CARE HOMES FOR OLDER PEOPLE
Seahaven 146 Beach Road South Shields Tyne and Wear NE33 2NN Lead Inspector
Nic Shaw UnAnnounced 28 April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Seahaven Address 146 Beach Road, South Sihields, Tyne Wea, NE33 2NN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 4564574 0191 4545743 Mr H J Stafford Mrs Kay Richardson Care Home 30 Category(ies) of OP Old Age 30 - DE (e) Dementia over 65 (6) registration, with number DE Dementia (6) of places Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: The DE(E) and DE service user categories relate to current service users only Date of last inspection 14 October 2004 Brief Description of the Service: Seahaven is care home which is registered to provide personal care for up to 30 service users, six of whom have a dementia type illness. Nursing care is not provided but District Nursing services can be accessed if required. Accommodation is over three floors with level access throughout. A lift provides access to each floor as well as two staircases. Accommodation consists of two lounges, one of which is a designated smoking area, a seperate dining area and a conservatory. There is a small garden to the rear of the home which provides service users with a paved seating area. The home is situated on Beech Road which is adjacent to the beach and is close to the town centre of South Shields where local facilities such as shops, pubs, GP surgerys and places of worship can be easily accessed. Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 7 hours and was a scheduled unannounced inspection. The inspection process involved spending time talking to a number of the people who live in the home as well as the manager and staff. A sample of records were examined including care plans, rotas, accident book and fire log book. A tour of the building took place which included all communal areas and a sample of service users bedrooms. The lunchtime meal was also sampled and observations were made of the support the staff offered to service users throughout this process. The judgements made are based on the evidence available on the day of the inspection. What the service does well: What has improved since the last inspection?
Some of the communal areas of the home have been re-decorated. The manager has also up-dated some of the records, policies and procedures.
Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 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. Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 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 standard(s) 1 The homes Statement of Purpose and Service User Guide provide prospective service users with details of the services provided in the home. This means that service users are able to make an informed decision as to whether they wish to move into the home. EVIDENCE: Discussion with the manager and records examined confirmed that since the last inspection The Statement of Purpose has been reviewed and amended to meet the requirements of the Care Homes Regulations 2001. This also now includes details of the fire precautions and associated emergency procedures. The manager confirmed that all service user’s, on admission to the home, are provided with a “welcome pack” which they keep in their bedrooms. This is the Service User Guide, which provides service user’s and their relatives with easily understandable information on the facilities available to them in the home. Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 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 standard(s) 7 and 8 The health and personal care needs recorded in the care plans do not reflect the service users current level of need. This potentially means that the service users heath and personal needs are not being adequately met and therefore their welfare is at risk. EVIDENCE: Service users spoken to said that they felt that their health and care needs were being met in the home. They said that they had access to their GP, District nurse and were always accompanied by staff to attend hospital appointments. Staff spoken to were knowledgeable of the service users individual needs and observations made on the day of the inspection confirmed that the staff addressed the service user’s daily care needs adequately. Observations made confirmed that equipment such as specialist mattresses have been provided. However, care plans lacked detail and did not reflect the level of care some of the service users currently need. There were no risk assessments or risk management strategies in place for those service users at risk of developing pressure sores, at risk of falling, and for whom a nutritional assessment identifies that this is an area of need.
Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 Page 10 Six of the current service users have developed dementia since their admission to the home. There was no information available in the care plan to inform staff of the interventions necessary to meet these service users needs, nor was there any evidence recorded to suggest that other medical professionals such as psychologists or community psychiatric nurses had been involved in their care. Monthly reviews are carried out by the home, which involves the service users relatives and the manager. However, discussion with the manager and records examined confirmed that a full review meeting involving the service users social worker/ care manager have not been held since some of the service users were first admitted to the home. This means that service users no longer know whether the home continues to be able to meet their needs. Care plans examined did not include any information in relation to the needs of those service users with special dietary needs such as diabetes, or for those service users who had suffered significant weight loss, which was evident from reading weight charts. . Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 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 standard(s) 12 and 15 Service users are offered a varied menu with wholesome food, which promotes their health and well being. However, there are limited opportunities for social activities therefore there is very little for the service users to do in the home. This restricts service users ability to lead stimulating and fulfilling lifestyles. EVIDENCE: Service users spoken to said that there were no planned activities available to them. Three of the service users spoken to said that the staff had recently taken them on a short trip to the park, which is opposite the home, although they said that this does not happen regularly. An activities co-ordinator was previously employed by the home and the service users spoken to reflected upon the enjoyment they received from taking part in activities and going to local places of interest. There was no recorded activities plan and opportunities for service users to go out are limited to outings with their relatives. On the day of the inspection
Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 Page 12 service users were observed to spend their time either in their bedrooms or lounges watching TV. All service users spoken to commented on the good food provided. They said that they were given a choice of main meal, food that they liked and that there was always plenty of it. They said that the cook takes time to talk to them to obtain feedback on the quality of the food provided, although they said that they are not directly involved in the menu planning process. Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 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 standard(s) 16 &18 The home has a satisfactory complaints system. Complaints are handled appropriately and the outcomes used to improve the service. Appropriate systems are in place to protect service users from abuse and potential harm. EVIDENCE: Service users spoken to said that if they had any concerns about the service provided then they would have no hesitation in approaching the manager. They said that some time ago they had complained to the manager about each day there always being a cooked main meal on the menu. They said that the manager had asked them what could be done to improve the menu and their suggestions were listened to and acted upon by her. Records examined confirmed that there is a complaints procedure in place and detailed records of any complaint made to the manager are maintained. The home has its own policy and procedure documents relating to abuse which are available to staff to guide them if they have any concerns in this area. The policy file was examined and staff have signed this policy as evidence that they have read it. This policy makes reference to South Tyneside’s local authority adult protection policy and procedure in order that staff are clear about who to report any suspicion of abuse to. Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 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 standard(s) 19 &24 The home is clean, warm and well maintained offering service users a homely and safe environment in which to live. EVIDENCE: Service users spoken to said that since the last inspection in October last year the communal lounges have been re-decorated. Although there is no maintenance programme the manager stated that areas that need attention are dealt with as required. This was evident as outstanding environmental issues from the last inspection, for example the damaged toilet flooring, have been addressed. All bedrooms are single occupancy. There are no en-suite facilities, however, communal toilets are located near to bedrooms and lounges. A number of service users took pride in showing us their rooms and how they have personalised them to suit their preferences and likes. Some of the service users have their own telephones so that they can make and receive calls in private. A particular striking feature of the home is the magnificent views
Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 Page 15 some of the service users have of the sea and harbour from their bedroom windows and all of the service users spoken to referred to this as a positive aspect. Since the last inspection the manager has confirmed in writing to the Commission for Social Care Inspection that all issues identified during the fire authority inspection have been addressed. Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 &,28. Staffing levels must be reviewed to ensure that there are sufficient staff on duty to meet the current needs of the service users living in the home. Service users are provided with continuity of care from a well trained staff team. EVIDENCE: On the day of the inspection the manager, 1 senior member of staff, 2 care staff, a cook, 2 domestics and a housekeeper were on duty. This is consistent with the previously agreed minimum staffing levels. However, observations made during the inspection indicated that the staff were very busy attending to the service users personal care needs and were not often visibly present. They did not appear to have the time to sit and chat with the service users. Records examined and discussion with the manager confirmed that there are currently no staff vacancies and the staff team has remained unchanged for some time. Discussion with the manager, staff and records examined confirmed that of the 15 care staff, 8 have achieved the care NVQ level 2 qualification in care, and 6 are completing either an NVQ level 3 or 4 qualification in care. The staff have received basic training in relation to the needs of people with dementia. However, the manager has recognised that the staff need more in depth training in order to understand the complex needs of people with this illness and how to address such needs. As such she has arranged for 10 of the staff to access a more intensive 4 day training course in relation to this.
Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 37 & 38 The service users health and welfare is generally well promoted by a home that is managed by an experienced, qualified management team. The systems for service user consultation in the home are inadequate with no formal processes in place to obtain the service users views. This needs to improve to promote and safeguard service user’s rights. EVIDENCE: The 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. The deputy manager spoken to said that she is currently completing the NVQ level 4 qualification in care and the senior staff are also completing this qualification.
Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 Page 18 Service users spoken to said that the proprietor often visits the home and consults them about the service provided. They said they knew who the manager was and said they felt they could approach her and the staff with any concerns they may have. However, there are no formal quality assurance systems in place to obtain the views of service users such as service users meetings, or questionnaires. Those records required by regulation which were requested were in place, with the exception of the staff rota. Of the sample of past rotas viewed these indicated that sometimes on a weekend the minimum staffing level had not been maintained. This was discussed with the staff who were on duty at these times who said that the minimum staffing level was always maintained and this must have been an oversight. The manager also maintains a staff signing in book. This provided confirmation that the minimum staffing level had been maintained. On the day of the inspection the home was free from any noticeable hazards. Records examined confirmed that accidents are recorded appropriately. However, the fire log book indicated that night staff had not received a fire instruction every three months and that all staff now need to be given a six monthly fire drill. Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 3 x x x x 3 x x STAFFING Standard No Score 27 2 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 2 x x x 2 2 Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement Service user plans must be in sufficient detail to provide clear guidance to staff on the actions to be taken to meet their health and welfare needs. Service user plans must be kept under review. The registered manager must ensure that where necessary service users recieve treatment and advice from specialist health professionals. Evidence must be available to confirm that the needs of those service users with special dietary requirements are being adequately met. A programme of activities must be arranged which meets the needs of the service users. A review of the dependency levels of the current service users must be carried out and if required staffing levels increased accordingly. (Previous timescale 30th January 2005). Systems must be put in place to obtain the views of service users and their relatives. The registered manager must Timescale for action 30th August 2005 2. 8 13(1)(b) 30th August 2005. 3. 4. 12 27 16(2)(n) 18(1)(a) 31st July 2005. 30th June 2005. 5. 6. 33 37 24 17(3)(a) 31st July 2005. 30th May
Page 21 Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 7. 38 23(4)(e) ensure that the rota is kept upto-date. All staff must recieve fire instruction and drill at the required frequency. 2005. 30th May 2005. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Seahaven B52-B02 S242 Seahaven V219768 280405 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Baltic House Port of Tyne South Shields Tyne and Wear NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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