Inspection on 21/02/08 for Seaton Hall

This inspection was carried out on 21st February 2008.

CSCI found this care home to be providing an Adequate service.

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

Seaton Hall 19/02/09

Seaton Hall 28/06/07

Seaton Hall 21/06/06

Seaton Hall 04/01/06

Seaton Hall 04/08/05

Seaton Hall 16/02/05

Seaton Hall 30/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Seaton Hall 10 The Green Seaton Carew Hartlepool TS25 1AS Lead Inspector Rachel Martin Key Unannounced Inspection 09:30 21st February 2008 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 Seaton Hall DS0000047718.V356870.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. Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seaton Hall Address 10 The Green Seaton Carew Hartlepool TS25 1AS 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) 01429 260095 01429 263318 Arnold George Barrington Wilks Carole Roberts Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP, maximum number of places: 31 The maximum number of service users who can be accommodated is 31 28th June 2007 2. Date of last inspection Brief Description of the Service: Seaton Hall is situated on the village green in Seaton Carew. The front of the building looks out over the promenade and has lovely sea views. The building is made up of a traditional old building, with a modern extension. An enclosed courtyard garden is located at the back of the building. Accommodation at Seaton Hall is provided over three floors, with lift and stair access to the upper levels. There are communal toilet and bathing facilities located around the home and one bedroom has a private en-suite bathroom. The provider is currently doing building work to provide more en-suite facilities. The home has two spacious lounges and a dining room. The home is registered to provide care for up to 31 older people. At the time of this inspection the cost of living at the home was between £360 and £386 per week. This does not include hairdressing, chiropody, personal toiletries, transport and newspapers. Up to date information about the home’s fees should be sought from the manager. Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience Adequate quality outcomes. Before the site visits surveys were sent to the home for residents, relatives and staff to complete. Eight people living in the home, five relatives and eight members of staff completed these surveys, telling CSCI about their experiences of living, visiting and working in the home. The inspection site visit took place on 21st February 2008 and was an unannounced visit. This meant that people at the home did not know that the inspector was coming. The inspector looked at a selection of the home’s records and spoke to the manager, a selection of staff and people living in the home. The inspector also looked around and observed daily life for people living in the home. This include observing the lunchtime meal and spending time in the lounge with staff and residents. What the service does well: People were very positive about the staff at Seaton Hall and the care that was provided there. Relatives and residents made the following comments about the home, ‘provides the care and love that residents need’, ‘I couldn’t ask for a more caring staff, I am so grateful for their efforts’ and ‘My family member came to Seaton hall with a broken ankle….but due to the support, encouragement and patience of the staff she is now walking again unaided’. Staff felt that the service provided ‘a warm and friendly atmosphere’ and ‘try’s to meet all their (the residents) needs’. People appeared relaxed with the staff and looked well cared for. People were happy with the meals in the home and comments made about the food included ‘the menus are always lovely. The cooks and waiters top notch. If we ask for something they haven’t got they’ll go out of the way to get it for you’. One relative commented ‘I have often stayed for lunch and the meals are beautiful and home cooked’. People spoke highly of the manager, describing her as approachable. Comments included ‘Carole (the manager) is always around – if not one of her lieutenants. If not, when he’s here, Mr Wilks the boss is the easiest person in the world to talk to’. People said that they knew how to complain if they needed to and felt that any concerns they had raised in the past had been handled appropriately. Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 6 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People are given information about the home and encouraged to visit before they move in. The manager gathers information about people’s needs and makes sure Seaton Hall can meet their needs. This helps to make sure that people can make an informed choice about moving into the home. EVIDENCE: Since the last inspection people have been given more information about their fees and the terms and conditions for living at Seaton Hall. Copies of this information and the home’s user guide had been kept in people’s care records and were seen during the inspection. People had signed their agreement on these records. The manager described how new people come to live at the home. The social service’s department send her a copy of their assessment paperwork. The Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 9 manager looks at this and then discusses any queries or special needs with the person’s social worker to find out of Seaton Hall can meet their needs. People are then encouraged to visit the home to look round, including spending the day or having a meal there. On the day that a new person moves into the home the manager goes through the home’s care plans and records with the person and their relatives. Copies of social services assessments and the home’s own assessments were seen in people’s care records. When asked if they received enough information about the home before moving in, to decide if it was the right place for them, all eight people who returned surveys said ‘yes’. The social services department sometimes uses Seaton Hall for short-term intermediate care. This is where someone moves into the home for up to six weeks, while they receive physiotherapy and rehabilitation to enable them to move back home. The social services department make all of the arrangements for physiotherapy and rehabilitation services to visit the home. Seaton Hall just provides accommodation and normal assistance with personal care. Seaton Hall DS0000047718.V356870.