Inspection on 28/06/07 for Seaton Hall

This inspection was carried out on 28th June 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

Seaton Hall 19/02/09

Seaton Hall 21/02/08

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 Dean Unannounced Inspection 28th June 2007 09:30 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.V343276.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.V343276.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 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2006 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, which has a modern extension. An enclosed courtyard garden is located at the back of the building. Accommodation at Seaton Hall is provided on two floors, with lift access to the upper level. There are communal toilet and bathing facilities located around the home and one bedroom has a private en-suite bathroom. The home has two spacious lounges and a dining room. The home is registered as a care home providing care for 33 older people. At the time of this inspection the weekly cost of living at the home was £354 per week. This does not include hairdressing, chiropody, toiletries, transport and newspapers. Up to date information about the home’s fees should be sought from the manager. Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was completed over two days by one inspector. During the visit to the home the inspector talked to some of the people who live there and some of their visitors. Eight people living in the home also completed surveys. Staff were observed while they carried out their work and a selection of staff completed surveys about the home. The inspector looked around the building and inspected a selection of the home’s records. The manager was involved through out the inspection. What the service does well: What has improved since the last inspection? What they could do better: Recruitment practices need to be improved, to make sure that they protect people from unsuitable staff. Full employment checks have not always been carried out before staff start work. The home’s systems for the storage, administration and recording of medication need to be reviewed and improved. This is very important so that Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 6 people are protected and medication is managed safely. At the moment medication is not always stored or recorded properly. Some aspects of health and safety and infection control also need to be improved, to protect people from unnecessary risks. For example, the home is not currently following good practice guidance on the safe use of bedrails or carrying out hot water temperature checks in accordance with the home’s own policies and procedures. A number of the home’s paper work systems could also be improved, to provide better information to staff and people living at the home. This includes the home’s contracts/statement of terms and conditions and people’s care plans and assessments. 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.V343276.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.V343276.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all people living in the home have been provided with a fully completed contract or statement of terms and conditions. This is important so that people know their rights and their financial obligations. People have their needs assessed before being admitted to the home, to help make sure that the home can meet their needs. EVIDENCE: The contracting arrangements for four people living in the home were checked. Only two of these people had fully completed statements of terms and conditions on their file. Out of eight people who returned surveys only four said they had received a contract, while two said that they had not received a contract. Information about the Office of Fair Trading’s recent report on ‘fair terms for care’ and what CSCI expects of providers has been provided to the home’s manager. The home’s current systems for providing terms and Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 9 conditions/contracts to people living in the home must be reviewed using this information. The assessment records of four people were inspected. Each person had an assessment in place, which had been reviewed on a yearly basis so that the assessment remained up to date. However, the assessment format was not very detailed, giving a brief ‘tick box’ overview of people’s needs, rather than a full and detailed picture of the person’s abilities, needs and preferences. Information from social services was available where they had been involved in arranging people’s care. People confirmed that they had been able to look around the home before admission. Seaton Hall does not provide specialist intermediate care. Seaton Hall DS0000047718.V343276.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Each person at Seaton Hall has their own care plan and record, although these could be more individual and detailed. People usually receive the care they need and feel that staff treat them well. Medication systems at the home need to be improved, as medication is not always being stored, administered, recorded or disposed of correctly. EVIDENCE: The care plans and records of four people living in the home were inspected. Each person had a care plan and a record of the care they received. However, the care plans were inconsistent and very general in content, and would benefit from being more person centred and individual. For example, they contained very little information about each individual’s needs and preferences and would be of very limited help to care staff. The care plans must also be developed to include nutritional assessments, regular weight monitoring when Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 11 nutritional assessments suggest that this is necessary and risk assessments for maintaining skin integrity. The inspector contacted the district nurse who visits the home regularly. This nurse was happy with the care people received at Seaton Hall, felt that she had a good working relationship with the home and was happy that nursing care was requested appropriately when it was needed. Care records included records of hospital and other health related appointments. Out of the eight people who completed and returned surveys four said that they ‘always’ and four said that they ‘sometimes’ received the care and support they needed. Comments made about the care provided included ‘sometimes they hesitate, but eventually act on what I say’, ‘some staff are more helpful than others, and wait to see if I can do it on my own, but it is hard for me to do