Inspection on 13/12/07 for Seahaven

This inspection was carried out on 13th December 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

Seahaven 10/12/08

Seahaven 06/10/06

Seahaven 28/04/05

Seahaven 14/10/04

Seahaven 10/06/04

Similar services:

22 Sandown Road

The Highlands

Turret Villa Retirement Home

Dilston College Of Further Education

West View House

Moor House

Prince Bishop Court

Park View (15)

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

CARE HOMES FOR OLDER PEOPLE Seahaven 146 Beach Road South Shields Tyne And Wear NE33 2NN Lead Inspector Mrs Irene Bowater Key Unannounced Inspection 13 December 2007 10:00 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 Seahaven DS0000000242.V350332.R02.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. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seahaven Address 146 Beach Road South Shields Tyne And Wear NE33 2NN 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) 0191 456 7574 0191 454 5743 Mr Harold John Stafford Mrs Kay Richardson Care Home 30 Category(ies) of Dementia (10), Learning disability (3), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Old age, not falling within any other category (30) Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service uses of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 30 Dementia - Code DE, maximum number of places: 10 Learning Disability - Code LD, maximum number of places: 3 Mental Disorder, excluding learning disability or dementia - Code MD, maximum number of places: 2 The maximum number of service users who can be accommodated is: 30 6 October 2006 2. Date of last inspection Brief Description of the Service: Seahaven is registered to provide personal care for 30 people, of whom up to ten may have a dementia type illness. The home also provides three places for people with a learning disability and two places for people who have mental health problems. Nursing care is not provided; support from the Community Nursing Service is arranged where required. The home is a converted house, which has been extended. . It is situated on Beach Road adjacent to beach and park. The accommodation consists of a dining room, two lounges and a large conservatory. A passenger lift services all floors. The bedrooms are spread over three floors and residents are able to gain access to all parts of the home. Many of the bedrooms provide people with views of the beach and sea. There is a small garden to the rear of the home with a paved seating area. The town centre of South Shields where there are local facilities such as shops, pubs, GP surgeries and places of worship are close by. Street parking is Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 5 available. The charge for a place at Seahaven is £349. There are extra charges for hairdressing and private chiropody services. The Home’s brochure confirmed that a copy of the most recent inspection report is available on request to residents, visitors and staff. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 6 October 2006 and 10 January 2007. • How the service dealt with any complaints and concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • The views of people who use the service and their relatives, staff and other professionals The Visit: An unannounced visit was made on 13 December 2007 During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors • Looked at information about the people who use the service and how well their needs are met • Looked at other records which must be kept • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for • Looked around the building to make sure it was clean, safe and comfortable • Checked what improvements had been made since the last visit • We told the deputy manager what we found. What the service does well: Staff gather information about the person before they move into the home to make sure they can meet their needs. Staff talk with other professionals to ensure residents care and health needs are met. Good relationships have developed between staff and residents Care was given discreetly and with sensitivity. Medication procedures are followed which promotes peoples health. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 7 The quality of meals remains very good. The home uses local suppliers so that food is always freshly delivered and cooked. The majority of bedrooms, both lounges and the conservatory have magnificent views of the harbour and sea, which is a particular striking feature of the accommodation. Everyone, without exception said that they would feel able to approach the manager or staff if they had any concerns or complaints. There is very little turnover in staff which means that people benefit from continuity of care. The staff have also received training at NVQ level 2 and 3, which helps them to carry out their job well. Four members of staff have completing the NVQ level 4 qualifications in management and care, which makes sure the home, can run effectively when the registered manager is not there. There are good arrangements for supporting residents to keep their personal monies in a safe place if they want. The registered manager makes sure that relatives can make suggestions and comments about the home and listens to what they say. Comments received included the following: “The phone is always available and the staff helped my mother programme it as she could not manage on her own” “I am always advised if X is ill or even feeling a bit down” “X is encouraged to do things for herself but help is always available. “This is the correct level of care for her” “Seahaven provides a safe environment where she has privacy when required. The regular routine and supervision of medication has seen her health improve.” “This summer she has enjoyed outings that have been arranged by the staff.” “The staff always have time to chat and she enjoys the interaction” “All staff are very friendly and respectful to residents and visitors” “Very good staff, look after everyone very well”. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 8 What has improved since the last inspection? What they could do better: The storage arrangements for medication needs to be reviewed The planned refurbishment and redecoration plan needs to be forwarded to the Commission. The carpets in the front lounge needs to be changed or deep cleaned on a regular basis. The home needs to continue with the refurbishment and redecoration of the communal areas including corridors. The bath needs to be repaired or replaced. Personal toiletries must not be used communally and must be stored in individual bedrooms. Staff must not use bar soap for hand washing. Liquid soap must be available throughout the home. The registered manager must ensure that the Home’s hoisting equipment is maintained on a regular basis. This will help ensure that residents are protected from potential harm. Comments included: “The staff may wish to make relatives aware of the role which they Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 9 perform” “Need more activities for residents” “Improve or extending the social programme top varied weekly events” 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. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 10 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 Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 11 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): 3 Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. People have their needs and wishes comprehensively assessed before they move into the home to ensure staff can care for them properly. EVIDENCE: Case tracking of three people showed that both the registered manager and care managers complete assessments in order to ensure that residents needs can be met in the home. Admission information is detailed and gives information about previous lifestyles, including background, cultural, religious or other needs and how this will help people settle into the home. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 12 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): 7,8,9,10. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Record keeping is good and demonstrates that the needs of people living in the home are fully met. . EVIDENCE: Since the last visit to the home the staff have worked very hard to bring care plans up to date. Each person has a care plan that has been developed with the help of information gathered before they came to live in the home. This includes likes, dislikes, social and religious preferences. The care plans are signed by them, or their relative, confirming their agreement with the contents. They are easy to understand, had been written in plain language and reviewed on a monthly basis. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 13 For example, one person likes going out on a regular basis and needs some help looking after the budgerigars. This person has had a few falls recently and is unsteady. There is clear information for staff to follow to make sure the risk of further falls is reduced. Expert advice is also being sough from the fall prevention specialist. Another care plan shows in detail how staff are to care for someone who is very poorly. Clear information about how to give pureed diet and stage three thickened fluids is available Staff are recording when fluids and diet are taken on charts, which are kept up to date. The care plan is detailed about how this person is to be moved in bed and how staff are to prevent further pressure damage. Abbreviations were used in the care plan, which made that part difficult to follow. Staff were able to confirm that it meant wear protective clothing such as plastic aprons and gloves. The district nursing services visit three times a week to attend to the nursing needs. Another care plan showed that care plans were in place should someone become anxious or verbally aggressive. Staff have contacted other professionals to see how this persons behaviour can be managed better. The care plan will assess triggers and show what staff can all do to diffuse potential difficult situations. Risk assessments are in place for falls, moving and handling, nutrition and pressure sore care. The residents have access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s including, opticians and chiropody services. Advice and support is available from other healthcare professionals when required such as the District Nursing Services, Continence Advisor, and Speech and Language Therapists. Historically medicines have been stored securely in the dining room. As this room is due to be redecorated in the New Year alternative safer storage would be beneficial. There is a staffing room upstairs where medicines could be stored in a locked cupboard. This room would hold other equipment such as the drug fridge and dressings. Staff would also have access to hand washing facilities. Policies and procedures are in place, which cover the storage, handling and administration of medication. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 14 Staff have completed training in safe handling of medication. The medication records were well maintained with no unexplained gaps demonstrating that people are receiving their medication as prescribed. Currently no one self medicates. There are no Controlled Drugs currently prescribed to anyone living in the home. Care was given in a discreet, respectful manner, with staff knowledgeable about peoples’ preferences. Examples include being able to have a key to their room, receiving their mail unopened, being addressed by their preferred name and being able to go wherever they wish inside and where possible, outside of the home. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 15 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Daily life experiences and opportunities to take part in activities have improved and they are being supported to keep control over decision-making in their everyday life. EVIDENCE: Since the last inspection the manager has employed an activities person who organises events both inside and out of the home. Care plans show that staff have asked about individual likes, dislikes and previous lifestyles. This information is then used to try and make sure people can maintain their own quality of life. There is an activities diary which records what events have taken place during the week Events have included sing longs. bingo, dominoes and reminiscence. Some of the people do not like to join in-group activities and time is spent with them on an individual basis. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 16 People said that the Christmas party was good and they enjoyed the entertainer. One person said that she had been to Blackpool for the day with a member of staff, which they both enjoyed. The home has also arranged trips to the theatre, out for Christmas dinner and there are plans to go to the Pantomime in the New Year. Several of the people living in the home have a dementia type illness .The new “Activities for Today” resource pack once fully operational will make sure that they are provided with equal opportunities to lead stimulating lifestyles. The staff supports anyone who wishes to go out locally to do shopping. Information about advocacy is readily available in the home. People have brought small items with then making their rooms individualised and reflective of their lifestyle and religious beliefs. There are no restrictions on visiting times and they confirmed that their visitors are made welcome at anytime. The tables were nicely set with tablemats, condiments, napkins and suitable cutlery and crockery. Residents said they were always asked what they wanted and could always choose something else if they didn’t like what was offered. The meal reflected the menu plan, and the choices of meal were written on a chalkboard in the dining area so that people were aware of what they could have. The lunchtime meal consisted of Lasagne or Sausage and Onion Casserole, with savoy cabbage, carrots and mashed potatoes. Choices for dessert were jam Madeline’s with custard or semolina and jam. Some residents chose to have yoghurt. Hot and cold drinks were readily available throughout the meal. Staff were kind, considerate and patient when serving and helping people to eat their meals. Nutritional risk assessments and information about food preferences were available in care plans. The cook knew about individual likes and dislikes and how food would be fortified should someone loose weight or become unwell. Staff have received support and advice from a speech and language therapist about how to ensure that people who may be at risk of choking received a good diet. Comments about the food included: “There is always plenty to eat” “The food is very nice” Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 17 “I can always have what I want to eat” Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 18 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): 16,18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The complaints and safeguarding procedures are clear This means people are confident that their views are listened to and acted upon and people are protected from harm. EVIDENCE: The home has clear complaints policies and procedures, which are displayed, in the home. The records showed that complaints are documented appropriately and include outcomes with signatures obtained to confirm the complainant’s satisfaction of the outcome. There have been five complaints received since the last key inspection and they have been resolved at home level. All of the people spoken with said they had nothing to complain about but were very clear that the manager would deal with any issue immediately. The Home has a Protection of Vulnerable Adults Procedure (POVA) in place and a copy of the Local Authority’s Procedural Framework for the Protection of Vulnerable Adults, is available to staff. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 19 The staff complete training with an external training agency. Staff have completed the “Alerter” training with the Local Authority. There have been two Safeguarding Alerts made to the Local Authority and reported to the Commission for Social Care Inspection. They have been resolved. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 20 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): 19,20,21,24,26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Although the home is clean, warm and comfortable further improvements are needed to make sure it remains a pleasing, safe place for those living there. EVIDENCE: The home is a converted house with accommodation provided over three floors. Access to all areas is via stairs and a passenger lift. There are a variety of lounges, conservatory and a large dining room. There has been an ongoing problem with occupancy over the last year. This means that some of the refurbishment and redecoration of the home has not been done due to lack of funds. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 21 However since the last key inspection a plan of how the home is going to be redecorated is in place. The dining room is due to be refurbished early in 2008. The doors have been re varnished, some damage to walls has been repaired, worn armchairs have been disposed of and the odour in one identified bedroom has been eradicated. There is still work to be done, including cleaning or replacing the front lounge carpet and repairing damage to walls and doors through wheelchair damage. The lounge upstairs offers magnificent views of the sea and adjacent park. The dining room carpet is regularly cleaned, however does get stained from food spillage. None of the bedrooms has an en-suite facility. However there are toilets and bathrooms close to all bedrooms and communal areas. Some of the toilets do not have grab rails and the decoration is quite bare. The enamel has been scraped of one bath by the bath seat, which makes it difficult to keep clean. The non-slip plastic bath mat was grimy and had mould on the back. All of the bedrooms were furnished and decorated to a satisfactory standard. All reflected the previous lifestyle and current preferences of the individual. Five bedrooms have been redecorated. All areas were clean, fresh and furnished to a satisfactory standard. The laundry and sluice is combined and the staff said the sluice disinfector had been repaired In all of the bathrooms there was evidence of communal toiletries and use of bar soap, which could be an infection risk. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 22 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Good systems are in place to ensure that enough competent staff are recruited and in place to fully meet the needs of residents. EVIDENCE: Four of the senior staff have completed the National Vocational Qualification (NVQ) level 4 qualification in care whilst other staff have either completed or are in the process of completing NVQ at level 2 or 3. Over On the day of the site visit there were four care staff on duty including the deputy manager and three care staff on duty in the afternoon and evening. An activities person has been employed on the afternoons. She also helps those who need assistance at meal times. In addition there are domestic staff and a cook. The home benefits from staff who have worked together for some considerable time. Three staff files showed that recruitment procedures are followed. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 23 Job descriptions and roles are clear and each file had an application form completed. There was evidence of Criminal Record Bureau checks, Protection of Vulnerable Adult checks, and proof of identity. Staff complete an induction programme and have a training and development file. Records show that staff have completed training in food hygiene, infection control, moving and assisting, fire prevention and safe handling of medicines. Other training includes positive dementia care. Over 70 of staff have a National Vocational Qualification. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 24 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): 31,33,35,38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home has an experienced manager who provides leadership and guidance to make sure the home is run in the best interests of people using the service. Lack of monitoring and servicing of all equipment has the potential to put people at risk. EVIDENCE: The registered manager has the Higher Diploma in Management and Care Services qualification and the Registered Managers Award with over 20 years experience as a manager in this home. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 25 She attends training to update her knowledge and skills whilst managing the home. The responses from the comment cards and from discussions on the day confirmed that she is approachable, available and supportive at all times. The Home had purchased a quality assurance package, which is in use. There was evidence that staff, service users, relatives and visiting professionals had been surveyed about the quality of care provided at the Home. Should there be any concerns raised about any aspect of the service the manager tries to resolve the issue without any delay. The quality of the service is also monitored by means of monthly audit checks, which cover a range of activities within the home including medication, staff training and supervision as well as regular audits of the complaints book and the environment. An audit of three personal allowances was carried out. There were no discrepancies. All had individual records and separate wallets containing their money. The records are dated with two signatures and receipts are available for all transactions. Evidence was seen in the records and staff confirmed they had received training in health and safety issues such as, food hygiene, first aid, infection control, moving and handling and COSHH (Control of Substances Hazardous to Health). Accidents are recorded and the manager carries out an analysis to examine any trends. Contract certificates were available and up to date for Legionella, fire, gas safety and the passenger lift. The 6 monthly servicing for the hoist and bath hoists were due service in October 2007. These certificates were not available on the day of the site visit. Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 26 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 3 8 3 9 2 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 X 18 3 2 2 2 X X 2 X 2 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 X 3 X X 2 Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 27 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 OP19 Regulation 23 Requirement The registered persons must ensure that the planned redecoration and refurbishment programme is forwarded to the Commission. This is to ensure people continue to live in a safe well-maintained environment. The registered persons must ensure that the carpet in the front lounge and dining room is replaced. Continue to repair damage to walls and doors throughout the home. This is to ensure the home remains a pleasant place to live. The registered person must ensure that the damaged bath is repaired or replaced and the non-slip mat replaced. This is to ensure that infection risks are minimised and people have suitable bathing facilities. The registered person must ensure that toiletries are for personal use and are not stored collectively in bathrooms. Provide liquid soap in all resident areas to enable effective hand DS0000000242.V350332.R02.S.doc Timescale for action 01/03/08 2 OP20 23 01/06/08 3 OP22 14,16,23 01/03/08 4 OP26 13,16,23 31/01/08 Seahaven Version 5.2 Page 28 5 OP38 13(2) washing. Bar soap must not be used for communal use. This is to ensure infection risks are minimised. The registered person must ensure that the hoist and assisted bath chairs are serviced every six months with records available This is to ensure the health and safety of the people who live here. 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP9 OP22 Good Practice Recommendations The registered person should make sure that abbreviations are not used in care plans. The registered person should consider transferring all medication storage to the upstairs staff room. The Registered Provider and Manager should review the provision of aids and adaptations within the Home’s bathrooms and toilets to ensure that they contain the necessary equipment. The assessment should preferably be undertaken by a person with training in this area. The Registered Persons should ensure that staff receives an annual performance appraisal. 4 OP36 Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Seahaven DS0000000242.V350332.R02.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!