Inspection on 20/11/06 for Seaview

This inspection was carried out on 20th November 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Seaview 12/08/08

Seaview 08/11/07

Seaview 25/01/06

Seaview 25/07/05

Seaview 24/03/05

Seaview 07/09/04

Seaview 26/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Seaview Blundell Avenue Freshfield Formby Merseyside L37 1PH Lead Inspector Ms Lorraine Farrar Unannounced Inspection 20 November 2006 10:55 th Seaview DS0000017271.V296439.R01.S.doc Version 5.2 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 Seaview DS0000017271.V296439.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 Adults 18-65. 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. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seaview Address Blundell Avenue Freshfield Formby Merseyside L37 1PH 01704 872155 01704 872155 jeanpugh@gotadsl.co.uk 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) The Frances Taylor Foundation Mrs Jean Pugh Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users to include up to 12 LD. The service should, employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 25th January 2006 Date of last inspection Brief Description of the Service: Seaview provides accommodation and support with nursing for 12 adults who have a learning disability. Many of the people living there also have physical disabilities and the home provides aids and adaptations to accommodate these. There are Staff available 24 hours a day, during the day there is also a registered nurse on the unit, at night they share the registered nurse with the other two homes located nearby. Seaview is owned and operated by the Frances Taylor Foundation, a national organisation who provide support to people with a variety of care needs. The home is located in the middle of Formby Pinewoods and shares the site with, two other registered homes, a day centre for 65 people and a convent. All the services are for adults who have a learning disability. Services share transport, kitchen facilities and administrative support. Most of the bedrooms are single rooms, where two people share, there are screens for privacy. Where needed all residents have their own toilet, this is either in or near to their bedroom and is adapted to meet their needs. There are two shared rooms, bathrooms and a small kitchen on the unit. The home has a small private courtyard and shares large grounds with the rest of the site. The home has operated for many years, it used to be a unit within St Joseph’s Adult Services, this was changed in 2005 to make the unit smaller and provide a more individual service. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two CSCI Inspectors, Lorraine Farrar and Natalie Charnely carried out this inspection. Information for this inspection was gathered in a number of different ways. This included an unannounced site visit where time was spent reading records and looking at the building. ‘Case tracking’ was used as part of the visit. This involves looking at the support a person gets from the home including their care plans, medication, money and bedroom, time is also spent meeting with the Service User and with Staff about how they meet the persons needs. Case tracking was used to look at life in the home for three of the people living there. Comment cards were sent out before the inspection. 2 were returned from professional visitors and 5 from Relatives and friends. 4 had been completed by Service Users with help from their Relatives. Any information the Commission for Social Care Inspection (CSCI) has received since the last inspection about the home is also taken into account. This included the results of comment cards sent out to Service Users, professionals involved with the people living in the home and Relatives. The home also contributed information to the inspection by completing a preinspection questionnaire. The current fee for living at Seaview is £924 per week What the service does well: The home is clean and well organised with equipment provided to meet Service Users needs and bedrooms areas in particular personalised and decorated to a high standard. There is a good format and procedure in place to assess potential Service Users and make sure the home can meet their needs and choices. Care plans provide detailed information about the persons’ health care, personal care needs and their choices and Staff are aware of this information and able to explain the support each individual requires and prefers. Service Users receive a good level of personal and health care with their needs being identified and met by the Staff team. The home provides a good level of support to Service Users in maintaining their relationships with family. Families and friends are satisfied with the overall care provided by the home and feel that their views are listened and responded to. Clear information is provided to everyone about how to make a Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 6 complaint or express a concern about the service and any complaints received are thoroughly investigated and responded to. What has improved since the last inspection? What they could do better: The way in which Staff work when they are understaffed needs to be reviewed to ensure that Service Users dignity is respected and that they receive a good service at all times. The Manager needs to spend time observing meals in the home and ensuring that these are sociable occasions for Service Users, and that they are supported in a manner which is unrushed and includes Staff demonstrating respect for them. This may mean that the times Service Users leave the home to go to their Resource Centre also needs reviewing, to make sure that practices are always in place for the individual Service User and not to suit long established routines. Staff training needs to be developed further to make sure that before they carry out specialist support, such as abdominal massage, they have received training to identify and lessen any risk to the Service User. The practices of Staff taking Service Users money or receipts for items bought by service Users, out of the home needs to be looked at. This could leave Service Users open to financial abuse and does not protect members of staff adequately. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 7 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. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Sufficient information is obtained about a person before they move into the home, to ensure that their needs and choices can be met. EVIDENCE: No new Service Users have moved into the home within the past year. Therefore whether the home obtains enough information about new Service Users to make sure they can meet their needs and choice, could not be practically assessed. However the home has a detailed pre-admission form, which, would be used for all potential Service Users. Previous inspections have evidenced that the home do carry out preadmission assessments and obtain a copy of the Health Authority and Social Services assessments prior to offering a place. This helps the home to ensure they can meet the person’s needs and plan for the care and support they will provide. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service Service Users individual needs and choices are identified and plans are in place to meet these. EVIDENCE: Care plans were read for three of the people living at Seaview. All stated that they had been written using the knowledge and observations of the keyworker, Staff and the person’s friends and family. This was confirmed in the comment cards of Relatives who said they are always consulted and kept informed about the persons care needs. Plans were up to date and contained information about the support the person needs and likes with their health and personal care as well as their individual choices and needs. For example one plan reminds Staff that a Service User likes to listen to hymns and another that the Service User has special oil to suit her hair. When meeting the Service Users it was evident that Staff followed these parts of their care plan. Detailed guidelines give information about how to communicate with the person. One plan contained clear guidelines for Staff to observe a persons Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 11 behaviour, how to interpret what this meant and how to support her appropriately. Information about the person’s finances is recorded on their file, where they are unable to make decisions in this area, their Relatives have been consulted and signed their agreement for recent petrol charges made by the home. One Service User has a long term advocate and friend who is involved in supporting her to make decisions. All plans have up to date risk assessments for the individual, these covered a variety of areas to suit the individual, including, using the garden, eating and bathing. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service Users receive support with choosing how to spend their time, however routines in the home are not always flexible enough to respect their rights. EVIDENCE: All of the people living on Seaview use the on-site Resource Centre, Fernley, several times a week. This is owned and operated by the organisation and caters for the three homes on site and people living in the wider community who have learning disabilities. The home also has an excellent hydrotherapy pool, which Service Users access whilst at the Resource Centre. Each Service User spends at least one week day at home. Relatives stated in the comment cards that there are always or usually activities arranged by the home that the Service User can participate in. Care plans contain information about the persons social likes and dislikes and a list of the activities they have engaged in each day. One plan stated the Service User liked to listen to music and this was observed to be playing in her room whilst she was resting. However activity records were looked at for November, for three people and many of the entries were around personal Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 13 care. Other than entries for attending the day service, one person had been out twice, attended the on site church and had a visitor. The other two people had no activities recorded other than going to the day service. The home has some access to an adapted mini bus and can also make use of local adapted taxis. A Service User spending the day at home was seen to sit in the lounge alone, with little interaction other than to have her lunch. When the Inspectors spoke with her she appeared eager to interact with others and when alone she was observed spending time gazing at the floor. In their comment cards Relatives said that they are always welcomed to the home and able to visit in private if they wish. Staff do support Service Users to visit their families if needed. Plans contain information about the person’s preferred routine and records showed that when not attending the Resource Centre people can choose when they get up in a morning. Staff were seen to knock on bedroom and bathrooms doors before entering and Service Users to make use of communal rooms as they chose. Main meals are prepared by a large kitchen, which caters for all the services on site. Within Seaview there is a smaller kitchen where meals can be heated up and snacks and drinks prepared. Both areas were clean and well stocked with fresh fruit, juice and vegetables. The Nurse in charge explained that the unit was short Staffed due to sickness during the site visit and that there is usually 7 or 8 Staff at lunchtime to help Service Users with their meal. However during the site visit there were 4 Staff available and the mealtime was noted to be a rushed affair with little social activity or interaction happening. One Service User was banging his head and trying to push away from the table, this was ignored by the three Staff present. After his mealtime he was pushed out of the dining room with no explanation. Another Service User was being supported by a member of Staff. Although the Staff member explained to her what was on the plate, no further conversation took place. A large spoon was used and the food was given to the Service User at a fast rate, with the next spoonful being held up to her chin before she had finished eating. A third Service User was given a drink whilst the member of Staff stood over him and broke off to attend to other tasks. The dining room appears stark with no cloths or condiments on the table; there is no communal dining experience for the people living there and little interaction from Staff. The whole meal time appeared rushed with large spoons regularly used to give people their meal and bowls and aprons held under their chin. One lady sat