so’, ‘the staff are kind and helpful…they take good care of me’ and ‘they are marvellous they really are, there’s not one I could say anything about’. During the inspection staff were observed to be friendly and to treat people nicely. The homes medication systems need to be thoroughly reviewed to make sure that medication is being stored, administered, recorded and disposed of safely. During the inspection a medication round was observed and a medication audit was attempted with the home’s manager. A number of shortfalls were highlighted, including medication being stored in the fridge that did not need to be stored there, medication that was significantly out of date still being stored, completely unlabelled bottles of medication being stored with the homely remedies, medication administration record sheets not being fully completed and discrepancies between the medication records and the stock balances available in the home. The current system also requires residents to visit the home’s dispensary to collect their medication during each medication round. This was observed to be disruptive for staff and residents and it is recommended that this practice be reviewed. The manager has contacted the home’s community pharmacist and the local Primary Care Trust pharmacist for advice and has agreed to undertake a full review of the home’s medication systems as soon as possible. Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides some entertainment and activities, but this needs to be developed, taking into account people’s interests and abilities. Routines are flexible and visitors are welcomed. The home provides nutritious meals and snacks, but the way choice is offered needs to be improved so that everyone has the opportunity to make real decisions about what they want to eat. EVIDENCE: When asked in the surveys if there were activities arranged by the home for people to take part in two people said ‘usually’ and five people said ‘sometimes’. Comments included ‘carer sometimes brings in a game to do, but otherwise no, not much going on’ and ‘not much, sometimes get people in, entertainers and the like’. However, people living in the home did comment on how they liked the trips out that were sometimes organised. During the inspection staff were observed to play games with some of the residents, however, staff and the manager commented on how it was difficult to get people to join in. The manager has arranged for ‘motivation’ classes at the home, to try and encourage people to be more motivated and join in with Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 13 activities. It is recommended that the home collects more information on what people like to do and their particular interests or hobbies. This information can then be used to develop ‘social activity’ care plans and to provide group and one-to-one activities that are of interest to people. Visitors confirmed that they were welcome to visit the home at any time and that there were no unreasonable visiting restrictions. Comments made by regular visitors to the home included ‘staff are very friendly, talk to you, chat to you, let you know what’s going on’. People living at the home confirmed that they could get up and go to bed when they wanted, that they could choose where to spend their time, some people preferred to eat in their rooms and some people preferred to have their baths in the evening. One relative commented ‘they use their common sense, if she’s tired they put her to bed’. Out of the eight people who completed and returned surveys one said that they ‘always’, four said that they ‘usually’ and three said that they ‘sometimes’ liked the meals at the home. Comments made about the food included ‘they make cakes and soups that smell lovely’, ‘it’s quite good, sometimes they tell you what’s on, but if you don’t like it you can ask for something else, but usually I’m content with what they offer’ and ‘not all that much choice, but do you want turnip, butter on your potatoes and things like that’. During this inspection the lunch-time meal was observed. Lunch was mince pie with carrots, broccoli and potatoes, followed by trifle. The meal looked pleasant, and although served on small dinner plates the portions looked to be adequate. However, no one was seen to have any of the alternative meals on offer or to be offered second helpings. When staff asked people what they wanted for their meal they were simply told what the main meal was and asked if this was ‘okay’, rather than being told what the alternatives were and being encouraged to make an informed choice about what they wanted. The home needs to develop ways of making this choice more explicit and fully available to all residents, not just those who are able to understand that there is always an alternative meal available or have the confidence to ask for it. Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People feel happy about approaching staff and the manager at Seaton Hall. Complaints and protection policies and procedures are in place and staff are aware of their reporting responsibilities. EVIDENCE: The home has in place a complaints procedure. Records of complaints are kept in a hard backed book and showed that complaints are looked into appropriately. However, this book did not make it easy to keep supplemental records together with the complaints record and it is recommended that this is reviewed (for example, using a file instead of the hard backed book). People spoken to during the inspection felt that the staff and manager were very approachable and that they could talk to them if they weren’t happy about something. Comments included ‘oh yes, I could do that easily (talk to the manager if unhappy)’ and ‘she’s (the manager) very good if you need her’. Seven out of eight people who returned surveys said that they knew how to make a complaint and ‘always’ knew who to speak to if they were unhappy about something. The home has in place a procedure setting out what should happen if staff suspect or witness someone being abused. This procedure appeared to be Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 15 suitable, although it needs to be updated regularly to make sure that the telephone contact numbers are correct. Staff have received training in recognising and reporting abuse and were aware of their responsibilities. Seaton Hall DS0000047718.V343276.