Inspection on 13/01/06 for Seahorses

This inspection was carried out on 13th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Seahorses 04/11/09

Seahorses 09/09/09

Seahorses 03/03/09

Seahorses 22/02/08

Seahorses 30/04/07

Seahorses 17/10/06

Seahorses 16/08/05

Seahorses 19/01/05

Seahorses 03/08/04

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

CARE HOME ADULTS 18-65 Seahorses 8 Park Road Gorleston Gt Yarmouth Norfolk NR31 6EJ Lead Inspector Linda Wells Unannounced Inspection 13th January 2006 12.00p Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 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 Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 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 Adults 18-65. 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. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Seahorses Address 8 Park Road Gorleston Gt Yarmouth Norfolk NR31 6EJ 01493 655731 01493 655731 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) Mr John Hallam Mrs Gillian Rose Hallam Mrs Wendy Bain Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Huntingtons Disease and other Neurological Disorders Date of last inspection 16th August 2005 Brief Description of the Service: Seahorses is an older style, chalet bungalow that is run as a residential care home providing twenty-four hour nursing care to six adults with Huntingdons Disease. All bedrooms are single, on the ground floor and contain a washbasin. Residents have communal use of a bathroom, a toilet, lounge and a conservatory that contains the dining area. There is a well-kept garden to the rear of the property and roadside parking to the front. Qualified nurses are part of the staff team and the manager is a qualified nurse. The Home is within walking distance of the sea front, close to healthcare facilities, local shops, hotels and pubs and has its own mini-bus. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 13th January 2006 over four hours and was carried out as part of a routine inspection plan. Prior to inspection comment cards were received from three residents and one relative/visitor. All of the residents indicated that they liked living at the home and felt safe and everyone demonstrated that they were satisfied with the overall standard of care provided for residents. On the day of inspection six residents were living at the home and all residents were seen to be sitting in the lounge, the conservatory or in their bedrooms, watching television. Conversation was limited for some of the residents and staff members were seen to talk openly with all residents in a warm, inclusive, respectful manner that promoted choice. The inspection took the form of a tour of the building, individual discussion with two residents, three staff members, the handyman and the owner, observation of all residents, examination of care plans, records and certificates and compliance with requirements and recommendations from the last inspection. What the service does well: What has improved since the last inspection? Residents have benefited from the improvements made to the information held and stored, the meals being cooked just prior to being eaten and the increased supervision of staff members. The home has been made more attractive by the replacement of the dining table and chairs and conservatory curtains, the redesigning of the front garden and the provision of increased storage space in the garden with the provision of a new garden shed. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 6 What they could do better: The requirements and recommendations from the last inspection have mostly been complied with but there is still more to do to completely ensure that residents are fully protected, consulted and the environment well maintained in all areas. The following eight requirements and one recommendation were made to further improve the experience of living and working at the home for residents and staff. • • • • • • • • Accurate and complete medication administration records must be held to ensure residents are protected. Where assessed as appropriate, the arrangements at death for residents must be recorded in the plans of care to demonstrate that the wishes of residents are known. Replacement of the damaged bath and stained toilet flooring is required to ensure that the health and safety of residents is fully protected. Planned to be refurbished. Repeated requirement. Recruitment checks must be fully completed and CRB checks held for all staff to ensure residents are protected. A photograph and proof of identity must be held for each staff member in their staff file to support the information held. The matron must undertake the NVQ4 in Management award to ensure that she has the knowledge necessary to manage the home. Clear and accurate financial records and correct amounts of money must be held for each resident that the home handles money for to demonstrate that they are protected. Immediate requirement made. A quality assurance system must be produced and include the views of residents, relatives, visitors, staff members and other professionals to ensure feedback and the opinions of everyone is sought on the standard of care and facilities provided in the home. It is recommended that a list of training and updated training carried out by each staff member is held in their staff file to assist in planning training and updates. • 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. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 4, 5 The written information available about the home is complete and enables residents and staff to make a decision on whether the home will meet the needs of anyone wishing to live there. EVIDENCE: The homes Statement of Purpose, Service User Guide and Terms and Conditions contract were seen and found to contain relevant information. The owner said that prior to admission as much information as possible was collected from a prospective resident, their family and other professionals. He said residents, their family or friends sometimes visited the home, that the matron often visited residents in their own environment and that residents were admitted on a one-month trial basis. No resident had been admitted to the home since the last inspection and the records held showed that an assessment was completed prior to admission to the home to ensure that the needs of residents were identified as being able to be met by the home, that the views of residents, their family members and other professionals were sought and that residents and their relatives, friends or advocates visited the home prior to admission. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 10 The health and personal care needs of residents were met, they were well looked after and the records held had improved but were not fully completed. EVIDENCE: Residents were seen to be well looked after and examination of four plans of care revealed that they were improved and contained personal health and social care information, history, choice, assessments, hospital reports, daily report, moving and handling assessment, a swallowing review, nutrition, involvement with other professionals, medical assessment and appointments, key worker reviews, risk assessments, social and leisure activities and a photograph of the resident. Staff members gave examples and records demonstrated that residents were consulted on their daily activities, given choice, supported to take risks, were protected and that their confidentiality was maintained by the individual and safe storage of their information. Observation of financial records managed for residents showed that it was not possible to track the debits and credits of money held for all residents and that Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 10 in one instance the money held did not correspond to the records. An immediate requirement was made that clear and accurate financial records and money must be held for each resident that the home handles money for to demonstrate that they are protected. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16, 17 Meals and social activities are both planned and provide daily variation and interest for the people living in the home. EVIDENCE: Residents have access to community leisure activities organised by the senior care assistant who said that activities were based on the interests and wishes of residents. Records were seen to demonstrate that residents enjoy both indoor and outdoor activities and took part in shopping, bowling, going for walks along the beach, outings and community events such as the theatre. The staff gave examples of how they work with residents to support them in their daily lives, with behavioural management and in maintaining friendships and relationships by working with other professionals, encouraging each resident to be independent and to make choices whilst ensuring that the rights of each resident were promoted and protected. Staff said that the menus were agreed with residents and based on the choice and nutritional needs of each resident. Records showed that detailed instructions on the nutritional content, preparation and consistency of meals Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 12 for each resident were available in the kitchen, that they were varied and balanced and that food hygiene certificates were held by staff members. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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, 20, 21, Personal support is given to residents in the way they prefer, their needs are met but they are not fully protected by the homes medication procedures. EVIDENCE: Residents were assisted with decision-making and the staff spoken to said that they assisted the residents with limited communication skills by understanding their response to questions and preferred manner of communication, observation and as recorded. The plans of care did not contain the arrangements at death for each resident and a requirement was made that where assessed as appropriate this information be held for each resident to demonstrate that they were consulted and their wishes known. Residents said that they received personal and emotional support from staff members who were always willing to listen to them and demonstrated that they knew who to tell if they wished to complain. Trained nursing staff were responsible for the administration of medication and records demonstrated that staff had undertaken training in medication administration, medication was stored correctly, policies and procedures were held but had not been fully complied with on six occasions when medication administration records were seen to be incomplete. A requirement was repeated that medication records be accurately completed to protect residents. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has an active procedure on the protection of vulnerable adults that protects residents and supports the investigation of any cause for concern. EVIDENCE: No complaints have been received by the home since the last inspection and the residents spoken to all said that if they wished to complain they would tell the matron or the owner and all agreed that they would be listened to and appropriate action taken to resolve the problem to the satisfaction of all concerned. Residents are protected from abuse, neglect and self-harm by the objectives, policies and procedures of the home and staff have undertaken training in Adult Abuse to help them recognise, prevent and deal with any potential abuse. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 The standard of the environment within this home is mainly good providing residents with an attractive, safe and homely place to live, however some areas require attention. EVIDENCE: A tour of the building revealed that residents benefit from a home that is decorated and furnished to a good standard. It contained some specialist equipment such as a hoist and ramps and the residents spoken to said that the home was comfortable, clean, tidy and odour free. This was found during the tour of the building and residents were seen to have personalised their bedrooms. However, a requirement was repeated that the communal bathroom is refurbished and the flooring in the toilet be replaced. The owner outlined his plans to extend the accommodation once the plans have been passed and said that the bathroom and toilet would be refurbished at this time. All infection control measures were in place and the laundry room contained a service sluice/washing machine and tumble dryer to aid in the protection of the health and safety of all residents and staff. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 32, 33, 34, 35, 36 The needs of residents are met, staff member are competent, but the procedure for the recruitment of staff does not fully provide adequate safeguards to protect people living at the home. EVIDENCE: Residents were well cared for and staff members were aware of the needs of each resident and their role and responsibilities. Staff members spoken to said that they felt supported by the matron, nursing staff, the daily handover, received supervision and attended staff meetings to ensure the protection of those living at the home. Records showed that some staff recruitment checks had been carried out and references, personal details, contract, job description and health declaration were seen however, two requirements were made that CRB checks be undertaken on all staff and a photograph and proof of identity of each staff member be held in their staff file. Half of the staff employed are trained nurses and records held demonstrated that care staff had undertaken basic training such as induction and foundation, food hygiene, emergency aid, medication, fire safety, moving and handling, challenging behaviour and some had completed or commenced NVQ 2 or NVQ3. A recommendation was made that a list of training and updated training be held for each staff member to show competence and aid planning. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42, 43 The matron is supported by the nursing staff, in providing leadership, guidance and direction to staff to ensure that residents receive a good standard of care and support. EVIDENCE: Residents and the staff spoken to said that the home was run in a way that promoted the best interests of those that live there, that the matron was supportive and had a friendly, open approach that promoted team work. She is a qualified nurse but has not completed the NVQ4 in management and a requirement was made that she undertakes this training. Residents are protected by the management and administration procedures carried out in the home. Policies and procedures have been produced on all aspects of the home and service provided and the records held promote and protect the rights and best interests of each service user. A Quality Assurance system is in the process of being produced that the owner said would be carried out with residents and relatives. A requirement was Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 18 made that the Quality Assurance system be further developed and include the feedback and views of residents, relatives, visitors, other professionals and staff members on the standard of care, service, facilities and lifestyle provided for residents and that an action plan of improvements be produced from the information gathered. To ensure that the health and safety of residents is protected the servicing and testing of all equipment had been carried out, relevant and timely certificates were held and records were stored securely. The owner said that he monitored identified financial budgets for the home and that there was no reason to doubt that the financial security of the home was not sound. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 2 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Seahorses Score X 3 2 2 Standard No 37 38 39 40 41 42 43 Score 2 3 2 X 3 3 2 DS0000032541.V270113.R01.S.doc Version 5.0 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 YA7 Regulation 17.2 Requirement Timescale for action 13/02/06 2. YA20 3. YA21 4. YA24 5. YA34 The registered person must ensure that clear and accurate financial records and money are held for each resident. 13.2 The registered person must ensure that records are completed for all medication administered or not administered. (Previous timescale of 1st October 2005 not met) REPEATED REQUIREMENT 12.2 The registered person must ensure that the wishes at death of each resident are recorded in their plan of care. (Previous timescale of 31st October 2005 not met) REPEATED REQUIREMENT 23.2.b The registered person must ensure that the repaired bath in the bathroom and the flooring in the toilet are replaced. (Previous timescale of 30th November 2005 not met) REPEATED REQUIREMENT 19.1 sch 2 The registered person must ensure that a photograph and proof of identity are held for each member of staff. DS0000032541.V270113.R01.S.doc 31/03/06 30/04/06 30/06/06 30/04/06 Seahorses Version 5.0 Page 21 6. 7. 8. YA34 YA37 YA39 19.1 sch 2 The registered person must ensure that a CRB is held for each member of staff. 10.3 The registered person must undertake NVQ4 in management training. 24.1.2.3 The registered person must develop a quality assurance system and produce an action plan. 30/04/06 30/06/06 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA32 Good Practice Recommendations It is recommended that a list of training and updated training completed by each staff member be held in their staff file to demonstrate competence and aid planning. Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Seahorses DS0000032541.V270113.R01.S.doc Version 5.0 Page 23 - 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. 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