Inspection on 18/05/05 for Seahorses

This inspection was carried out on 18th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Seahorses 23/10/07

Seahorses 12/02/07

Seahorses 30/09/05

Seahorses 12/10/04

Seahorses 25/05/04

Seahorses 10/03/04

Seahorses 26/11/03

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

CARE HOMES FOR OLDER PEOPLE Seahorses 73 Draycott Road Chiseldon Swindon Wiltshire SN4 0LT Lead Inspector John Hurley Unannounced 18 May 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. Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Seahorses Address 73 Draycott Road Chiseldon Swindon Wiltshire SN4 0LT 01793 740109 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) Mr Peter Coleman Mrs Shirely Cole Care home 15 Category(ies) of DE(E) Dementia - over 65 - 15 registration, with number of places Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No more than 15 service users with DE/E at any one time Date of last inspection 12 October 2004 Brief Description of the Service: Seahorses is a private 15 bed home that provides for men and women aged over 65 years who have dementia. The home is situated on the outskirts of Swindon in the village of Chiseldon. Close by is Junction 15 of the M4.The accommodation is mainly on the ground floor with two bedrooms on the first floor. It consists of 2 shared rooms and 11 single rooms. The homeowner takes a keen and personal interest in the running of the home and resides on the premises most of the time. The homes manager has the day to management of the service. Support staff give the personal care and provide for the welfare needs of the service users. Their duties also include cooking, cleaning and administration as part of their job role. The home provides a garden with flat level access. Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over five hours and was prompted following a vulnerable adults meeting. The inspector viewed all areas of the home and met with visiting relatives and three care staff on duty. A number of records were examined including four service users care plans, risk assessments and health and safety records. Due to the service users mental health problems their views are not used in the report, but visiting relatives opinions have been incorporated along with the inspector’s observations. What the service does well: What has improved since the last inspection? What they could do better: The management needs to ensure that it learns from issues that are raised and takes action promptly. They need to ensure that they are seen to be working in partnership with other statutory agencies in an open and constructive way. Furthermore the management need to ensure there are sufficient food stocks at all times. All staff need to be empowered to put their own learning into practice. They need to feel confident that they can raise issues with their management and that their concerns are acted upon in a professional manner Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 6 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 DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.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 Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.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) 3,4,6 There is a clear admission procedure that ensures service users needs are assessed prior to admission. Relatives confirm that they were consulted and listened too when their family members took up residence. EVIDENCE: The file concerning the last service user to take up residency contained good details relating to the individuals presenting issues as well as a good social history. There was a community care assessment, which detailed the needs of the service user provided by social services along with a discharge assessment and diagnosis from the local hospital. A care plan had been generated from these documents, which demonstrates how the home will met the assessed needs. Visiting relatives confirmed that they had been consulted on the general requirements of their relations as well as more detail on the service users social history and personal history. Intermediate care is not a feature of this service. Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.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) 7,8,9,10 The assessment documentation and care planning is detailed and provides a good basis for providing care. Staff failed to treat the service users with the respect they require by failing to report alleged poor practice in a timely fashion. EVIDENCE: The individuals care plans reflect admission assessments. Relatives confirmed that they had been involved in ongoing reviews of the initial care plan and were confident that they were kept informed of issues that affect their relative. Presenting risks have been assessed and the necessary action taken in consultation with the relatives. The service users files evidence that health care needs are addressed through regular health care visits from a general practitioner, chiropody and district nursing services as well as external appointments to dental and community health services. Due to mental health issues the service users do not self-administer their own medication. The reasons to take control of the medication are made through a risk assessment framework and agreement of others. Through the investigation of a complaint it has been established that staff failed to bring concerns of alleged poor care practice to the attention of the Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 10 management. This failure undermines the ability of the home to ensure that the service users are respected and treated with dignity. Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.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) 13,14 Service users are encouraged to maintain links with people important to them. The weekly menu would provide a balanced diet if followed and sufficient food stocks were maintained at all times. EVIDENCE: Visiting relatives confirmed that they could visit at any reasonable time of day. They further confirmed that they could take their relative out whenever they wish. The service user records provide further evidence that were possible friends and family visit and note important people in the service user’s life. The meal observed at the time of the inspection appeared to be served in a well-maintained area in an unhurried and pleasant manner. Those service users who required assistance were given help in a inconspicuous manner. Relatives informed the inspector that they were satisfied with the quantity and quality of the food on offer. The meal served at the time of the inspection was not the meal that was planned on the menu. The food stocks were insufficient to provide the planned meal for dinner or tea. Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 12 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) 16,17 The information supplied so far by the registered person with regards to the one of the complaints demonstrates a poor understanding of vulnerable adults procedures. The staff group failed to protect the service users by allowing alleged poor practice to take place over a six-month period. EVIDENCE: Two complaints have been referred to the registered person for them to investigate. One of these complaints has been resolved and one is currently under further investigation through the vulnerable adults procedure. In response to the latter complaint staff have provided written statements to the registered person that alleges poor practice that would have put service users at risk. The registered person failed to pass these concerns on to the regulator at the time they were made. At the time of writing the report they have not made all of the evidence mentioned in the investigation report available to the vulnerable adults group and failed to contact the regulator to discuss the issue further as requested at the time of the inspection. Through discussion with staff and management on the issue of vulnerable adults procedures it is clear that they knew what to do if abuse was suspected. Whilst they knew what they should do it is also clear that they did not act on their own observations and concerns. Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 13 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) 19,23 The home provides an environment that retains many domestic features. It appears to be safe and well maintained. EVIDENCE: The environment was observed as clean and safe. Some of the service users rooms are highly personalised some are sparsely furnished. The reasons for these differences relate to the behaviours of the individuals. If domestic type furnishing are restricted, i.e. vases or ornaments etc these restrictions are agreed and recorded through the risk assessment process. Visiting relatives confirmed that their relative’s room was basic but they had been involved and agreed to limiting the amount of non-essential furnishing to protect their relative. Some of the toilet areas have had new floor coverings since the last inspection. Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 14 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) 28,30 Whilst there is evidence that staff have received training in key areas as discussed under the Complaints and Protection section, there is insufficient evidence that the staff put learning into practice. EVIDENCE: Relatives report that they are kept informed of any incidents via the telephone or when they visit. They consider that the staff are helpful and work hard to ensure the service users receive care in a sensitive manner. The staff records appear to confirm that they have attended training in key areas such as dementia care, health and safety issues, vulnerable adult procedures and national vocational qualifications. Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 15 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) 32,38 The management need to be able to show leadership in promoting good practice to ensure the safety of service users at all times. EVIDENCE: The registered manager and registered person failed to report allegations of poor practice in a timely fashion to the regulator and chose only to alert the regulator via a complaint investigation report. At the time of the unannounced inspection there was no evidence that they had taken any action to prevent further reoccurrence of poor practice. No changes to the management approach to the home had been considered or acted upon At the time of the unannounced inspection the registered manager was not able to inform the inspector of the actions that needed to be taken in light of the internal investigation. Staff training, supervision and staff meetings had not been planned or considered. The registered person was asked to contact the inspector on their return from holiday the next day but has not. Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 16 Staff the inspector spoke to are unable to explain why they had not approached management and reported their concerns earlier. This undermines the ability of the staff and management to be able to evidence how they promote the safety of the service users. Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 17 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 x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 2 15 x COMPLAINTS AND PROTECTION 3 x x x 3 x x x STAFFING Standard No Score 27 3 28 x 29 x 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 1 x x 1 x x x x x 1 Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 18 no 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 10 & 31 Regulation 12 (5) (a)(b)(4) (a) 18(c)(i) Requirement Timescale for action 7/07/05 2. 18 3. 15 16(2)(i) 4. 37 37(1)(af)(2) The registered person must ensure service users are treated with dignity and respect at all times. The registered manager, 7/07/05 registered person and all staff must staff receive training on the protection of vulnerable adults. Any training must be in line with Wiltshire and Swindon vulnerable adults procedures. The registered person must 19/05/05 ensure that there is sufficient food stocks to enable catering staff to follow the planned menu at all times. The regestered person must give 7/07/05 notice to the Commission without delay of any event which may affect the well being of the service users or any allegation of misconduct by any staff member. 5. Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 19 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 31 Good Practice Recommendations The registered person should consider what they have learnt through the recent complaint and ensure that they do not allow this situation to present itself again Seahorses DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 20 Commission for Social Care Inspection Suite C, Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB 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 DD51_D01_S3171_SEAHORSES_V224454_180505_STAGE4.doc Version 1.30 Page 21 - 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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