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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Seaton Hall provides traditional and homely accommodation for the people who live there, although some areas would benefit from refurbishment or redecoration. The home is kept clean and pleasant, although some aspects of infection control could be improved. EVIDENCE: Seaton Hall is a very old building, which has been extended and adapted for use as a care home. As a result the home has character and original features, such as wood panelling and traditional decoration. However, this also means that the home’s layout can be confusing for people who are unfamiliar with it. The home is decorated in a traditional and homely style, although some parts would benefit from ongoing redecoration and refurbishment. For example, some paintwork was scraped and some furniture was worn and in need of Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 17 replacement. The home was observed to be clean, although some areas (for example, around the senior carers desk) would benefit from being tidied up. Comments made by people living in and regularly visiting the home included ‘the home has been refurbished over these past few years and is kept clean and tidy’, ‘I’ve got a lovely room’, ‘it’s reasonable, but old fashioned I think…my room is lovely, absolutely perfect’ and ‘they have the cleaners in every day, they have one or two cleaners and polishers’. The home has a laundry with one washing machine and one drier, with care staff doing the laundry. This meets the home’s needs on a day-to-day basis, but does not provide any back up if the machines breakdown. If this happens the manager uses a local laundry until the fault is fixed. People living in the home said that they were happy with the laundry service. However, some infection control issues need to be improved, to make sure that staff and people living in the home are not put at risk of infection. For example, the hand soaking of soiled laundry should stop. The home should consider providing dissolving laundry bags and using the sluicing programme on the washing machine instead, to reduce the handling of soiled laundry. The use of bar soaps and hand towels in communal bathrooms should be replaced with paper towels and soap dispensers, as these are more hygienic and will minimise the spread of infection. Staff would benefit from training in infection control. Seaton Hall DS0000047718.V343276.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 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although staffing levels look appropriate for the number of people living at Seaton Hall, staff are not always able to respond to requests for help as quickly as people would like them to. Most staff have completed a recognised care qualification, but staff would benefit from some additional training. Recruitment practices need to be improved, to make sure that people are protected and looked after by suitable staff. EVIDENCE: Survey results showed that when asked if staff were available when needed three people answered ‘always’ and five people answered ‘usually’. Comments made about staffing levels by people living in the home included ‘they do eventually come’ and ‘it’s sometimes a bit awkward, like when I ring for help to go to the toilet and they can’t come straight away’. Staff comments about staffing levels at Seaton Hall included, ‘staffing levels at present are fine and care staff are able to manage’, ‘sometimes it feels like we’re understaffed, depends on the day’ and ‘understaffed I think’. Observations made during the inspection showed that there were sometimes quite long periods of time when no staff were available in the home’s main lounge, because they were busy elsewhere in the home. A copy of staffing rotas for were provided by the Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 19 manager. These showed that, in addition to the manager’s hours, three staff were on duty during the day and night, to look after 24 residents. 80 of the care staff at Seaton Hall have achieved an National Vocational Qualification in care. Training records were available for each staff member. Training over the last year has included abuse, fire safety, manual handling and first aid. Senior staff have completed training on handling medication. However, not all staff (including the manager) are up to date with training in manual handling, which should be updated on a yearly basis. Training in subjects like infection control, health and safety, care planning, nutrition and maintaining skin integrity in older people would be useful. A selection of recruitment records were inspected. These records highlighted a number of shortfalls in the home’s recruitment practices. Two written references were not always being obtained, a complete employment history (including an explanation of any gaps) was not always available and a new carer had started work before her Criminal Records Bureau disclosure had been received, with no record of a PoVA First check having been completed. The home must urgently improve its recruitment practices to make sure that people living in the home are fully protected. Seaton Hall DS0000047718.V343276.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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a new manager who is approachable and enthusiastic, but needs formal support and supervision in order to develop her skills and make the necessary improvements in the home. Quality assurance systems and some aspects of health and safety need to be improved. EVIDENCE: Since the last inspection of Seaton Hall the previous manager has retired and the deputy manager has taken on the role of manager. The new manager has been registered by CSCI and has almost completed the Registered Managers Award. She intends to start the level 4 National Vocational Qualification in care in the near future. People described the new manager as being Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 21 approachable and supportive. During the inspection she appeared to be aware of the limits of her knowledge and experience and was enthusiastic and willing to learn. However, this inspection has highlighted a number of important issues that need to be addressed by the manager and provider. For example, the medication issues already discussed in this report and that manager did not know that she had to notify CSCI of certain events under Regulation 37 of the Care Homes Regulations. Although the manager felt that she was well supported by the home’s owner, there are currently no formal supervision arrangements. It is very important that the new manager receives regular, formal supervision, from someone who can help her develop her management skills and make the necessary improvements in the home. Systems are in place to help people manage a small amount of personal