Inspection on 08/06/06 for Seabrooke Manor Nursing Home

This inspection was carried out on 8th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Seabrooke Manor Nursing Home 05/12/05

Seabrooke Manor Nursing Home 30/06/05

Seabrooke Manor Nursing Home 24/08/04

Seabrooke Manor Nursing Home 29/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Seabrooke Manor Nursing Home Lavender Place Ilford Essex IG1 2BJ Lead Inspector Ms Gwen Lording Key Unannounced Inspection 09:30 8th June 2006 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seabrooke Manor Nursing Home Address Lavender Place Ilford Essex IG1 2BJ 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) 0208 553 5538 0208 514 2283 maherb@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Limited Mr Brent Jonathan Maher Care Home 120 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (30), Old age, not falling within any other category (90) Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 60 nursing care beds in two units for elderly people, including 4 named beds for under 65s 30 beds for elderly people with mental health problems, including 5 beds for age 50 30 beds for elderly people requiring personal care only Date of last inspection 5th December 2005 Brief Description of the Service: Seabrooke Manor is a 120-bed home owned and operated by BUPA Care Homes Ltd. The home is purpose built and is divided into four separately staffed units. These provide care for specific client groups: people over sixtyfive years requiring nursing care and personal care due to frailty/ illness and people with dementia, some of whom require assistance with personal care. The home is situated in a residential area of Ilford in the London Borough of Redbridge; approximately 10-15 minutes walk from the main road and public transport. The external grounds and building are well maintained and secure. On the day of the inspection the range of fees for the home was between £480.00 and £700.00 per week, this range is dependant on whether the resident requires residential or nursing care. A copy of the Statement of Purpose and Service User Guide to the home is made available to both the resident and the family. There is a copy of the guide in each bedroom, and copies of both these documents are available at the main reception and on each unit. Copies of the most recent inspection report are located on each unit and on request from administrative staff. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.30am. It took place over eight hours during the late morning and afternoon. The inspection was undertaken by two inspectors, namely the lead inspector Gwen Lording and Sandra Parnell-Hopkinson. The registered manager and deputy manager were available throughout the visit to aid the inspection process. This was a key inspection visit in the inspection programme for 2006/2007. Discussion took place with the registered manager; deputy manager; several members of nursing and care staff; the person in charge of the kitchen; and the person in charge of the laundry on the day of the visit. The responsible individual for the service was also visiting the home and she was able to join the inspectors’ discussion with the manager at the beginning of the inspection. Nursing and care staff were asked about the care that residents receive, and were also observed carrying out their duties. The inspectors’ spoke to a number of residents and relatives. Where possible residents were asked to give their views on the service and their experience of living in the home. In order to gain additional information about the quality of the service the lead inspector was able to attend a relatives meeting held on Roman House; and a staff meeting held on Norman House. More detailed information about these meetings can be found in the main report. All parts of the home were visited and a number of staff, care and home records were looked at. The inspectors’ would like to thank the staff and residents for their input and assistance during the inspection. What the service does well: Although Seabrooke Manor is a large care home, there is a relaxed atmosphere on all units and residents appeared unhurried and are given sufficient time and support in their everyday activities. The home has an experienced manager who sets high standards for the home. He works with strong staff teams across the home that are committed to further improve the quality of care for people living in the home. This is reflected in the provision of care to residents. Many of the residents have high dependency levels and require a great deal of assistance from both nurses and care staff. The routines of daily living and activities are flexible and varied and suited to the differing needs of residents. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 6 The attitude and practice of the service and that of the staff teams promote opportunities for residents to remain independent, exercise choice and express their wishes and needs. The nutritional needs of residents are well considered so that food and mealtimes are seen as being important for all residents. The deputy manager has delegated responsibility for training and there is a well-developed and comprehensive training programme. 70 of care staff are qualified to NVQ level 2, and a further 8 staff are working towards this qualification. This demonstrates a very positive commitment to training from both the organisation and the care staff. What has improved since the last inspection? What they could do better: It is strongly recommended that all reference requests sent out by the home, be returned accompanied by for example, an official stamp to confirm the authenticity of the referee. Work is in progress to develop a service user guide in a simpler format for the benefit of those residents who are living with dementia. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 7 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. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive assessments are being undertaken for all residents prior to them moving into the home. Care plans are drawn up from the information in this assessment, ensuring that the needs of the residents are identified, understood and met The home does not offer intermediate care. EVIDENCE: Individual records are kept for each resident. A total of sixteen files were examined, four on each unit of the home. All records inspected have assessment information recorded and the information had been used to continue assessment following admission to the home and develop written care plans. The records showed that residents, where capable and their relatives/ representatives are involved in the assessment process. Where appropriate, information provided by the placing authority was also on file. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 10 Through discussion with the manager and observation during the day of a visit by the relatives of a prospective resident, it was evident that prospective residents and their relatives are given a copy of the Statement of Purpose, service user guide and other useful information is made available to them. There is always the opportunity to visit the home prior to making any decision to move in. A welcome pack is placed in each bedroom and this contains a copy of the service user guide. Work is in progress to develop a service user guide in a simpler format for the benefit of those residents who are living with dementia. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal care and social care needs are set out in individual care plans and provide staff with the information they need to satisfactorily identify and meet residents’ needs. Care plans are being used as working tools and residents benefit from the attention to detail paid by staff at the home in meeting their needs. All residents could be assured that at the time of their death, staff would treat them and their family with care, sensitivity and respect. EVIDENCE: General A major improvement was noted in the standard of care plans on all four units. Care plans are very comprehensive and are being used as working tools. They are sufficiently detailed as to be understood by all staff and to others who may not be as familiar with the individual resident. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 12 Management of risk routinely takes into account the needs of a resident balanced with maintaining their independence and choice. The inspectors were able to evidence many positive examples of this during the visit. The wishes of individual residents about dying and death are openly and sensitively discussed with both residents and their family members and end of life issues detailed on care plans. There are arrangements in place, to enable family and friends to stay with a resident and to assist with their care if the resident wishes. Staff in the home routinely support relatives following the death of a resident through sympathy cards, floral tributes and support for staff to attend funerals. From discussions with staff on all units it was evident that residents could be assured that at the time of their death, staff would treat them and their families with care, sensitivity and respect. The principles of respect, dignity and privacy were evidenced throughout the inspection. Residents are treated with respect and the arrangements for their personal care ensure that their right to privacy is upheld. On the day of the inspection the weather was particularly hot. Staff were observed throughout the visit offering and encouraging fluid/ iced drinks; and ensuring residents were comfortable in their clothing, positioning of fans and where residents were seated. Whilst the inspectors were able to evidence that the ethnic and cultural needs of residents were respected and met, not all files evidenced that this area was routinely addressed on the initial assessment. This was discussed with the manager who would ensure that the assessment forms were revised to include information around ethnic origin. There are policies and procedures for the handling and recording of medications. An audit was undertaken of the management of medications within each unit of the home and a random sample of Medication Administration Record (MAR) charts were examined. The following issues were discussed with the manager and the nurses’ in charge of the particular units: • Handwritten entries on MAR charts must be signed and dated by the person making the entry. The entry must also include the source of the information i.e. GP, registered nurse • When directions for administering medications are variable e.g. one or two tablets, then the dose given is to be entered on the MAR chart. Roman House The files of five residents were case tracked and discussions held with the senior sister, staff nurse, care workers and two residents. All residents had comprehensive care plans, which promoted the values of choice and independence by considering all aspects of a person’s life. Care plans were reviewed at least monthly and more frequently if necessary. Following Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 13 discussions with the senior sister she will ensure that care plans are put in place for those residents who may have a behavioural problem, together with the necessary risk assessment. It was evident that where possible residents were involved in the development of their care plans, and where this was not possible relatives were involved. Where necessary risk assessments were in place, and the management of risk takes into account the needs of residents with regard to independence and choice Records indicated that arrangements are made for health professionals to visit when necessary and on the day of the inspection a dentist was conducting a surgery at Roman House. At the time of the inspection the senior nurse reported that no residents had any pressure sores. All turning regimes and fluid monitoring charts were up to date. Care plans indicated that where residents were at risk of falls, sensor pads were in place especially during the nighttime. Nutritional screening is undertaken on admission and records are maintained of nutrition, including weight gain or loss with appropriate action being taken where necessary. During the inspection it was evident that that all staff treated residents with respect and their privacy was respected at all times. Staff spoken to said how much they enjoyed working on Roman House and particularly caring for people living with dementia. All residents could be assured that at the time of their death, staff would treat them and their family with care, sensitivity and respect. There were many thank you cards and notes from families praising the care given on this unit. One in particular referred to the end of life care given to a resident and of the support given to the family. A quote from the letter said “We would like to commend them for all their help over the last week of my husband’s life. They made our pain so much easier to bear by the way he was looked after and cared for. Nothing was too much trouble for the staff”. Saxon House Case tracking was undertaken for four residents and it was evident from these files that there had been major improvements in the development of care plans. Work was still in progress to make even more improvements especially in the area of developing “life histories” of residents. Care plans were being regularly reviewed and updated. Nutritional screening was undertaken on admission and a record was being maintained on nutrition including weight gain or loss with appropriate action being taken when necessary. Files indicated evidence of health professionals involvement and on the day of the inspection a dentist was holding a surgery. