Inspection on 19/04/06 for Seacroft Court

This inspection was carried out on 19th April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Seacroft Court 06/11/07

Seacroft Court 01/09/05

Seacroft Court 24/03/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Seacroft Court Seacroft Esplanade Skegness Lincs PE25 3BE Lead Inspector Mr Ken Hague Key Unannounced Inspection 18th April 2006 08.00 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 Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 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. Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Seacroft Court Address Seacroft Esplanade Skegness Lincs PE25 3BE 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) 01754 610372 collegiacare@aol.com Collegia Care Limited Mrs Angela Smith Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (8) of places Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered to accommodate 7 persons in category of Physical Disability aged 40 years and over. The home is registered to accommodate 1 named person in category of Physical Disability aged 33 years. This person is to be accomodated in Room 7. Date of last inspection Brief Description of the Service: Seacroft Court is a care home providing accommodation for 50 residents requiring personal and nursing care in the category Older People. The home is also registered to accommodate up to 8 people with a physical disability; 7 places for persons over the age of 40 and 1 named place for a person below that age. The home is owned by Collegia Care Ltd., the directors being Mr and Mrs Cooper. Mrs Cooper is the Responsible Individual for the organisation. The home is situated in a residential area of Skegness in a quiet cul-de-sac overlooking the sea. Local amenities are a 10-minute walk away. The residents have access to the home’s transport, which is used to take them into the local community and Skegness town centre. The home is a detached property set in large landscaped grounds. The layout is over 2 floors, which are served by 2 passenger lifts. The home has a Registered Manager, Mrs Angela Smith, who is supported by a Care Manager. Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors, one of the inspectors being a qualified nurse, undertook the inspection. The report has been written with input from both inspectors. The main method of inspection used was ”case-tracking” and involved seven residents. This is a system which looks at the needs of the resident and follows this through by talking to the residents concerned, where this was possible, and the staff who deliver the care, as well as observation of care practices. In addition the individual care records for each residents was studied. The Inspector spoke to four members of the care staff, a relative, the registered manager and the proprietor of the care home. Informal discussions were held with domestic staff. The service history of home was studied prior to the site visit. The social services department gave feedback regarding the provision of service to social services funded residents. A tour of the home was also undertaken. Samples of regulatory records were seen. What the service does well: What has improved since the last inspection? Since the last full inspection carried out in October 2005 the home has reviewed all policies and procedures. At the follow-up inspection in February 2006 the requirements identified in October 2005 were met. The management structure of the home has been reviewed and simplified removing one tier of management. Staff state morale has improved there was evidence found of an increase in team working within the home. Quality assurance systems are being introduced and developed. There has been a new appointment made within the management structure to ensure that quality assurance is carefully monitored and that records and care practice is reviewed consistently. Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 6 What they could do better: 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. Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 7 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 Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 8 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): 3&6 The home undertakes comprehensive assessments before people are admitted to the home to ensure that the home can meet their needs. Potential residents visit the home prior to admission to make sure that the home is suitable for them EVIDENCE: Three files were inspected of residents admitted to the care home since February 2006. All of these files contained an assessment carried out prior to the resident being admitted. One resident admitted on the 18th of April confirmed that she had visited the home prior to making decision to stay there. Residents interviewed confirmed that they had been involved in the initial assessment and that the home had discuss their choices and wishes in respect of the way care should be provided. Staff had explained to them also the resources and facilities offered by the care home. The proprietor stated “the initial assessment is normally carried out by two members of staff, One of the assessors being the registered manager”. Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 9 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): 7,8,9 &10 Care plans do not always reflect all the care needs of an individual and therefore residents could be at risk and all the healthcare needs of the residents may not be met. The medication policy of the care home is being followed. Residents feel that staff respect their dignity and privacy. EVIDENCE: The care records for a resident admitted on the 18th of April 2006 contained a full assessment. The needs identified in this assessment had not been transferred into a personal care plan for the resident. This work was being completed on the day of the inspection. All residents admitted to the home must have an initial assessment, which includes a risk assessment completed and an initial care plan in place on the day they are admitted to the care home. In the case of the resident admitted on the 18th of April no formal care plan had been written. Risk assessments were not in place. There were documents not signed or dated by a member of staff. There were no resident’s signatures on some care plans. Care records provided evidence that cot sides were been used for four residents. There was no risk assessment in place for the Use of these bed Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 10 rails. The home could not demonstrate that residents or relatives had consented to the use of these bed rails. The registered manager stated that one resident had asked for bedrails to be provided. This was however not documented within the care records. The inspectors also asked the proprietor to review the manner in which self medication is recorded. Care records contain a statement whether residents were self medicated but provided no evidence that all residents had been given the choice to self medicate if appropriate. A resident receiving nursing care had a waterlow score of 29 on the 3rd of January 2006. There was no care plan in place to demonstrate how tissue viability was being managed. There was no recorded evidence that consideration had been given to provide a different type of mattress for the resident. A second resident’s care records contained no waterlow score. Nursing care records were not always signed by staff. A third resident’ had a waterlow score of 26 recorded on the 26 March 2006. There was no care plan in place to demonstrate how this problem was being managed and monitored. A fourth resident had a waterlow score of 29 it had been identified that this person required a cushion for his chair. A member of staff stated this had been ordered but this was not recorded within the residents care records or the action being taken to obtain one. The proprietor the home informed the Commission for Social Care Inspection on the 20th of April 2006 that she had contacted the tissue viability specialist within community healthcare services to visit the home to discuss the policy and procedure the home for dealing with tissue viability. The care records have improve since the last inspection in October 2005. The proprietor of the home and staff stated that a great deal of effort had been made to try and ensure that all care plan met the National Minimum Standards. Staff stated in formal interviews that they were aware that not all care plans were being written to the same standards. They were also aware of care plans not being completed fully at the time the resident was admitted to the care home. Staff stated this resulted in care plans not been used consistently as live working documents. A member of staff interviewed stated she was totally committed to ensure that the hard work carried out by care staff was reflected into the care records. The proprietor stated to the inspectors that she had been aware of a problem relating to care records and had already instigated action to address the deficiency. Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 11 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): 12,13,14 &15 The home provides a range of leisure and social activities. Contact with relatives and friends are encouraged. The home provided a daily choice of menu, which was appealing, nutritious and well balanced. Resident’s views are sought regarding the everyday management and running of the care home. EVIDENCE: Resident stated in their discussions with inspector and the questionnaires returned to the Commission for Social Care Inspection that they were satisfied with the lifestyle being offered by the home. A relative visiting the home during inspection stated that there were made very welcome and encouraged to visit their grandmother. Two other residents stated our friends and family are made welcome. The statement of purpose for the home’s which was rewritten in April 2006 states “a full programme of leisure activities are available to residents, both internally and participating in the local community”. The home provides a 15 seater minibus used for external outings. The resident’s notice board located outside the lounge displays information regarding the events and activities offered to residents. Residents was seen to be taking part in activities during this inspection. There was one care plan however which did not contain the details of the chosen activities of the individual resident. The records on the care home demonstrated that choice is offered in terms of the menu and individual dietary needs are met. Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 12 The inspectors joined the residents for lunch. There was a choice of menu the food was appetising and very well-prepared. Resident spoken to do his inspection confirmed the satisfaction with choice of food being offered and the quality of the food. Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 13 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): 16,17 & !8 There are systems in place to help protect residents to ensure that their safety and welfare is promoted. staff are able to identify potential abuse situations and take action to protect the residents. Residents are enabled to take part in the political voting system. EVIDENCE: The home has a complaints procedure included in the service users guide. This policy is displayed in a communal area within the care home. Residents interview stated they would be able to raise concerns with the managers of the care home. There has been no complaints made to the home since the inspection in February 2006. Staff were able to describe in their formal interviews the action to be taken in the event of them having any suspicion that abuse was taking place within the home. The proprietor and staff confirmed that all staff had received training in the identification and management of abuse in the last six months. The proprietor stated that further courses were planned with an external consultant to take place during 2006. The Commission for Social Care Inspection is aware of an adult protection inquiry, which commenced in October 2005. This investigation was carried out under the Lincolnshire county council vulnerable abuse procedures. Lincolnshire police investigated and no charges were brought against any member of the care home. The Company co-operated fully with the Commission for Social Care during the investigations. Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 14 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): 19 &26 Service users live in a home with a clean, comfortable and home environment. The health and safety policy of the care home is being followed. EVIDENCE: A tour was made of the care home all areas were very clean and smelt fresh. Fixture and fittings were the domestic nature and furniture was arranged in a sensitive manner to present a homely and domestic environment. Residents spoken to confirmed the total satisfaction with the environment of the care home. The bedrooms seen during this visit had furniture and fittings which met the National Minimum Standards and contained personal possessions belonging to individual residents. Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 15 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): 27,28,29 &30 The home provides training for all care staff and encourages NVQ training. There are always sufficient staff on duty to provide essential care for service users. The recruitment policy of the care home is being followed. EVIDENCE: The recruitment records for three member of staff were studied all the appropriate documents required by the Care Home Regulations had been obtained prior to the staff being offered employment. The proprietor described the training plans for the care home and showed records of training included specialist training being offered to care staff. All but one residents spoken to during this visit confirmed in their opinion there was always suffer sufficient staff on duty. Staff stated that they felt the are sufficient numbers of staff on duty with appropriate skills to be able to answer the needs of all resident staying in the care home. The residents feedback form supplied to the inspectors during this inspection all included the statement that they were happy with present staffing levels. One resident stated “all the staff are helpful and kind”. A resident stated “I still havent got used to be in here but the staff are very good”. A second resident stated “staff help me pick out my clothes they are always helpful and patient”. There was only one resident who stated “sometimes there could do to be more staff on duty, they do not always have time to talk to you. The Pre- inspection questionnaire supplied to the Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 16 commission for social care inspection states that 40 per cent of care staff hold the equivalent of NVQ level 2. Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 17 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): 31,33,35, & 38 An experienced proprietor and registered manager manages the home. Staff find the management team very supportive. Staff are being supervised in accordance with they National Minimum Standards. The home has a health and safety policy which is being followed by all staff. EVIDENCE: The care home has reviewed its management structure in 2006. One tier of management has been removed which simplifies the structure. The proprietor has engaged a new member of management to monitor the quality assurance of the home service. This member of staff is also on tasks with ensuring that the care factors and care records the national minimum standards. They will make unannounced visit to the home and report directly back to the proprietors. Staff interviewed during the inspection stated that staff morale had improved and teamwork continued to improve. One member of staff stated “ I find the management structure much better roles are clearly Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 18 identified and I feel more confident in be able to carry out my own individual role within the care home. All staff interviewed stated the management are supportive and approachable. The proprietor gained the inspectors copy of the new quality assurance process which has been devised to ensure that the whole is run in the best interest of residents. This will involve taking a regular opinions from residents and their families regarding the services being offered to residents. Staff stated that supervision and appraisals are being offered in accordance with National Minimum Standards. There were no health and safety issues identified at this inspection. Staff stated that they are following that they are following the infection control policy the care home Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 19 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 x x 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X 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 3 3 x x 3 x x 3 Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1)(2) (a)(b)(c)d Requirement Care plans must be completed for all residents on admission and updated when care needs change. They must reflect all the care needs of a resident. The health needs of residents must be identified and met, using all other health professional resources as necessary. Timescale for action 30/05/06 2 OP8 13 (1) (b) 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Seacroft Court DS0000002551.V289531.R01.S.doc Version 5.1 Page 22 - 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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