Inspection on 05/12/07 for Seaswift House

This inspection was carried out on 5th December 2007.

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 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

Seaswift House 26/05/09

Seaswift House 16/11/06

Seaswift House 24/01/06

Seaswift House 02/08/05

Seaswift House 04/03/05

Seaswift House 13/08/04

Seaswift House 31/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Seaswift House Sea Hill Seaton Devon EX12 2QT Lead Inspector Teresa Anderson Unannounced Inspection 10:00 5 December 2007 th 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 Seaswift House DS0000022024.V343886.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. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seaswift House Address Sea Hill Seaton Devon EX12 2QT 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) 01297 24493 01297 21149 Mrs Kathryn Sara Jackson Ms Carole Rundle-Drew Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th November 2006 Brief Description of the Service: Seaswift is a care home that has been adapted from a row of 3 houses. The home provides accommodation and personal care for up to 14 residents who have needs associated with old age. Accommodation is provided over three floors and is linked by stair lifts. All bedrooms are single occupancy and 10 of the 14 have en-suite facilities. There is a communal lounge/conservatory and two dining rooms, all situated on the ground floor. The home is close to the centre of Seaton and the seafront. The front aspect overlooks a bowling green and gardens. The rear of the home has a small patio style garden. Seaswift does not have dedicated parking. The fees charged at this home range from £305.00 to £455.00 per week. This fee does not cover items such as newspapers etc but does cover toiletries and the majority of transport. Further information about this home, including reports, is available from the home. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place as part of the normal programme of inspection. The visit to the home started at 10.00am and finished at 4.30pm. During that time we spoke or saw thirteen of the fourteen people who live here (one person was not at the home); we spoke with two members of staff, with the owner and with the manager. Three people who live here were case tracked (this means we looked closely at the care and services offered to these people as a way of assessing the quality of care and services overall). We looked at records in relation to assessments, care plans, medication, personal allowances, fire safety, menu planning, food hygiene and accidents. In addition we looked at the communal areas of the home and at the majority of bedrooms. Prior to this visit we sent surveys to some of the people who live here and five were returned; to some relatives of the people who live here and two were returned; to some staff and four were returned; to health and social care professionals and none were returned. Their feedback and comments are included in this report. In addition the manager completed a preinspection questionnaire giving details of the management of and future plans for the service. What the service does well: Seaswift House provides a very homely environment within a small and friendly home. The staff working here know the people who live here well and people who live here say it is ‘home from home’. People who consider coming to live here are assessed to ensure that their needs can be met. And each person has a plan of care and their health and social care needs are met through referrals to appropriate agencies. There is a ‘low key’ approach to meeting peoples’ social needs and many of the people living here enjoy their own company, coming together for weekly bingo and for meals. Meals are sociable and people enjoy the variety and standard of cooking. People who have special needs, such as vegetarians, are well catered for. Visitors are made welcome and feel that they are kept up to date with developments and changes. No formal complaints have been received against the home and people’s requests, views and minor grumbles are dealt with easily. People feel safe, are treated with respect and they and their belongings are kept safe by staff who receive training in how to do this. Staff are described as ‘caring’ and ‘loving’. People living here say that staff ‘go that extra mile’ to make life good for them. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Everyone has a care plan, but these are not always written in sufficient detail to ensure that needs can be met to a consistently high standard. Reviews don’t always take place and some peoples mental health needs are not being met. Some people have access to inappropriate pressure relieving equipment that might lead them to developing pressures sores. In general, people’s social needs are met but these should be kept under review as some people say they can get bored. Some people need help with decision-making and help to stay safe. However, these processes are not being guided by the Code of Practice relating to the Mental Capacity Act (2005). Practices and record keeping relating to the management and administration of medicines could be improved for the safety of people living here. In particular hand written entries on medicine charts are not being checked, signed and dated by two people; some medicines are not being given as prescribed by the doctor; the temperature of the fridge where medicines are stored is not being recorded so staff cannot be sure that medicines are being stored at the correct temperature; the home does not have any facilities for storing controlled medicines. We shall carry out an unannounced inspection to check that this has improved. Some people living here are sometimes prevented from having free movement. The reasons behind this have not been fully justified or documented and decisions regarding restraint have not been made in line with the Mental Capacity Act (2005). Fire checks are carried out but have not identified problems with fire doors that do not close. In addition, as the manager has not consulted with the local fire department about the use of locking door guards (used to keep people in their bedrooms), people could be at risk if a fire were to break out. We have contacted the local fire service to carry out an assessment. Infection control practices such as not having liquid hand gel and paper towels in bathrooms mean that the spread of infection is not well controlled. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 7 There are some staffing issues. There are no waking staff on duty at night and some people have needs that are currently being met by restraining them in their rooms because of this. Recruitment procedures are not as robust as they should be meaning that people are at risk of being cared for by inappropriate people. Staff are not receiving induction training which prepares them to care for people safely and 50 of staff do not hold a National Vocational Qualification (NVQ) in care (as is the national standard). The above issues demonstrate that the overall management of the home could be improved. 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. Seaswift House DS0000022024.V343886.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 Seaswift House DS0000022024.V343886.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): 3 (this service does not provide intermediate care). Quality in this outcome area is good. People who come to live here can be assured that staff will have the information they need to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person who wants to come to live here is assessed (usually) by the manager. These people tend to have low to medium needs and therefore assessments are not carried out in great depth. We looked at one assessment that demonstrates that the service can meet this persons needs and that staff had sufficient information about this person before they moved into the home. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8,9 and 10 Quality in this outcome area is adequate. Some people who live here would benefit from improved planning of their care so that their health and welfare needs could be better anticipated and met. The way that some people’s medicines are managed is not safe. People who live here have their right to privacy protected and are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In surveys the majority of people say that their own or their relatives needs are always met and that they receive the medical support that they need. We looked at the care plans of three people and found that appropriate and timely referrals are made to health and social care professionals. We saw that the advice sought is put into practice. For example, one person has blood Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 11 circulation problems and the home have asked the district nurses to help plan their care. They have devised a plan of care which staff are following. The majority of people who live here have low to medium needs. However, some are developing memory and dementia type problems. These peoples care plans were not detailed enough to ensure that their needs are consistently met in an appropriate way. For example, we met with one person who was in their bedroom. This is a very comfortable, nicely furnished and warm room. The TV was on and this person appeared to be watching it. They had a drink close to hand. However, they could not leave their room as a gate has been attached to the doorway. When we checked why this is, the owner says this person has a tendency to wander. The manager reports that this used to be the case, but they do not do this now. The care plan shows that staff had consulted with the doctor about this persons wandering a year ago. However, the care plan has not been reviewed, it does not include records of how the decision to use this form of restraint had been made and what other interventions have been tried. It does not include details of the effects of restraint on this person or how their other needs, such as their need to be social or their need to make decisions about their daily life, could be met. In addition, the care plan does not give clear details about time restrictions for using this restraint and does not say when it should be used and when it should not be used. Records in the care plan clearly show that this person does come out of their room and sit in the lounge with other people. However, records are not made on a daily basis meaning that staff could not prove this happens every day. The care plan of another person contains details of their needs on admission. However, staff and the manager report that these needs and this person’s behaviour has changed considerably over the past few months. The care plan has not been updated to reflect these changes and the plan of care does not provide staff with clear instructions on what might help to manage this person’s behaviour. Staff spoken with are knowledgeable about this persons needs and about how to manage these needs and their behaviour. However, this is not written down, meaning that the interventions described might not be consistently applied, especially as a new member of staff has just joined the team. Some of the language used in the daily records indicates that not all staff understand what might be making this person act in this way. This person is described as ‘irrational’ and ‘confused’. He has recently been commenced on a medication that has a sedative effect. Daily records indicate that this person is unsteady on their feet, restless and that their mobility is worse. The care plan does not indicate that all this information has been used in the review process to provide the most appropriate interventions. The manager reports that she is planning to change the system used to plan care in order to improve this. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 12 The majority of people living here have low pressure relieving needs. However one person is becoming less mobile and requires a pressure-relieving cushion. We found a cushion in this person’s room that should not be used. When we asked this person, they said they had been given it to sit on but found it uncomfortable. They were sat on an appropriate cushion. When we spoke with the manager she did not know where the inappropriate cushion had come from. We looked at the way medicines are managed. We found that they are kept locked away and that there is limited access to this, as is good practice. When we checked the medicine records we found that some records were less than satisfactory. For example, one hand written entry did not record the number of times a medicine should be given, and had been added to the record of another medication because there was not room to put it any where else. This is potentially confusing and increases the risk of a mistake being made. We also found that there are gaps in some records where staff should have signed to say they had given a medicine or, if appropriate, explained why they had not given it. Another record shows that a medicine prescribed to be given once, was recorded as being given twice, although the manager says it wasn’t. One person living here administers their own medication. Whilst records show how many medicines are received into the home, staff do not record how many are given to this person at any one time. This lack of audit trail means that these medications are open to being taken without anyone noticing. Since the last inspection a fridge for keeping medicines that need to be refrigerated has been bought. However, there is no thermometer attached to this and staff are unable to record the temperature of this fridge. No one living here is receiving a medicine that should be stored as a Controlled Drug. However, were someone to be prescribed such a medicine, the home do not have the appropriate facilities for storing them. People living here say their privacy is respected and that staff treat them very respectfully. Staff spoken with say they like to treat people like they would like their own Mum or Nan treated. We observed many examples of staff being respectful throughout the inspection. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. People have easy contact with the community and their visitors, have control over their daily lives and enjoy the food served. Some people’s social lives could be further enhanced. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In surveys people say that there are usually or sometimes activities arranged by the home which they can take part in. Some people comment that their disabilities prevent them from joining in and some that they can get bored. The manager and owner report that the home does not have a programme of activities except bingo, which takes place once a week, and staff sometimes play skittles with people. In addition a visiting chaplain offers communion monthly. The owner also says that trips to the local theatre are arranged. However, when we spoke with people they said they had not been, and only the very able tend to go. The manager confirmed this as the home does not have transport that can accommodate people who use wheelchairs. Many of the people living here spend time alone in their room. Although some are able Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 14 to go into town themselves, others said they would like to be helped to go into town or would like to chat with staff. The manager reports that people really enjoy ‘the music man’ who visits the home and enjoy parties used to celebrate events. She also says that the home has tried activities such as poetry reading but these have not well attended. People say their visitors can come and go as they please and that they are always welcomed. In surveys visitors say staff are friendly and helpful and keep them up to date with developments or changes. People living here say they enjoy the food and like that lunch is always such a social occasion. A roast dinner is served at lunchtime, nearly always with wine and/sherry. One person who is a vegetarian says that their preferences and needs are managed very well. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. People who live here have their views heard and acted upon. People are safe, although the use of restraint may be limiting the lives of some people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In surveys people who live here and relatives say they know how to make a complaint but have not needed to. When we spoke with people, they say they have no complaints and that any minor grumbles are dealt with easily. Neither the commission nor the service itself has received any formal complaints. People say they feel safe living here and that staff are kind and lovely. Staff receive training in safeguarding adults and demonstrate a good understanding of what abuse is and what to do if they suspected or saw abuse. Some people are restrained in their bedrooms or in areas of the home using door guards, especially at night. The owner explains this is to stop people from wandering and hurting themselves. However, records of how these decisions were made and who was involved have not been kept in accordance with the Mental Capacity Act. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. People live in a home that is very homely but which poses some risks to peoples safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In surveys all the people who responded say that the home is always fresh and clean. Communal areas are very homely and tidy and each bedroom is personalised for the person whose room this is. The furniture is of a domestic type and the chairs and settees are low. This might mean that some people find it difficult to get in and out of these seats. However, when we spoke with people and observed the people living here, everyone managed. People say they like having the ‘normal’ type furniture that adds to the ‘home from home’ environment. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 17 During this inspection we found a number of fire doors that do not close properly. We found one bedroom door that would not close because of the placement of furniture. We found that although records show that weekly checks are being carried out to make sure that fire doors close, that the person carrying out these checks had not noticed this. We reported this to the owner during the visit who immediately made arrangements to address this. We have written to Devon Fire and Rescue Service to inform them of our concerns. The fire officer as since visited the home. The manager reports that the home are not using any door gates not approved by the fire service and that all fire doors now close. She reports that the fire officer was happy with the current fire management at the home. In the pre-inspection information provided by the manager, she reports that the home has an infection control policy and that staff have completed infection control training. However, we found that some areas of the home did not have liquid soap and paper hand towels. We found bars of soap at sinks, meaning that cross infection is more likely to happen. The owner reports that all staff use liquid alcohol gel. When we checked we found that some staff were not carrying these. The owner arranged to have liquid hand gel at each sink during the inspection. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 18 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 adequate. People who live here benefit from a staff group who have the skills to meet their needs. However, there may not be sufficient staff on duty at night and staff are not always recruited using robust methods. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In surveys the majority needed. Staff are really whom see staff as their always going that extra of people say that staff are always available when appreciated by the people who live here, many of friends. They are described as ‘lovely’, ‘caring’ and as mile. We looked at the staff rota and saw that there are usually two carers on duty all day until 9pm. The manager works as one of the carers for three days of the week, and has ‘manager days’ two days a week. In addition there is a cook, a cleaner and a maintenance man. At night there are no waking night staff. The owner and her partner sleep on the premises, as does the maintenance man. However, none of these people have formal care training or qualifications (apart from moving and handling). This arrangement is usually satisfactory to meet peoples’ needs. However, the owner reports that because Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 19 there are no waking night staff door guards are being used to prevent some people from leaving their bedrooms. In surveys staff say they receive the training, supervision and support they need, and that they are never asked to care for anyone outside their area of expertise. The manager reports that four of the five care staff have a National Vocational Qualification (NVQ) in care, which is above the national standard of 50 . Staff also receive other training including caring for people with dementia and with Parkinson’s Disease. The manager has completed a training course relating to the Mental Capacity Act. We looked at the recruitment files of the two members of staff who have been recruited since the last inspection. We found that one did not contain an application form and references were not signed or dated by the person who had written them. There was no record in this file of the start date of their employment at this home, so we could not check if the police check had been carried out prior to their employment. The second recruitment file did not contain a police check or references. However, the manager reports that these had been requested and after the inspection found them in her post. She provided evidence of this. In some circumstances it is permissible to employ a carer without a full police check. However, other checks such as obtaining references must be carried out. In addition when someone is employed before a police check has been received, the member of staff should always work supervised. We observed that this carer was one of two on duty and was working alone with the people living here. We also found that this person had had a one-day induction before starting to work alone. This did not include fire training that was planned for the day after this inspection. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 20 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 and 38. Quality in this outcome area is adequate. People live in a home they love. However, the overall management of this home is putting some people at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Seaswift House is managed by Carol Rundle Drew. Carole is well liked and respected by the owner, staff and the people who live here. She has been consistently helpful and committed. She works as a manager of this home two days each week. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 21 Ms Rundle Drew has completed the Registered Managers Award and has worked at this home for ten years. She ensures that requirements made by the commission or, if appropriate, other regulatory bodies are carried out. The owner lives on the premises and is easily available to staff and the people who live here. The people who live here benefit from living in what they describe as ‘home from home’. The atmosphere is relaxed and staff know the people who live here really well. They go out of their way to help improve the quality of their lives. Quality assurance surveys are implemented, usually at an informal level, and the people who live here say they could not see how the home or service could be improved. People’s monies and belongings are kept safe. Staff enjoy working here and, in surveys, say how proud they are to provide a service that puts the people who live here at its heart. However, issues that have arisen during this inspection demonstrate that the overall management of this service could be improved. For example, fire safety, care planning, the management of medicines and recruitment are not sufficient to keep all the people who live here safe. The use of restraint, particularly at night, together with the absence of waking night staff has not been discussed with Devon Fire and Rescue and may be introducing risks to some of the people who live here. Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 1 x x x x x x 1 STAFFING Standard No Score 27 4 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 (1) (2) (b) Timescale for action All the people who live here must 28/02/08 have a plan of care that details how their health and welfare needs are to be met. Actions taken to meet needs and the outcomes of these actions should be recorded and reviewed so that only appropriate care is delivered. If decisions are being made on behalf of any person living here, these must be done using the Mental Capacity Act (2005) and decisions must be made and recorded in accordance with the related Code of Practice. People who have psychological problems should have these monitored and recorded so that appropriate preventative actions can be taken and appropriate care given in a consistent way. The people who live here must have their medicines managed safely. Any hand written entries on medicine charts must be written in full and checked, signed and DS0000022024.V343886.R01.S.doc Requirement 2. OP7 15 (2) (c) 28/02/08 3. OP8 13 (1) (b) 28/02/08 4. OP9 13 (2) 28/02/08 Seaswift House Version 5.2 Page 24 dated by two people. All medicines should only be given as prescribed by a doctor. Any medicines prescribed to be given ‘when needed’ should not be given regularly. The reason for giving ‘when needed’ medicines and the effects these medicines have must be recorded. Any medicines that require refrigeration must be stored at an appropriate temperature and this must be done by checking the temperature of the fridge where they are kept. Records kept in relation to the management of medicines must be kept up to date. This includes staff signing for all medicines given or recording the reason for not giving medicines. In addition, where people are managing their own medicines, records relating to these must be accurate and up to date. 5. OP18 13 (7) People living at Seaswift should not be restrained unless this is the only practical means of securing their welfare and there are exceptional circumstances. Where restraint is used staff must keep a record of this and records must include the reasons for this. People living here must be safe from the effects of fire. This includes: Ensuring that all fire doors close properly. That the placement of furniture Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 25 31/01/08 6. OP18 17 (1) (a) Schedule 3 23 (4) 31/01/08 7. OP19 31/01/08 does not prevent fire doors from closing. That checks carried out identify where there doors do not close and that actions are taken to deal with this. That the manager checks with the local fire service, before using locking door guards, that the use of these do not pose unacceptable risks to the people living here. People living here must be protected from infection by ensuring that good infection control procedures and practices are in place. People living here must have their needs met 24 hours a day. There must be sufficient staff on duty at night to meet people’s needs without resorting to the use of restraint. People living here must be kept safe from being cared for by inappropriate people. All staff should undergo robust recruitment checks which should be received before they begin working with people unsupervised. People should live in a home that is managed with sufficient care, competence and skill to ensure that their needs are met, that they have rights and that they are kept safe. 8. OP26 13 (3) 31/01/08 9. OP27 18 (1) (a) 31/01/08 10. OP29 19 (1) (b) Schedule 2 31/01/08 11. OP31 10 (1) 31/03/08 Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP8 OP9 Good Practice Recommendations People should have access to only appropriate pressure relieving equipment. Although people living at the home are not currently prescribed any controlled drugs, the manager should consider obtaining facilities to store these so that if people need these medicines, they could be stored safely. People living here should all their social needs met and these needs and the activities provided should be reviewed. Staff should receive an induction that ensures they have the competence to care for the people living here and can keep them safe. 3. 4. OP12 OP30 Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Seaswift House DS0000022024.V343886.R01.S.doc Version 5.2 Page 28 - 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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