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 14 The inspector was able to speak with a couple of residents who said that they “were well cared for”. Some staff had undertaken training in the care of people living with dementia and the benefits of this were evident in the interaction observed between staff and residents, and in the way that residents were treated with respect at all times. The training had also improved their understanding of residents, which enabled improved care provision. Norman House Individual care plans were available for each resident and the files of four residents were case tracked. All the care plans were found to be detailed and comprehensive. There was evidence that care plans were being reviewed at least monthly, more frequently if necessary, and updated to reflect changing needs. The documentation/ health records relating to wound management and the management of a resident with insulin dependant diabetes, were detailed and being adequately maintained. Records indicated that residents are seen by other health professionals such as Vascular Surgeon; tissue viability nurse; dietician and Parkinson’s Disease nurse. Care plans are detailed to the degree of identifying specific choices around the number of pillows preferred and the time a resident wishes to have their nightlight turned off. Particularly of note was the detail of care plans relating to residents who have specific religious or cultural needs and methods for staff to be able to understand and assist with the communication of the individual’s needs. The care plan of a resident with Parkinson’s Disease was also of note. It clearly detailed the action for staff to take when the resident suffered sudden, immobilising episodes of his condition, and ensured that any distress to the resident was minimised. Risk assessments are routinely undertaken on admission around nutrition, manual handling, continence, risk of falls and pressure sore prevention; and reviewed on a regular basis. There is a designated nurse in the staff team that has responsibility for wound care and continence. Several residents were asked about the care they receive in the home. Comments included: “I am 96 years of age and have lived here for three years. I am very happy and enjoy spending time in my room”………….”I have been living in Seabrooke Manor for more than four years. I am well cared for – any problems I can approach any member of staff”. Belgae House Individual care plans are available for each resident and the files of four residents were case tracked. All the care plans were found to be generally Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 15 detailed and comprehensive. There was evidence that care plans were being reviewed at least monthly and updated to reflect changing needs. The documentation/ health records relating to wound management, the management of a resident with diabetes and the care plan of a resident recently admitted to the home, were detailed and being adequately maintained. Records indicated that residents are seen by other health professionals such as dentist, optician, dietician and tissue viability nurse. Risk assessments are routinely undertaken for all residents around nutrition, manual handling, continence, pressure sore prevention and risk of falls; and reviewed on a regular basis. All fluid monitoring charts were up to date. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The lifestyle within the home matches the expectations and preferences of residents. The attitude and practice of the service and that of the staff teams promote opportunities for residents to remain independent, exercise choice and express their wishes and needs. The nutritional needs of residents are well considered so that food and mealtimes are seen as being important for all residents. EVIDENCE: General Menus are varied and food served was observed to be appealing, wholesome and nutritious. Food was presented and served in ways that were suited to the individual needs of residents. Those who required assistance with feeding were not rushed and were given sufficient time to eat. Religious or cultural dietary needs are catered for and this is recorded in care plans. Dining tables were laid with cloths, cutlery and glasses and the settings were very congenial. Hot and Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 17 cold drinks were readily available and frequently offered to residents by either nurses or care workers. Residents with dementia are enabled to make a choice as to a meal at the time the meal is served and can do this by sight and smell. However, it would also be beneficial for some residents to choose from a pictorial menu and the inspector was informed that these are being developed. The inspector was able to observe that the routines of daily living and activities were flexible and varied and suited to the differing needs of residents. A visit was made to the main kitchen and the inspector discussed the storage and preparation of food and menus with the cook in charge. She demonstrated a good knowledge and understanding of the importance of well balanced and well presented meals for older people. Each day the kitchen prepares nutritional milkshakes for those residents whose diet requires supplementing due to reduced food intake/ diminished appetite. This is a recent initiative, but has proven to be popular and has been extended, so that a jug is prepared and routinely sent to each unit of the home on a daily basis. Visiting times are flexible and relatives and friends are encouraged to visit whenever possible and such visitors are involved in the lives of residents. Roman House The inspector was able to observe that the routines of daily living and activities were flexible and varied and suited to the differing needs of residents. Many of the residents have high dependency levels and require a great deal of assistance from both nurses and care workers. At all times it was observed that residents were treated with respect and dignity. Signage and décor was appropriate to the needs of people living with dementia, and activities are now more individually planned. However, with the introduction of the “cinema” on Saxon House, this has enabled some residents from Roman House to watch a film in similar surroundings to those provided in the community, and relatives are welcomed and encouraged to accompany them. One resident was finding it difficult to settle because she missed her pet dog. With the involvement of the registered manager, all staff on the unit and the social worker, arrangements had been made for the dog to visit the resident until permanent arrangements could be finalised for the dog to become “resident” on the unit. All of the necessary consultations and risk assessments were in place and the resident was very happy. All staff would be involved in the care of the dog, such as feeding, exercising with the help of the resident whenever she was able. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 18 Saxon House Generally daily life and social activities have greatly improved on this unit. Appropriate signage and décor were now evident throughout the unit, and work is still in progress in providing pictures of the local areas along the corridors. One resident who used to enjoy cycling is going to have an old bicycle brought to the home so that he can have the pleasure of looking at it. During the inspection visit, one of the activity co-ordinators was encouraging residents to participate in small group and individual activities. with a great deal of success. Some residents were dancing to music, and were assisted by staff members. All really seemed to be enjoying themselves. Again the introduction of the “cinema” on this unit has been beneficial and this is open on Wednesday and Friday afternoons for all residents at Seabrooke Manor. Sweets, ice creams and drinks are made available so that it is a “whole experience” for residents. Several residents became restless and staff were on hand to take them for a walk in the gardens, and again it was apparent that residents enjoyed this. Norman House The inspector observed members of staff allowing time for residents to express their wishes and supporting individuals to make choices in their daily lives, for example choosing a drink, newspaper or where they wished to take their meal. There is a very relaxed atmosphere on the unit and residents appear to enjoy the friendly social interaction with staff, particularly observed during the preparation for the lunchtime meal. At the staff meeting attended by the inspector prior to the visit, there had been a discussion by staff, that on occasion there was only a short period between breakfast and the serving of lunch. Staff proposed a number of solutions and it was encouraging during the visit to see that flexible team working had improved this situation. There is a dedicated group of “cinema” enthusiasts on Norman House who look forward to this activity. The home is also in the process of identifying an appropriate range of films in other languages, for example Urdu and Punjabi. Whilst talking to one resident he shared pictures of his granddaughter’s recent wedding. He very much wished to attend and this was made possible by a member of staff accompanying him for the day. He had greatly appreciated this and commented: “It was a pleasure to have such a companion for the day, attentive but not intrusive, polite and friendly to my family and friends”. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 19 Belgae House Many of the residents on this unit have a high level of dependency and require increased assistance from both nursing and care staff. During the visit staff were seen to be attentive to residents needs and treated them with respect and dignity. The inspector observed members of staff allowing time and encouraging residents to express their wishes and supporting individuals to make choices in their daily lives, for example choosing a drink, where to sit and type of music to listen to. There is a relaxed atmosphere on the unit and residents appeared unhurried and are given sufficient time and support in their everyday activities. A referral is being progressed for a resident who wishes to attend a Jewish day service. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff make every effort to sort out any problems or concerns and makes sure that residents and their relatives feel confident that their complaints and concerns are listened to and will be acted upon Staff working in the home have received training in Adult Protection/ Abuse Awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a written complaints policy and procedure and the records inspected indicated the number of complaints received and included details of investigation and any action taken. All complaints are recorded whether formal written or verbal expressions of concern. When such concerns are expressed they are recorded on the individual resident’s daily record. The manager actively addresses all concerns and aims to resolve to the satisfaction of the complainant. On many occasions the manager has met with a complainant if they consider that his formal written response has failed to address their concerns. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 21 There is an in house training programme for all staff in adult protection and this has been extended to include all administrative/ ancillary staff and for all new staff during their induction. The outcome for any adult protection referral is managed well and the registered manager works co-operatively with the Commission and the local authority to address all matters. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 22, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment on all units of the home is of a good standard and provides residents with a clean, safe and comfortable place in which to live. EVIDENCE: General A tour of the whole home was undertaken by the inspectors. The standard of the décor, furnishings and fittings are being maintained to a good standard. There is an ongoing programme of refurbishment and re-decoration. Two maintenance personnel are employed and there is an effective system in place for staff to report items requiring attention or repair. The external grounds are being well maintained. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 23 Bedrooms on all four units had been personalised to the individual needs of residents and were well furnished and decorated. Call alarm systems are provided and were accessible and within reach of residents whilst in their own rooms. Since the last inspection all units have been provided with an additional hoist and there is a replacement programme for beds and wheelchairs. Adaptations and equipment are in situ which are capable of meeting the needs of all residents. Hand washing facilities are prominently sited and staff were observed to be practising an adequate standards of hand hygiene. On both Roman and Saxon House the signage and décor were appropriate to the needs of residents living with dementia, and this was being further developed especially on Saxon House. On both units residents were able to walk around and to enter their bedrooms when they wished because bedrooms doors were not being routinely locked. The laundry area was visited by the inspector and this was clean, with soiled articles, clothing and infected linen being appropriately stored, pending washing. Laundry staff were aware of health and safety regulations with regard to handling and storage of chemicals. Personal protective clothing and equipment were available and in use. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. Residents benefit from committed staff teams who have the skills and training to meet their needs. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: General Staff rotas were inspected and the staffing levels of qualified nurses and care staff on all four units were sufficient to meet the nursing and personal care needs of residents. Effective team working was observed and evidenced throughout the inspection. Staff have undertaken some training in caring for people with dementia and this training was evident in the attitude of staff with residents. Staff interacted very well, both with each other and residents, and were keen to introduce new ideas. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 25 In discussion with the deputy manager, staff and examination of training records it was evident that nurses and care staff have undertaken a wide variety of training. The deputy manager has delegated responsibility for training and there is a well-developed and comprehensive training programme for both nurses and care staff. Staff had received training in essential areas such as fire safety, protection of vulnerable adults, moving and handling, basic food hygiene and infection control. A number of key staff will be attending a workshop around “End of Life Care”; this workshop will be evaluated and then cascaded to all staff. 70 of care staff are qualified to NVQ level 2 and a further 8 staff are working towards this qualification. This demonstrates a very positive commitment to training from both the organisation and the care staff. A random sample of personnel files were inspected and showed that the home is undertaking all the necessary checks to ensure the protection of residents. An organisational audit was recently undertaken which included staff files. It is strongly recommended that all reference requests sent out by the home, be returned accompanied by for example, an official stamp to confirm the authenticity of the referee. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 34, 35, 36, 37, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the home. The manager of the home is a well qualified and experienced person and residents benefit as the home is run in their best interests. Monitoring visits are undertaken regularly by the responsible individual to monitor and report on the quality of the service being provided in the home. EVIDENCE: All staff spoken to throughout the visit, both care and departmental staff, spoke very positively about how well supported they felt by the manager and his deputy. Mr Maher has an open and inclusive style of management and staff feel valued. He is very resident focused and works continuously to improve services and provide an increased quality of life for residents with the support Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 27 of strong staff teams and in partnership with the family of residents and professionals. The inspector was able to attend a relatives meeting held on Roman House, prior to the inspection visit. Meetings are held regularly on all four units of the home and either the manager or the deputy attends. Written minutes of the previous meeting were circulated, the senior sister updated relatives on progress /action taken to address issues raised and refreshments are served. The meeting was well attended and relatives were encouraged and felt able to discuss individual matters; as well as asking questions about future plans for the home; its policies / procedures and staff training. Under his leadership there have been great improvements in the service delivery and quality of care in the home, over a period of less than one year, across all areas of the service. All staff work as a team and in such a large home the manager and his staff are to be commended for this. The home benefits from the quality assurance procedures adopted by the registered organisation, BUPA Care Homes. Regulation 26 visits are undertaken regularly by the responsible individual and a copy of the report is sent to the Commission. An organisational audit was undertaken in April this year that covered a number of records and systems in the home including, finance records. An audit report is provided with details of any actions required by the manager. A wide range of records were looked at including fire safety, emergency lighting, water temperature checks and health and safety audits. These records were found to be detailed, up to date and accurate. Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 3 3 3 3 3 Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 29 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 OP9 Regulation 13 Requirement All handwritten entries on Medication Administration records (MAR) charts must be signed and dated by the person making the entry and include the source of the information.(Timescale of 31/01/06 not met) When directions for administering medications are variable e.g. one or two tablets, then the dose given is to be entered on the MAR chart. Timescale for action 30/06/06 2. OP9 13 30/06/06 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 OP29 Good Practice Recommendations It is strongly recommended that all reference requests sent out by the home, be returned accompanied by for example, an official stamp to confirm the authenticity of the referee. DS0000025961.V295145.R01.S.doc Version 5.2 Page 30 Seabrooke Manor Nursing Home Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Seabrooke Manor Nursing Home DS0000025961.V295145.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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