The inspectors noted that one lock on bedroom door was not working and stiff. This should be addressed. Staff were observed interacting with and talking to service users in a polite respectful manner. Staff showed an understanding of service users’ needs. The inspector looked around the kitchen. The kitchen was clean and orderly, however some of the cupboards were stiff. The home does not have a dishwasher. Crockery is washed and dried by hand. Service users take part in this washing and drying process. Thought should be given to a more hygienic method of washing and drying crockery especially as the home has some elderly residents on a risk assessment basis. Fresh fruit and vegetables were seen in the larder. Care staff prepare the meals at the home. The hot meal of the day is served in the evening with service users all choosing to eat together in the dining room. On the day of the visit the evening meal was steak and onions, potatoes, carrots and leaks. Since the last inspection the fridges and freezers have been removed from the laundry/staff room and are sited in a room at the back of the property. The kitchen has suitable hand washing facilities with disposable hand towels to use. Service users said: ‘the food is good’; ‘I can always have something else’. The larder and fridges and freezers were well stocked. The inspector was pleased to note that some brands have been purchased other than value brands as noted at a previous visit. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Service users know their personal care needs will be met. Further adaptations may be needed to ensure service users’ independence is maintained. EVIDENCE: Service users looked clean and well cared for and were dressed in their own clothes. One service user said ‘the staff help me with my bath’. Most of the service users require support with their personal care. Staff showed awareness of service users’ personal support and care needs. Staff and service users said that there is no set time for going to bed or getting up. Bathrooms are fitted with indicator locks and there are two assisted baths to maintain independence. Service users have their own toiletries, which they keep in their own rooms. All rooms have a wash hand basin. There are two female care staff and the manager is male. This enables service users to be supported by same gender staff. As previously mentioned, the personal care rotas are displayed, which may compromise service users’ privacy and dignity. Staff said that any concerns they have about a service users’ health are recorded and passed to the manager. The inspector noted that medical advice was sought promptly recently in respect of one service user. This service user recently visited the Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 16 local hospital following a fall in the home. This same service user previously fell in the home and broke a bone, which lead to surgery and a stay in hospital. Staff said the service user had lost some confidence with their mobility. The inspectors observed this service user holding onto chairs, tables and worktops in the kitchen as they walked around the home quite gingerly. In some communal areas like the ground floor hall to the kitchen the service user only had narrow architrave to hold. The inspectors acknowledge that the manager has employed the services of a private occupational therapist to assess the building and service users. However, the mobility of the individual service user observed and others should be kept under continual review and further assessments by a suitably qualified professional should be arranged in response to any changes to mobility. Medication continues to be stored in the larder with food and records. A previous requirement has been made regarding this. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Service users know who to complain to. EVIDENCE: The home has a complaints procedure, which is included in the home’s Statement of Purpose and Service User Guide. A complaint was made about the home to the Commission, which lead to an adult protection investigation. The Inspector understands that the adult protection investigation is now closed. Service users told the inspectors that they would tell the staff if they were not happy about something. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29, 30 Further investment is needed to improve the environment and enhance service users’ quality of life. EVIDENCE: The home is a Victorian terraced house with accommodation on several levels. There is no lift, so all rooms are accessed by stairs. There are two ground floor bedrooms at the back of the house accessed, by one step down. The house overlooks the sea and is in keeping with other house in the area. All bedrooms are for single occupancy and have wash hand basins. One ground floor bedroom has an en suite assisted bathroom. Bedrooms are personalised with service users’ own pictures and ornaments. Service users said they are happy with their rooms. There is a small garden to the front of the property with some fragrant rose bushes and a bench seat. Service users sit in the garden in the summer. The majority of the front garden is used for off street parking. There is a small garden to the rear, which consists of a small patio area with walls to three sides limiting the amount of sunlight. At present there are ladders and other items stored here restricting the use for service users. On the day of the visit Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 19 the home was clean and suitably fragranced. In some areas of the home especially on landings the lighting was not sufficient. Some items of furniture in communal areas and bedrooms are a bit worn and