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 & 10 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Each person at Seaton Hall has their own plan and record of the care they need and these have been improved since the last inspection. However, the home’s approach to risk assessments could be improved and some care plans were not as detailed or fully up to date as they could be. Medication systems have improved. Safe systems for storing and administering medication are now in place, although some aspects of recording could still be improved. People are treated with care and respect by staff and their privacy is respected. EVIDENCE: Since the last inspection the manager has done a lot of work on the home’s care plans. This has included using a different care plan format. Each person now has a care plan and record of their care in this new format. Four of these records were inspected and in general showed an improvement. People had regular access to doctors, district nurses and other professionals. Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 11 However, one or two issues need to be worked on and these were discussed with the manager during the inspection. The current risk assessments aren’t all personal or relevant. For example, some cover things that are simply general home policy (such as staff not wearing jewellery), rather than specific personal things to do with the care of that individual. Some things that were relevant to people were not being risk assessed (such as maintaining skin integrity for people who were at risk of pressure damage). The care plans themselves were quite brief and could be developed to contain more personal and specific detail about people’s wishes and preferences. Although monthly reviews took place and were recorded, some changes to people’s care needs that were highlighted during the reviews were not then recorded in people’s care plans. For example, one review talked about staff now using glycerine sticks to clean someone’s mouth, but the care plan didn’t mention this. Unless care plans are updated the valuable information and decisions made during reviews might be forgotten or not passed on to all staff who need to know about them. Since the last inspection the manager has sought help from the local PCT pharmacist to improve the way medication is managed in the home. The pharmacist visited the home on 8th January 2008 to look at medication and commented in her report that ‘Carole (the manager) and her staff have worked extremely hard since last years audit to implement most of the recommendations made’. However, one or two issues were still in need of action, such as always recording the use of inhalers and topical medications on the medication administration record (MAR), removing discontinued medication from the MAR’s and always signing for medication that has been administered or recoding a reason why the medication has not been administered on the MAR. The manager was aware of these issues and now carries out regular audits once a week to identify problems and raise them with the staff concerned. The home was starting to use a monitored dosage system, which will help to simplify the storage and administration of medication. On the day of this inspection the dispensary was neat and tidy and the records that were checked were in good order. Relatives made the following comments about the home, ‘provides the care and love that residents need’, ‘I couldn’t ask for a more caring staff, I am so grateful for their efforts’ and ‘My family member came to Seaton hall with a broken ankle….but due to the support, encouragement and patience of the staff she is now walking again unaided’. Staff felt that the service provided ‘a warm and friendly atmosphere’ and ‘try’s to meet all their (the residents) needs’. Observations made during the visit showed staff interacting well with the residents; singing and chatting with people, checking that footplates were fitted to wheelchairs before use and people seeming relaxed and comfortable in the company of the staff. People looked neat and tidy, with some people wearing shoes, others slippers and women wearing make up and with their nails nicely done. Staff were observed to assist people in ways that respected Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 12 their privacy and dignity. For example, quietly taking people to somewhere private for personal care tasks to be carried out. Seaton Hall DS0000047718.V356870.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 & 15 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Staff are flexible and try hard to meet peoples individual wishes and lifestyle choices, although this is sometimes limited by resources. There are no restrictions on visiting, with people thinking the home has a friendly, homely atmosphere. People like the food at the home and receive an appealing diet, with staff providing alternatives when people don’t like the main meal. EVIDENCE: When asked in the surveys if the home provided activities that people could take part in, four people said ‘always, three people said ‘usually’ and one person said ‘never’. One person commented that ‘activities are arranged but my condition does not enable me to take part’. Discussions with the staff and observations showed that each morning staff do an activity with the residents. For example, ball games and quizzes. Residents confirmed that an ‘activities lady’ visits the home regularly and does other activities, games and sing-alongs. One resident told the inspector that the library visits the home each month and that she liked to read her books before bed. Occasionally trips out take place and have included a visit to Eden Camp and a concert. Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 14 Discussions with residents and staff showed that people can spend time in their rooms if they want to and that staff try to be flexible and accommodate people’s wishes. Comments included ‘if I wake up in the night I’ll buzz and they’ll come up with a cupa’. One person would like it to be easier to organise staff support for trips away from the home, saying ‘it takes a lot to organise a trip into town’. This was thought to be due to staffing levels. The home has an open visiting policy, with people being able to visit the home at any time. The five relatives who returned surveys all said that the home ‘always’ helped their relative keep in touch with them. On the day of the inspection visitors came in and out of the home without any unnecessary restrictions. One relative commented that the home ‘tries to provide a friendly, homely atmosphere’. The lunchtime meal was observed during this inspection. The main meal was gammon and pineapple with vegetables, followed by banana flan with cream. There was no formal alternative, but staff asked people if they wanted pineapple and what vegetables they wanted. One person didn’t want the main meal and had something else instead. The food looked nice and staff were very pleasant while serving and assisting people with their meals. Staff spent a lot of time encouraging people to eat, including offering alternatives to try and tempt people who didn’t eat the main choice. Out of the eight people living at Seaton Hall who returned surveys, five said they ‘always’ and three said they ‘usually’ liked the meals at the home. Comments made about the food included ‘the menus are always lovely. The cooks and waiters top notch. If we ask for something they haven’t got they’ll go out of the way to get it for you’. One relative commented ‘I have often stayed for lunch and the meals are beautiful and home cooked’. Seaton Hall DS0000047718.V356870.