Inspection on 23/10/07 for Seahorses

This inspection was carried out on 23rd October 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 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 12/02/07

Seahorses 30/09/05

Seahorses 18/05/05

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 Pauline Lintern Unannounced Inspection 23rd October 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 Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 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 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 Peter Coleman Mrs Shirley Cole Care Home 15 Category(ies) of Dementia - over 65 years of age (15) registration, with number of places Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 15 services users with DE/E at any one time. Date of last inspection 12th February 2007 Brief Description of the Service: Seahorses is a private 15 bed home that provides care and accommodation 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 two 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 responsibility of the service. Support staff give personal care and provide for the welfare needs of the people living in the home. Their duties also include cooking, cleaning and administration as part of their job role. The home provides a garden with flat level access. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over five hours. The manager and the registered provider were at the home when the inspector arrived. The manager assisted the inspector throughout the visit. The registered manager explained that she was in the process of moving into another office and therefore it may be difficult to access some information. The inspector toured the premises including the bedrooms and communal living areas. We met the majority of the service users and had the opportunity to speak to seven people during the day. A relative of one person living in the home was visiting and the inspector was able to obtain their views on the service being provided. As part of the inspection process three care plans were sampled along with risk assessments, recruitment files, health and safety documents and medication records. We also looked at how quality assurance is measured. Feedback on the preliminary findings was given to the manager at the end of the site visit. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people who use this service. The fees currently charged at Seahorses are £570 per week. What the service does well: The home completes an assessment of any prospective new service users prior to offering them a place to ensure that their needs can be met. People or their representatives are able to visit the home before deciding if they wish to move in. They are provided with a statement of purpose and a service user guide, which contains information about the service. Throughout the visit staff were seen to be interacting with service users, treating them respectfully and with sensitivity. People told us that staff members treat them well. Most days there is some form of entertainment or activity for people to participate in if they wish. Meals are varied and people told us that they enjoyed the food. There appears to be good communication links between the night staff and the staff coming on duty in the morning, which ensures important information is passed on. Arrangements for administering medication appear good and medication administration records are satisfactory. The home has not received any complaints in the last twelve months. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Environmental risk assessments are in place however they are not dated or signed, which makes it difficult to ascertain if they are current and have been regularly reviewed. The fire risk assessment is in need of updating and there has not been a recorded fire drill since June 2007. The registered provider explained that they are in the process of fitting thermostats to individual hot water taps. It was noted however that in one bedroom the hot water temperature was in excess of 43 c. It would be good practice to record the starting date for new staff and keep this in the staff recruitment file. Although there are few complaints about the home it is a requirement that the manager develop a complaints log and record any concerns raised to enable her to monitor any trends or patterns, which may emerge. As good practice the manager should ensure all hand written additions to medication administration records should be signed and dated. It would be good practice to place a photograph of each person receiving medication on the front of the medication administration record (MAR). Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 7 Where possible care plans should be agreed and signed by the service user or their representative. The registered manager must ensure when daily notes are completed staff use terminology, which is respectful to the service user. The manager must ensure that all staff members receive regular refresher training in subjects such as manual handling. The manager reported that she was unable to access some records due to being in the process of moving her office. As part of the inspection process we would expect all records to be readily available for examination. The home need to evidence that quality assurance is reviewed at least annually. Questionnaires returned from relatives should be dated to demonstrate that they are kept under frequent review. 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. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 8 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 Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 9 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): NMS 1, 3 and 6 Quality in this outcome area is good. Information is available to enable people to decide if they wish to move into the home or not. Prospective new admissions have an assessment carried out to ensure the home can meet their needs and have the opportunity to have a trial visit. This judgement has been made using available evidence including a visit to this service. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 10 EVIDENCE: The statement of purpose and service user guide provides potential new people with information about the service and it’s ethos. There is evidence to show that potential new people have an assessment of their needs completed prior to being offered a place at the home. The manager explained that generally she will visit people in their previous living environment to complete the assessment and when this is not possible this is now recorded along with the reason why it did not happen. This was the case for one person living at the home as they had been admitted as an emergency placement. Case records contained the reason an assessment did not take place prior to admission. The statement of purpose and the service user guide informs people that they will have the opportunity to visit the home and stay for a meal before they are offered an overnight stay. Trial visits are recorded in the person’s case file. Case files show that the manager now confirms in writing whether they can meet the person’s needs at that time. Assessments include all areas of the person’s needs such as mobility, communication, personal care, health, cultural, behaviour, allergies and social and leisure needs. The home does not provide intermediate care. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 Quality in this outcome area is adequate. Each person living at the home has a care plan, which is kept under monthly review and reflects his or her assessment. Risk assessments are in place and regularly reviewed People told us that their healthcare needs are met. The arrangements for managing medication are satisfactory. Peoples’ dignity is compromised by the disrespectful terminology used in the daily notes by some staff members. This judgement has been made using available evidence including a visit to this service. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 12 EVIDENCE: As part of the inspection process three care plans were sampled. There was evidence to show that care plans and risk assessments are kept under monthly review and reflect the person’s assessed needs. Specialist interventions are now documented and inform staff of ways of collecting information. Care plans provide the reader with information on strengths and needs, planning, goals, medical needs, personal care needs, communication, behaviours and mobility. One plan reminds staff to encourage the person using the service to do as much as they are able to enable them to maintain their independence. Another plan states that although the person may need support with their personal care, they like to put on their own make-up as this is important to them. People living at the home told us they have their personal care delivered with sensitivity and their privacy is upheld. It was noted however that some care workers had made entries in the daily notes using judgemental language contrary to the ethos of the home as reflected in the statement of purpose. This was discussed with the manager during feedback at the end of the inspection. During the visit to the service staff members were observed interacting with people who use the service in a communicative manner and not necessarily just task based. People told us that they liked the staff. The home has a key worker system in place. One staff member reported that they spend a lot of time sitting and chatting to the person they key work. She added “sometimes she (the person using the service) needs direction with her personal care but I encourage her to help herself where possible”. Records show that people living at the home have access to all required health care professionals as and when needed. The manager confirmed that the doctor visits the home for a ‘in house ‘ surgery fortnightly. The manager now keeps a record of all visits made by the doctor and any changes made to prescribed medication. One person told us that the home will call the doctor if they are feeling unwell. Medication appears to be managed satisfactorily. MAR sheets were completed properly; although hand written entries have been dated, they also need to be signed by the person making the entry and another if possible. Staff members confirm that they receive ‘safe handling’ of medication training. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 13 Following a requirement set at the last inspection all ‘as required’ medication is now recorded on the MAR sheet. One eye preparation stored in the fridge, as required, was dated on opening to ensure it is discarded at the correct time. The manager reported that all medication is stored securely now. The cupboard previously used for storing excess stock is no longer used for this purpose. The manager reported that each week she carries out a stock check of all medication in the home. It would be good practice to have a photograph of each person using the service on the front of his or her MAR sheet. The home is currently holding one controlled medication, which is stored securely, two staff signs the medication out and there is a running total of the remaining medication. The administration of this controlled medication is recorded on the MAR sheet. The manager confirmed that she had asked the district nurse if the method of storing and recording this medication was satisfactory and she had confirmed she was happy with the arrangements in place. A section in each case file contains all the relevant information, which may need to be accessed in the event of a person living at the home having to go into hospital, which is good practice. People are regularly weighed to ensure they maintain a healthy weight. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15. Quality in this outcome area is good. Although there are activities provided, these could be further developed to meet individual needs. Visitors were observed being made welcome. Meals are well presented and smell appetising, although care needs to be taken to ensure that people do not have to wait too long between meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff members report that they try to provide at least one activity a day for the people who live at the home. They confirmed that most people enjoy the music and dance sessions. This was taking place on the day of the inspection. People told us that they join in the sessions if they choose. The manager reported that outside entertainment ‘music for health’ visits twice a month. One person using the service told us that she “wanted to do some work”. Their visiting relative added that they feel that the person would benefit from more stimulation and “having something to do”. They added that it was important for their relative to feel they are doing something worthwhile. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 15 This was later discussed with the manager who agreed to look at areas where the person could be involved in day to day activities around the home. One person living at the home told us that they miss not going to church, as this is important to them. The manager reported that the local clergy does drop in for main festivals such as Christmas and Easter and when he is available. Staff members confirmed that they turn the television onto ‘Songs of Praise’, but not everyone takes an interest. The manager confirmed that matters relating to peoples personal finances are managed by relatives, the funding authority or the person’s legal representative. The main meal of the day is provided at lunchtime. It was noted that on the day of the inspection the meal was not served until 1.15pm, which meant that more than four hours had passed since breakfast was served. People appeared to be waiting for their food and a couple of people commented ‘ I think we will be having our dinner soon’. This was discussed with the manager during feedback and it was felt that it could have been as a result of the inspector being present and taking time to talk to the staff member who was responsible for cooking the food that day. This does need to be monitored in the future to ensure that people do not have too long a gap between meals. This said the food served looked appetising and the mealtime appeared relaxed and unhurried. Staff members report that they know what food people like and can tell by facial expressions if someone is not happy with their food. If this is the case an alternative is offered. Overall comments regarding the food were positive and people confirmed that the food is served hot and the portions are satisfactory. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 17. Quality in this outcome area is good. Following a requirement set at the last inspection the home are giving more attention to recruitment practices to ensure that people who use the service are protected. This home does not receive many complaints. Staff have a good understanding on the protocols for reporting any alleged abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager confirmed that there have been no complaints received since the last inspection. She added that the home does not have a complaints log as no complaints have been made. This said it remains a requirement for the home to have a complaints log in place to ensure that any concerns as well as complaints that may be raised are monitored for any trends or patterns that may emerge. Discussion with staff members demonstrated that they have a good understanding of the local protocols for reporting any suspected abuse. One staff member told us that she had attended safeguarding people training at the police station. Another reported “I would feel confident to report it if I had concerns”. Staff confirmed that they had seen a copy of Wiltshire and Swindon’s ‘No Secrets’ protocols and understood the homes ‘whistle blowing’ policy. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 17 People living at the home told us that were happy there. Comments included; 1. 2. 3. 4. 5. 6. I like it here it’s nice. The food is nice and I have what I want. It’s all right –not too bad. It’s ok I have everything I need. It would be nice to have something to do. I’m happy here –no complaints they look after us well. At the previous inspection safe recruitment practices were not being followed for all staff employed at the home. The manager confirmed that no staff members now commence their employment without a satisfactory check with the Criminal Records Bureau (CRB). This was evident in the recruitment files of the last couple of staff to be employed by the home. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 18 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): Standard 19 and 26 Quality in this outcome area is good. Seahorses offer a homely environment, which is well maintained. Bedrooms are comfortable and clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection, the home was clean and tidy although there was a slight offensive odour in certain areas of the home. The manager explained that new carpets have been fitted in some areas, which are easier to keep clean. We toured the premises and found all areas to be clean and tidy. Bedrooms are individualised and people are able to bring in their own belongings or furniture if they wish. People told us that they were happy with their bedrooms and had everything they needed. One person commented “I have a TV in my room but I don’t watch it, I prefer my own company”. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 19 Another said, “ The girls (staff) are good company and they help me”. The manager reported they have made many improvements over the last twelve months by replacing carpets, purchasing a new hoist, redecoration, installing a new kitchen and replacing dining room furniture. They have also fitted some thermostats to various hot water taps. The registered provider confirmed that they would soon be fitted to all hot water taps. It was noted that one hot water outlet in a person’s bedroom was in excess of the recommended 43c. The manager confirmed that she had informed the registered provider on the day of the inspection. Most radiators are guarded and risk assessed. The laundry room is situated away from any food preparation area. There is a commercial washer and dryer and walls and floors were easily cleanable. The manager explained that red alginate bags are used for transporting soiled laundry in order to reduce the risk of infection. The home has a supply of protective clothing for staff to wear such as aprons and gloves. Staff were observed wearing their aprons whilst serving up the lunch. Bathrooms and hand washing areas are provided with antibacterial hand wash. The home has a copy of the infection control guidelines and training records show that staff receives training in this subject. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is good. Recruitment practices have now improved. Staff members told us that they receive regular training although it appeared that some refresher training is overdue. The manager could not provide evidence of staff supervision or team meetings. The home has a new induction format, which is now being used for new staff members. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A recommendation was made at the last inspection regarding introducing a more flexible rota during peak times. The manager showed us the home’s rota and explained that where possible she now ensures there is more staff on duty during 6.00pm and 8.00pm, which is a busy period. On the day of the visit there were four staff on duty, not including the manager and registered provider. The home currently employs fifteen members of staff. The manager confirmed that eight members of staff have their NVQ level 2 or above and seven staff are currently working towards their NVQ level 2 or above. The next NVQ session starts in November 2007. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 21 The staff training file was observed and showed that staff receive training in mandatory training courses such as fire safety, basic food hygiene, medication, abuse awareness and manual handling. It was noted that some staff members have not received regular refresher training in manual handling. This was discussed with the manager during feedback. It would be good practice for the manager to develop a matrix where she could easily identify when staff are due for refresher training to ensure that people do not get missed. The manager confirmed that she would implement this. The manager explained that she has arranged for the staff team to attend training in MRSA. Some staff have attended training in dementia care. Staff members told us they received an induction and the manager showed us the new format workbook that is to be used now for new staff in line with the ‘Skills for Care’ standards. One person told us that their induction had included shadowing a more experienced member of staff until they were deemed competent to work alone. Staff recruitment has improved. No one commences employment without receipt of a satisfactory CRB and POVA (Protection of Vulnerable Adults) check. The recruitment records for two members of staff recently recruited were examined and demonstrated that all relevant checks had been made. Records did not clearly state when the member of staff commenced employment, although the manager reports to have copies of starting dates it would be good practice to have this information readily available. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36 and 38 Quality in this outcome area is adequate. The home is run in the best interests of the people who live there by a qualified and experienced manager. Mechanisms for measuring quality are in place however better recording would provide further evidence of its frequency. Generally health and safety is satisfactory. This judgement has been made using available evidence including a visit to this service. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has many years experience within the care sector. She holds the registered managers award and an NVQ level 4 in care. Discussion took place with the manager regarding accessing training for herself and some staff to attend a training course on the Mental Capacity Act and what implications it may have for the people living at the home. The manager reported she would explore this further. Staff members spoke well of the manager stating that she is supportive and approachable. Overall this is a service that is being successful at assessing and meetings people’s needs. They have met the requirements from the last inspection and the good practice recommendations. Greater attention needs to be taken with regard to the dating and signing of records/documents to ensure there is a clear audit trail of good practices. Records need to be easily accessible for inspection in the future. There is evidence to show that an independent qualified person is employed to undertake a quality assurance report on the service. The copy of the report shown to the inspector was dated as 2005, however the manager confirmed that further audits have taken place. The home has completed a satisfaction audit, which was sent out to relatives. The copies shown to the inspector did not display a date of when the audit was carried out and therefore we could not ascertain if this was a current response. The home does not hold any money on behalf of the people living there. The manager was unable to locate staff supervision records or minutes from team meetings due to the upheaval of her office move. Staff members told us however that they receive regular supervisions and attend team meetings. The manager explained that they are planning to hold the next team meeting in the evening at the home to enable the night staff to attend. One staff member confirmed that the next team meeting was planned for an evening. The home has a health and safety policy in place. Staff records and discussion with staff members demonstrates that staff receives training in safe working practices. Environmental risk assessments are in place, however they are not dated or signed, which again does not provide any evidence of review. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 24 The arrangement relating to health and safety were reviewed. It was noted that the fire risk assessment needs updating and there is no record of a fire drill taking place since June 2007. Fridge and freezer temperatures are recorded daily along with the probing of hot food. The manager reported that they do not record checks made on hot water outlets. It is recommended that records are kept of temperatures of hot water to ensure the safety of the people living at the home Records showed that the checking of portable electrical appliances is overdue. The manager confirmed that she has the paperwork ready to instruct this work to be carried out. The manager was unable to locate the home’s Gas safety Certificate, however she confirmed that there is one in place. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 25 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP10 Regulation 14(a)(b) Requirement The registered manager must ensure that inappropriate judgements / terminology are not used in people’s daily records. The registered manager must ensure all portable electrical appliances are checked annually. The registered manager must ensure the fire risk assessment is updated to ensure the safety of the people living at the home. The registered manager must ensure that a complaints log is kept at the home to ensure any complaints raised are recorded with timescales and outcomes. Timescale for action 23/11/07 2. 3. OP38 OP38 13(4)(a)( b)(c) 13(4)(a) 23/12/07 23/12/07 4. OP16 17(2) Schedule 4(11) 23/12/07 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 OP7 Good Practice Recommendations Where possible it would be good practice for the person DS0000003171.V348925.R01.S.doc Version 5.2 Page 27 Seahorses 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. OP9 OP9 OP15 OP26 OP30 OP38 OP36 OP38 OP33 OP30 using the service or their representative to sign and date the care plan. It is recommended that all hand written entries on the medication administration record are signed and dated by two staff. It is recommended that medication administration records have a photograph of the person receiving the medication on the front to easily identify them. It is recommended that gaps between meals do not exceed 4 hours. It is recommended that the registered manager ensure the home is kept free from offensive odours. It is recommended that the registered manager and some of the staff team attend training in the Mental Capacity Act. It is recommended that the registered manager ensure fire drills take place every three months. It is recommended that the registered person ensure all supervision notes and team meeting minutes are made available for examination when requested. It is recommended that the registered manager ensure a copy of the Gas Safety certificate is available for examination. It is recommended that the registered person ensure that there is a date on all quality assurance audits providing a clear audit trail. It is recommended that the registered manager develop a training matrix to ensure staff do not miss out on refresher training such as manual handling. Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Seahorses DS0000003171.V348925.R01.S.doc Version 5.2 Page 29 - 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. 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