are in need of repair or replacement. Some knobs and handles were missing from wardrobes and drawers. A requirement was made that the Manager audit the home’s furniture and fittings and produces an action plan with timescales for the repair or replacement of broken, worn and damaged items. Since the last inspection restrictors have been fitted to windows. The Inspector noted that the window in one of the bathrooms was broken with several large cracks. The broken glass had been made safe but must be replaced. The home has a communal lounge/dining room and kitchen. As mentioned there is a lean to type room with no definitive use. The home has no private room for visitors. There is potential to improve and extend the communal space if the manager applies to register two unused back rooms. There is no allocated sleep-in room for staff. One staff uses a spare bedroom to sleep in the other said they use a camp bed that they erect in the lounge when all have gone to bed. The home has two bathrooms with WC’s and wash hand basins and two separate WC’s. One communal bathroom has a bath chair. One ground floor bedroom also has an assisted bathroom en suite. The inspector noted that bar soap and cloth towels are still provided. The manager must ensure that methods of washing and drying hands are hygienic. The taps in two WCs failed to turn off and there was no lampshade in one WC. Soiled laundry continues to be carried through the kitchen to the lean-to where a washing machine and dryer are sited. This is not ideal as the home deals with some incontinent laundry. Since the last inspection three spare bedrooms have been decorated and other work has been carried out. The Manager has produced a development plan for the home with timescales detailing future redecoration and updating. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33 There is not enough staff to provide good quality, effective and consistent care. EVIDENCE: There is one less care staff than at the last inspection. Previous requirements have been made and continue to be unmet regarding the number of staff. When the inspectors arrived there was one care staff on duty with five service users. At 13.30 a second care staff arrived. Staff shifts are: from 07.30 to 19.30; 07.30 to 13.30; and 13.30 to 19.30. One care staff and the manager share the sleep in duties. Staff said sleep in duty starts from 1930. Staff said the last service user is usually in bed by 22.00. This is when staff go to bed. Staff said the first service user is up at around 05.30. This means whoever is sleeping in works alone from 19.30 to about 22.00 and then from 05.30 to 07.30 when a second member of staff may join them. On some mornings there is no second member of staff if service users are attending day centres. Staff are responsible for supporting 2 service users fully with their personal care and for all of the cooking, laundry and cleaning at the home. At present two service users attend day centres five days a week and one service user attends two days a week. Some staff have left since the last inspection. There is one new staff in post, who commenced employment in December 2004. This new staff said she heard about the vacancy through a friend. Staff said a previous staff Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 21 member left suddenly without giving notice taking some staff confidential information and her training certificates with her. This was not reported to the Commission. The inspectors viewed the rota on display on the communal notice board. For the week commencing 30/05/05 it showed three members of staff, H, A and the manager Mr Sheikh. The rota is reproduced below. Sea View Lodg e Staff rota H A Mr.S Mon 30/0 5 Tues 31/0 5 Weds 1/06 Thurs Fri 2/06 3/06 Sat 4/06 Sun 5/06 Total weekly hours not includin g sleep in hours. 48 48 60 Total weekly hours includin g sleep in hours (approx ) 61.5 48 78 1330 1930 0730 1930 Off 1330 1930 0730 1930 Off Off 0730 1930 0730 1930 Off 0730 1930 0730 1930 0730 1930 Off 0730 1930 0730 1930 Off 0730 1930 0730 1930 Off 0730 1930 The three members of staff are covering over two hundred ‘waking hours’ needed between them. This means on average staff are working approximately 68 hours a week each. There is limited opportunity for one to one time with service users, little time for administration, limited flexibility in an emergency. There is an on-call system that means staff call the manager. However the manager lives in Surrey, over one hour drive away. The inspector was also concerned about contingency in the event of staff sickness and leave. Priority must be given to the recruitment of more staff. In the meantime the manager must ensure that there are sufficient numbers of staff to provide a good quality consistent service and that there is a contingency plan in place for emergencies. Staff were aware of their roles and responsibilities when asked. Staff are caring and obviously committed to the home. Staff were observed talking to and supporting service users in a respectful polite manner. One staff has started a National Vocational Qualification at level 2 since the last inspection. The inspectors were unable to assess the progress made towards producing a suitable induction as required at a previous inspection, as staff did not know where records were. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 22 The inspectors were unable to assess if recruitment procedures had been followed as staff did not know where records were kept. These records must be accessible to inspectors at all times. Staff said they had attended some training via KCTA including first aid on 4/04/05, health and safety 20/12/04 and risk assessment planned for 6/06/05. Staff said they ‘missed the fire training’. However they have a certificate from a training session attended at a previous work place, although this is not individualised to the building of Sea View Lodge. The manager must ensure that all staff are competent in fire awareness. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41,42,43 Service users’ health and safety is not fully protected. EVIDENCE: Since the last inspection the manager has arranged for an electrical hard wire test to be completed as required at a past inspection. Some of the records required by legislation were not available to the inspectors on the day of the visit. This included staff files and training and induction records. The inspector looked around the home with staff for the records with no success. Staff said they have attended some courses relating to health and safety although had one staff had ‘missed the fire training.’ but had previously attended this, although needs to be competent in evacuating sea view lodge. Some products including bleach and disinfectant were not stored securely as required but in a shower cubicle. An immediate requirement was made to remedy this. There was a broken window in one of the bathrooms, although this had been made safe. As mentioned some areas of the home are in need of updating and improving. Staffing levels are not sufficient. Some accidents have occurred at the home recently, namely falls. These accidents have not been reported appropriately to the commission under Regulation 37. Due to the Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 24 environmental issues, the inaccessibility of records and insufficient staffing levels the health and safety of service users is not assured. No judgement was made at this inspection about the viability of this home. There appears to be no planning relating to human resources or quality monitoring. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x 2 x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x x 1 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 2 2 2 2 2 Standard No 11 12 13 14 15 16 17 3 3 2 2 3 x 2 Standard No 31 32 33 34 35 36 Score 3 2 1 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sea View Lodge Score 2 x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x 1 1 1 H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 26 Yes 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 YA16 Regulation 16(2)c Requirement Suitable locking devices must be provided on all bedroom doors unless the service user chooses otherwise and this is recorded in the service user plan. The home must have a medication policy that is workable in the home and in line with the Royal Pharmaceutical Society Guidelines. NOT INSPECTED The home must have a policy covering medication given outside the home. NOT INSPECTED Medication must be stored in line with the Royal Pharmaceutical Society Guidelines. NOT INSPECTED The Registered Person must ensure that standards of hygiene are maintained in the home. Hygienic means of washing and drying hands must be provided. Induction training must be provided for new staff. This induction training must be in line with TOPPS guidelines and within the Learning Disability Awards Framework. Records must be accessible. Timescale for action 30/11/04 2. YA20 13(2) 30/11/04 3. YA20 13(2) 30/11/04 4. YA20 13(2) 30/11/04 5. YA30 16(2)jk 30/11/04 6. YA35 18(1)abc 30/11/04 Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 27 7. YA34 19(1)abic 8. YA33 12(1) 18(1)a 12 9. YA42 10. YA24 16 11. YA42 12 12. YA41 12 13. YA29 13 14. YA10 12(4)a 15. YA13 16(2)m The Registered Person must operate a thorough recruitment procedure ensuring the protection of service users. Documents required under Schedule 2 of the Care Homes Regulations must be at the home in relation to all staff. Records must be accessible. The Registered Person must ensure that there are sufficient staff to meet the individual needs of service users. The manager must comply with the Control of Substances Hazardous to Health Regs 1988. Bleach etc must be stored securely. An audit must be completed of all furniture and fittings. Broken and worn items must be repaired or replaced within timescales set within the managers action plan.The action plan should be sent to the Commission. The health and safety of service users must be protected. Health and Safety legislation must be complied with. All parts of the home must be safe and free from hazards as detailed. Records required by legislation must be kept at the home and be available to inspectors at all times. Aids and adaptations must be provided following individual assessments by professionals to maintain and develop service users mobility and independence. Service users confidentiality must be protected. Confidential information must be removed from the notice board. The manager must consult service users about their preferences in local , social and 30/11/04 30/11/04 extended to 30/07/05 Immediate 30/07/05 30/06/05 30/06/05 30/08/05 30/06/05 30/08/05 Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 28 community activities. This consultation with results and actions should be reorded in service user plans. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA37 YA32 Good Practice Recommendations The Manager should be qualified to level 4 NVQ in care and level 4 NVQ in management by 2005. 50 of staff should be qualified to at least level 2 NVQ by 2005. Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 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 Sea View Lodge H56-H05 S23424 Sea View Lodge V223114 060505 Stage 4.doc Version 1.30 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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