money. Records are kept for each person, including the signatures of two people, receipts and records of regular balance checks. The use of a lockable cupboard or safe to store people’s money in should be considered, as the current arrangements are not very secure. Seaton Hall carries out surveys to find out what people living in the home think of the care they receive. However, the manager needs to develop a quality system of internal audits, checks and reviews. For example, regular accident analysis, medication and financial audits and quality checks of the home’s record keeping. This is important, to make sure home is meeting its legal obligations, providing a good level of service and identifying areas it needs to improve. Information provided to CSCI in the home’s Annual Quality Assurance Assessment did not provide a realistic picture of how the home was functioning and it is important that the manager and provider have effective ways of assessing, monitoring and improving the home’s performance. During this inspection a selection of the home’s maintenance records were inspected. These showed that important servicing work, like the homes electrical installations, gas safety and manual handling equipment, had been completed and were up to date. Thermostatic valves are fitted to hot water outlets. However, regular checks of the hot water temperatures at these outlets were not being carried out, despite this being in home’s policies and procedures. Regular checks must be carried out and recorded, to make sure that the thermostatic valves are functioning correctly and to protect people from the risk of scalding. Since the last inspection the home has been working with the local fire authority to improve fire safety at Seaton Hall. Staff training in fire safety has been provided, regular drills have taken place and the fire alarm system has been serviced. There is now a fire safety file, containing records of regular checks carried out by the home’s maintenance man. However, from these records it was not always clear what was being checked or how often the checks should be taking place, so the manager should make sure that these records are clear and that the maintenance person has clear written guidance on what checks need to be completed and how often. Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 22 The home was using bedrails at the time of this inspection and these were not all in correct working order. The incorrect use and maintenance of bedrails can be very dangerous and the broken bedrails were removed during this inspection. The manager must make sure that bedrails are only used where absolutely necessary and in accordance with up to date good practice guidance. Where they are used regular maintenance/safety checks should be implemented and recorded, with staff checking that the bedrails are functioning correctly each time they are used. Seaton Hall DS0000047718.V343276.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 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Seaton Hall DS0000047718.V343276.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 OP2 Regulation 5A Requirement Timescale for action 31/10/07 2. OP8 12 (1) 3. OP10 12(2) Everyone must receive a fully completed contract or statement of terms and conditions, which provide full information about their fees and terms and conditions of occupancy. The home must promote and 30/09/07 make proper provision for the health and wellbeing of service users, by undertaking regular nutritional screening and identifying people who are at risk of developing pressure sores. These assessments and any resulting preventative action should be recorded in people’s care plans. The home must provide safe 31/08/07 systems for the storage, administration, recording and disposal of medication. Infection control practices must be reviewed and improved. This includes the handling of soiled laundry and use of communal bar soaps and towels in communal toilets. The recruitment of care staff must include obtaining two DS0000047718.V343276.R01.S.doc 4 OP26 13(3) & 16(2)(j) 31/10/07 5. OP29 19 (1) & Schedule 10/08/07 Seaton Hall Version 5.2 Page 25 2 6. 7. OP36 OP31 18(2)(a) 37 8. OP33 24 9. 10. OP38 OP38 13(4)(a) & (c) 13(4)(a) & (c) written references, a CRB disclosure and a full employment history (including an explanation of any gaps) before new staff start work. All staff, including the manager, must receive appropriate supervision. The provider and manager must ensure that CSCI is notified of all appropriate events, as required by Regulation 37 of the Care Home Regulations. The provider and manager must develop a system for reviewing and improving the quality of care provided by the care home. This should include internal audits and checks to make sure the home is being managed in accordance with the home’s legal responsibilities. Regular checks of hot water temperatures at hot water outlets must be carried out. Bedrails must only be used in accordance with up to date good practice guidance and with appropriate maintenance/safety systems in place. 30/09/07 10/08/07 31/10/07 10/08/07 10/08/07 Seaton Hall DS0000047718.V343276.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 OP7 OP12 Good Practice Recommendations Care plans should be developed to provide more detailed and individual information about peoples, abilities, needs and preferences. The home should collect more information about people’s hobbies and interests, record these in their care plan and use the information to develop individual and group activities. The home should develop the way it offers a choice of meals to the people who live there, particularly to people who are confused or lack the confidence to ask for alternatives themselves. It is recommended that the way the home keeps complaints records is reviewed, so that complaints records and information can be kept together easily. Staff would benefit from training in the following subjects; infection control, health and safety, care planning, nutrition and maintaining skin integrity. All staff should receive regular manual handling training. The home should make appropriate arrangements for the secure and safe storage of service user’s money and valuables. The records of regular fire safety checks should be maintained clearly, showing exactly what checks have been carried out and how often. 3. OP15 4. 5. OP16 OP30 6. 7. OP35 OP38 Seaton Hall DS0000047718.V343276.R01.S.doc Version 5.2 Page 27 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.V343276.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. 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