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 & 18 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People know how to complain, feel happy talking to the home’s manager and owner and think that any concerns raised in the past have been handled appropriately. People are protected from abuse by the homes procedures and staff training. This makes sure that any suspicions of abuse are handled properly. EVIDENCE: Since the last inspection there have been no formal complaints made to the home or directly to CSCI. Information about the home’s complaints procedure is included in the Service User’s Guide. When the eight residents who returned surveys were asked if they knew who to speak to if they were unhappy, seven said ‘always’ and one gave no answer. Comments included ‘Carole (the manager) is always around – if not one of her lieutenants. If not, when he’s here, Mr Wilks the boss is the easiest person in the world to talk to’. All eight people who returned surveys said they knew how to complain if they needed to. All five relatives who returned surveys also said they knew how to complain if they needed to and felt that any concerns they had raised in the past had been handled appropriately. The home has procedures telling staff what to do if they suspect anyone is being mistreated or abused. Staff have also being trained in the recognition Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 16 and reporting of abuse, with only a couple of new staff still needing to do this training. There has been one safeguarding adults referral affecting a resident since the last inspection, but this was not about the home. The home made sure the incident was handled appropriately through local safeguarding procedures. Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 17 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 & 26 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The home is kept clean and tidy and equipment is maintained appropriately. People have a safe and homely environment to live in, although ongoing maintenance and refurbishment is needed to make sure that the appropriate standards of decoration and facilities are maintained. EVIDENCE: Seaton hall is an old building that has more recently been extended and converted into a residential home. The old parts of the building have character and original features, such as wood panelling and traditional decoration. However, it also means that the buildings layout is not straight-forward or ideal for a care home environment. For example, lots of corridors in which it is easy for people to become confused or disorientated and a spread-out layout that is difficult to staff. The home is decorated in a traditional and homely Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 18 standard and the owner is in the process of installing en-suite bathrooms to improve the home’s facilities. People’s individual rooms were homely and individual, with personal possessions in them. However, some parts of the home are looking old and worn, such as the upstairs bathroom. An ongoing programme of refurbishment is needed to maintain the building in a comfortable and pleasant state of repair. Comments made by people who live, work and visit in the home included ‘only improvement that can be made is the decoration of the home, but that is just the surface’ and ‘the building could be maintained to a higher standard, but we know this area is already in hand’. Equipment in the home was being serviced and maintained appropriately. A random selection of maintenance records was checked. Up to date maintenance records were seen for fire equipment, the gas system, the passenger lift and the bath lifts (which help people get in and out of the bath). Since the last inspection the home has improved the way it prevents the spread of infection by installing liquid soap and disposable hand towel dispensers. They have also improved how soiled laundry is handled, now using special laundry bags that disintegrate in the wash. People said that the home is kept clean and tidy, with comments including ‘the cleaners are grand’ and ‘the place is kept clean and tidy, last week they did a spring clean, pulled the bed out to get behind’. Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 19 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 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Staff receive the training they need to do their jobs. There are an appropriate number of staff on duty to run the home safely, although some people felt that more staff would improve the level of individual care that could be provided. Checks are carried out on staff before they start work in the home, to make sure staff are safe to work with vulnerable people. However, records of these checks need to be improved so that the home has all of the information they legally need about their staff. EVIDENCE: Discussions with the manager, the home’s staff and inspection of the home’s rotas showed that the home is always staffed by three care staff, plus the manager during her working hours. Administration and cleaning staff are also employed. At the time of this inspection these staff were looking after nineteen residents, four of who had high level needs. Although these staffing levels seem generally appropriate, some people felt that increasing staff levels would improve the care people received. Comments made by staff when asked if staffing levels were appropriate included ‘(they should) provide more staff to the ratio of residents’ and ‘depends on the kind of day it is’. Out of eight staff who returned surveys, one said there were ‘always’, five said ‘usually’ and two said there were ‘sometimes’ enough staff on duty to meet the Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 20 individual needs of all the residents. Comments made by people living in the home and their relatives about staffing levels included ‘I believe the level of care is impacted by, and due to, the limitation of