Inspection on 06/11/07 for Seacroft Court

This inspection was carried out on 6th November 2007.

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 19/04/06

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 Ken Hague Unannounced Inspection 08:30 6 November 2007 th 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.V340527.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. Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 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 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.V340527.R01.S.doc Version 5.2 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 accommodated in Room 7. 19th April 2006 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 care home is owned by Collegia Care Ltd, which is owned by Prime Life Ltd. The responsible individual for the company is Peter van Herrewege 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 had no registered manager on the day of this inspection. However an experienced acting manager was in post who will be making a formal application to become the registered manager. The home’s weekly fees ranged from £348 - £450 depending on the resident’s assessed needs. Additional charges are made for services such as chiropody, hairdressing and toiletries. Information about these costs as well as the dayto-day operation of the home, including a copy of the last inspection report, can be found in the home statement of purpose and service user guide. These documents are made available to all new and potential residents, and explain the resources and services offered by the care home. A dedicated intermediate care service is not provided by the home. Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key announced inspection took place on the 6th of November 2007 and the visit to the home was carried out over approximately 9 hours on one day. Two inspectors were involved in the inspection one being a qualified nurse inspector. The care received by six residents was followed in detail. Seven residents spoke about their experience of living at the home. The inspectors read and discussed their individual care records with them. General house records including care records, staff records and policy and procedures were also looked at. Staff and the acting manager were spoken to and the care being provided was observed. Information already held by the commission was also used as part of the inspection process. It is normal procedure to obtain written feedback from residents using a document called “have your say”. This document asks the residents to answer 12 questions, which seek their opinions about the services offered by the care home. At this key inspection nine documents were returned. The opinions of the residents were also sought in discussions held on the day of the site visit. These views are reflected within this report. The company chairman supplied an AQAA (annual quality assurance assessment) prior to the site visit. This sets out the registered managers opinion on the quality of service provided by the home and is used as part of the overall assessment of the home. Nine “have your say” documents were sent out to members of staff. This documents asked staff for their opinions and comments relating to the provision of care at the home, staff training and development and the management of the home. What the service does well: What has improved since the last inspection? Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 6 Collegiate care was purchased by the company Prime Life Ltd in July 2007. Since then a major exercise has been undertaken by Prime Life Ltd to review the standards of care being provided at the home. This has resulted in many improvements taking place since July with further improvements planned in the near future. Prime life Ltd and are satisfied that the home is operating at a level acceptable to the Company and providing safe quality care to residents. Staff and residents stated consistently that the home has improved since the change of ownership. 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. The summary of this inspection report can be made available in other formats on request. Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 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.V340527.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a range of accessible information about the service they receive, and involvement in a robust assessment process. EVIDENCE: Six individual resident’s files were examined as part of the case tracking process. These included three files for residents receiving residential care and three files for residents receiving nursing care. All six files contained a full assessment for each individual resident completed prior to the resident entering the care home.The assessments sets out the care needs, social needs and health needs of each individual resident. The acting manager confirmed that residents are involved in the completion of care plans and in the review of their care plans. Signatures on the care plan support this statement. Staff also confirmed that residents are involved in the review of their care plans. Residents were able to discuss the details of their assessment on the day of the site visit. Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 9 The Acting manager stated that all residents are given a copy of the homes updated service users guide which sets out the facilities and services offered by the home. Residents confirmed that they did have a copy of theis document. The home has a copy of the statement of purpose displayed in communal areas, which sets how the full resources of the care home and enables residents to understand the facilities available to them. The acting manager confirmed that all residents are given a contract, which states the cost of their stay at the care home and includes a contribution. A sample contract was seen on the day of the visit. The care home does not offer a dedicated intermediate care service. Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans identify all areas of need and provide detailed care instructions for staff; this enables staff to provide appropriate care and ensures residents’ health needs are met. Risk assessments however are not being completed consistantly which could place residents at risk. The medication procedure of the home is not being consistently followed this could result in residents not being given their prescribed medication. EVIDENCE: Six individual care plans were studied and showed that the information gained at the initial assessment has been transferred onto individual residents care plans. There was a difference in emphasis between the care plans written for residential residents and those receiving nursing care. Residential care plans were more personalised. Nursing care plans gave no details regarding the individual wishes and choices of residents. Care plans written for nursing residents tended to give more detail of medical care and no detail of social care needs. The information provided to staff in care plans did inform staff how care needs were to be met. However risk Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 11 assessments were not personalised. These were standard common documents where any identified risks from a list are recorded but not in detail. Risk management strategies were poorly recorded and did not give clear explanation as to how the risk was to be managed. In the case of one resident being case tracked a risk had been identified but no management strategy for the risk was recorded in the resident’s care records. One resident was using oxygen but there was no risk assessment in place for the use of oxygen within the home. No training had been provided to staff in the use of oxygen. Care plans are being reviewed since the change of ownership. The acting manager stated that work has been carried out to update and review care plans. Those seen during the site visit were generally of good quality. New care plans are being written with the assistance of residents and where appropriate the family. Health care needs including medication are recorded on care plans. There was evidence of visits by general practitioner, district nurses and chiropodist. Details of hospital appointments were recorded in care records Residents stated that the home enables them to visit doctor or hospital as required. The “have your say” documents completed by residents confirmed that in their opinion their health care needs are being met. All comments relating to health care was positive. The care home has an updated medication policy, which staff are aware of. Medication training has been provided. However on the day of the site visit it was found two qualified members of staff had not completed the medication records as set out in the home’s medication procedure. Six residents were spoken to as part of the site visit. A resident stated, “staff are kind and caring, and they do respect our privacy and dignity”. Observations made by the inspectors during the site visit provided further evidence to support the statement. “Have your say documents” from staff and residents provided further evidence that residents privacy and dignity is respected. A resident stated, “staff always knock before entering my room. They are careful to allow me privacy when I am getting washed. They will assist me with things I cannot do but give me privacy when I am washing some parts of my body.” Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The range of activities offered by the home is limited. This means residents with limited mobility cannot take part in activities. The homes menu offer choices and meets the dietory needs of residents. The home encourages relatives and friends to visit thus maintaining resident’s links with the community. EVIDENCE: Activities offered to residents are set out in the AQAA. Residents stated in the “have your say” document that they are not happy with the range of activities offered. One resident says “Im bed bound no activities are provided for me”. A second resident stated “I am unable to take part in activities due to mobility problems”. A third resident said, “ I have poor eyesight and am therefore unable to join in the activities provided. Care plans seen on the site visit did not contain the individual choices and wishes of activities. This limits some aspects of choices within their social life. Activities were seen to be taking place during the site visit. The home has a policy of encouraging friends and relatives to visit and maintain links with residents. Relatives were seen to visit during the site visit. Residents spoken to on the day of the site visit said that their families were Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 13 made welcome. The details of family and extended family were found recorded on the care records. This included the contact numbers and addresses of the family members. The company supplied a copy of the home’s menu, which demonstrated choices. The Inspector spoke with residents and discussed the menu. Comments from residents were all positive. A resident stated, “the food is very good here”. Other residents stated, “the food here is excellent it looks nice”, “I need a special diet but staff ensure that I it and given a choice of food which answers my dietary needs.” The “have your say” documents completed by residents provided further evidence, that residents are satisfied with the menu. Questionnaires contained only positive comments regarding food offered by the home. Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from updated comprehensive complaints and adult protection procedures. EVIDENCE: The evidence from the inspection of the complaint procedures, records at the home and discussion with staff and residents is that the complaints procedure is accessible to all residents. This ensures residents can raise concerns or make a formal complaint. Only one complaint has been received since the last key inspection. The company investigated this and a report was sent to the Commission for Social Care Inspection. The complaint was resolved to the satisfaction of the complainant. Residents stated they were confident in being able to raise concerns with staff and the manager of the home. Residents and staff interviewed during the site visit stated the acting manager was very approachable and would act immediately if any complaints or concerns were raised with her. There have been no notifications since the last key inspection that have raised any concerns. There has been no Adult protection enquiries held at the home since the last key inspection. The inspection of training records and discussion with staff provided evidence that staff have received training in the identification and prevention of abuse. Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and well-maintained care home, which provides them with a comfortable and safe accommodation. EVIDENCE: The home has an ongoing maintenance program and improvement plan, which states the changes and repairs to be made to the home to improve the environment for residents. The AQAA states that the new company has substantially improved accommodation for residents. They have created a reminiscence café and a summer pavilion on the front lawn. A croquet and putting green has been added. The home was clean and tidy and free from any odour. The acting manager confirmed that the infection control policy of the care home is being followed. No health and safety issues were identified during the site visit. Residents stated their satisfaction with the environment of the care Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 16 home in the “have your say” document. No negative comments were made at the site visit by staff or residents regarding the environment. Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff on duty to meet the needs of residents. The use of the new updated recruitment procedure ensures the safe recruitment of staff. Communication between qualified and unqualified staff is poor. This failure to work together will directly affect quality of care for residents. EVIDENCE: Resident stated at the site visit that they felt there was sufficient staff on duty to meet their needs. “Have your say” documents from staff and residents provided further evidence to support this judgment The inspection of a sample of records for new staff provided evidence that the recruitment policy of the care home is being followed. The individual files of two new staff members contained written references, proof of identity and criminal record bureau checks (CRB). The new company has reviewed the training needs of staff and written a new comprehensive training plan. It is acknowledged by the company that additional training is required, particularly specialised training. Staff stated communication between qualified and unqualified staff is not good. Teamwork was described as inconsistent, with some members of staff working Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 18 well together, and some refusing to carry out good teamwork. The company is addressing this issue. Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is leadership and guidance for staff. The environment is safe. The home’s health and safety policy and infection control policy is being followed which ensures that a safe environment is maintained. EVIDENCE: The care home has an acting manager in post who has been a registered manager for many years at another home. She is to make a formal application to be the registered manager for Seacroft care home. Staff stated the manager is supportive and committed to ensuring good care practice is maintained. She provides good leadership and is found to be very approachable by staff and residents. Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 20 The inspection of care records and discussion with staff provided evidence of good positive leadership and direction to all staff members. Residents and staff stated, they could go to her office at any time if they were concerned. Staff and residents said the acting manager deals with the problems immediately in a positive and helpful manner. The evidence from quality assurance documents and discussions with residents being case tracked, provided evidence that in their opinion residents feel the home is being run in their best interest. The acting manager demonstrated in discussions that the home has appropriate policies and procedures in place to protect the financial interests of residents. She stated said that supervision and appraisals are being carried out appropriately now but were not carried out at the correct frequency prior to the new company buying the home Staff confirmed in formal interviews that supervision is being provided on a one-to-one basis in accordance with National Guidelines. Staff records demonstrated that supervision is now being provided to staff No health and safety issues or infection control issues were identified during the site visit. The acting manager demonstrated, a detailed knowledge and understanding of the needs of people within the category of the home’s registration. Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 21 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 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 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 X 3 3 3 2 3 3 Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 22 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. This is to ensure that the plans reflect all the care needs of a resident, and that those needs can be met. The medication policy of the care home must be followed to ensure residents receive prescribed medication safely. Activities must be provided to meet the choice, wishes and abilities of residents. This is to ensure social stimulation is provided to all residents. Staff must received formal supervision to determine their individual training and personal development needs. Timescale for action 31/01/08 2. OP9 13 – 1 (2) 31/12/07 3 OP12 16 – 2 (n) 31/12/07 4 OP36 18 - 2 31/12/07 Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 23 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.V340527.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Seacroft Court DS0000002551.V340527.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!