staff numbers’, ‘I wish the staff would spend more time in amongst the residents, in the lounge’ and ‘I seem to want something and catch them on the way to somebody else’. All eight staff who returned surveys said that they were provided with the training they needed to do their jobs. Records showed that training in the last year has included national vocational qualifications (NVQ’s), fire safety, health and safety, first aid, stroke awareness, manual handling, food hygiene and no secrets. Individual training records were available for each staff member, showing that most staff were up to date with training in key areas. Comments made by people living in the home and their relatives included ‘the staff are wonderful from the manager to the cleaners. They are so patient and will do their utmost for you’, ‘I couldn’t have asked for a more caring staff’ and ‘all mates together’. Since the last inspection the home has recruited two new staff. The recruitment records for these staff were inspected. The records showed that the home had checked the protection of vulnerable adults (PoVAfirst) list and obtained two written references before they started working at the home. Staff confirmed this. However, a copy of one written reference could not be found and the home is not currently keeping a photograph and copy of identification on each persons staff file. The manager also needs to make sure that she keeps full records of the supervision given to staff who start work using a PoVAfirst check, until their full criminal records bureau (CRB) disclosure is returned. Supervision should be provided in accordance with the department of health guidance that was provided during the last inspection. However, the manager had not extended one staff members contract after their probationary period, due to concerns about their performance. This is good as it shows the manager will not tolerate staff who do not perform to the expected standard. Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 21 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 & 38 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The manager has made improvements in the home, is highly thought of and focused on the needs of the residents. People are now protected by regular management checks, which make sure that things are being done safely at the home. The health and safety of people living and working at Seaton Hall are promoted by staff training, safety checks on equipment and regular maintenance. EVIDENCE: The home’s manager has completed the registered manager’s award (a special qualification for care home managers) and is registered with CSCI. People spoke highly of her during the inspection, saying she was approachable, with Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 22 comments including ‘oh yes, I can talk to Carole’. Since the last inspection the manager has worked very hard to improve the management systems at Seaton Hall. Improvements have been seen in care planning, the storage and administration of medication, infection control, staff supervision and notifying CSCI of relevant events that take place in the home. Discussions with the manager showed that she was keen to learn and very focused on the needs of her residents. Since the last inspection the manager has started to do a number of regular checks, making sure that things are being done properly and that people are happy with their care. These checks include medication audits, accident analysis and regular supervision of staff. The manager now receives regular supervision from the home’s owner. She also has regular contact with residents and their families to make sure they are happy. However, these quality assurance tasks would still benefit from being brought together into a formal system that includes a yearly review and report. The home helps people look after small amounts of personal money and keeps records and receipts for these financial transactions. A selection of these records were checked and found to be up to date and accurate. Residents money is now stored in a safe and secure place. Since the last inspection the use of bed rails in the home has been reviewed. The home no longer uses them and has found alternative equipment that meets people’s needs. Regular checks of hot water temperatures are carried out to make sure that the thermostatic valves are functioning correctly and people are not at risk of scalding themselves. Checks of fire equipment are carried out and recorded, and the fire officer last visited the home on 5th June 2007. The manager now carries out monthly accident analysis to identify patterns and ways of preventing further accidents. Staff have received training in health and safety. Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 23 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 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 24 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 OP8 Regulation 12 (1) Requirement The home must develop its approach to risk assessment. For example, by undertaking regular nutritional screening and identifying people who are at risk of developing pressure sores using an appropriate tool. These risk assessments and any resulting preventative action should be recorded in people’s care plans. Timescale for action 30/06/08 2. OP29 19 (1) & Schedule 2 Staff recruitment records must 30/04/08 include two written references, a photograph and proof of identity. 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 Care plans should be developed to provide more detailed and individual information about peoples, abilities, wishes DS0000047718.V356870.R01.S.doc Version 5.2 Page 25 Seaton Hall and preferences. 2. OP9 The use of inhalers and topical medications should be recorded on MAR sheets. Discontinued medication should be removed from MAR sheets. All doses administered should be signed for or a reason for omission should be documented. An ongoing maintenance programme should take place to refurbish and maintain the buildings facilities and decoration. Staffing levels should be regularly reviewed. This review should take into account the dependency of residents at the time of the review, the layout of the building and any other factors that are appropriate. The provider and manager should continue to develop a system for reviewing and improving the quality of care provided by the care home. This should include seeking the views of residents and their supporters. 3. OP19 4. OP27 5. OP33 Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Seaton Hall DS0000047718.V356870.R01.S.doc Version 5.2 Page 27 - 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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