at her table for several minutes with food on Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 14 the table, floor, her face and clothes. A member of Staff wiped the floor then led her from the dining room without wiping her face. Not all the Service Users eat together as many need support. Whilst some were in the dining room, one man was sat in the corridor, appearing agitated, several Staff walked past without speaking with him, another lady was sat on a bathroom floor, again Staff walked past without speaking with her. The Nurse in charge explained that the home was short Staffed and that lunchtimes are time limited in order for people to get back to the Resource Centre on time. She stated that tea times and other mealtimes are not as rushed. A second member of Staff said she does not think lunchtimes are rushed she thinks they are individual to the Service User. The Manager needs to spend time observing the mealtimes in the home and prioritise Staff workloads so that time constraints do not impact in a negative and disrespectful way on Service Users. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service Users receive a satisfactory level of support with their personal and health care however Staff training needs to be expanded to cover the more specialist services they provide. EVIDENCE: Relatives all said in their comment cards that, Service Users receive the support they need with personal and health care and that they are satisfied with the overall care provided. One Relative commented, “Service Users are always clean and tidy no matter what time you arrive”. Care plans contain clear information about how to support the person with their personal and health care. This includes assessments of their moving and handling needs and regular checks of their weight. One plan gave information about the need for the Service User to be positioned in a certain way and to have bed rest; this was seen to be followed by Staff. Good practice was observed in that clear guidelines had been written for monitoring a Service User’s health whilst he reduced his medication. Another plan stated the Service User required daily abdominal massage with essential oils and records confirmed this was carried out. Although an information leaflet about abdominal massage was available there was no evidence that Staff had received training from a competent person in this. The Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 16 person’s plan also stated they should receive regular physiotherapy and this was on going. There was no information to evidence that this had been carried out or by whom. Before Staff provide specialist services such as these to Service Users they must have adequate training to identify and lessen any risk to the Service User. Records show that Service Users receive support to attend and make health appointments such as with the GP and Dentist and that Staff are provided to accompany them. The home has a separate storage room for medication, this was clean and tidy with medications generally stored correctly. Records of the temperature of the fridge used for medications were up to date. However the thermometer was not working and must be replaced in order to ensure that medication is stored correctly at all times. Records of medication received and given were up to date and had all been signed. On one medication sheet tipex had been used to make alterations, this practice should be stopped to make sure that there is always a permanent record and audit trail of medication available. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Clear polices and procedures are in place to protect Service Users however these need to be further developed to protect Service Users from financial abuse. EVIDENCE: The home has a complaints procedure in place, information about this is in the Service Users guide and at the front door of the home. In their comment cards Relatives said that they are aware of whom to speak with and how to make a complaint. A recent complaint about the service was dealt with professionally by the organisation who investigated the complaint, prepared a report and acted upon the outcomes and recommendations of this. Information about the local authority’s adult protection procedures is available in the home and Staff have received training in this area. Three Service Users monies were looked at during the site visit. One recorded £45 taken out by Staff to get presents for the person’s Relative. The money had not been returned and no receipt was available for goods bought, although a signed petty cash voucher was in place for the money taken. The Nurse in Charge explained the member of Staff had taken the money to buy the goods but was now off sick. A second Service Users file recorded £450 spent, again no receipts were available for this. The Nurse in Charge explained that they check purchases against receipts and that on this occasion the member of Staff had taken the receipts to itemise them. The practice of Staff taking money out of the home Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 18 without the Residents and it not being returned swiftly means that there is no clear audit trail in place and no protection for either the Service User or Staff. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27, 29 & 30 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Seaview provides a suitable, well adapted place for Service Users to live in. EVIDENCE: The home is in the middle of Formby pinewoods and although in lovely surroundings it is quite isolated from the nearby local community. Other facilities on site include two other registered homes and a resource centre for adults with learning disabilities. There is also a Convent attached to the home. Seaview provides 2 double bedrooms and 8 single bedrooms, where Residents share a bedroom screens are provided for privacy. Shared space includes a dining room, two small lounges and a private courtyard. Within the home there is enough space for Residents, Staff and Visitors. Outside, the home shares large grounds with other services on site. These provide a peaceful place to sit, go for a walk or have some privacy. All of the bedrooms in the home are well decorated with attention to detail and the persons taste and likes and dislikes taken into account as much as possible. Each Resident has a designated toilet, which is decorated and furnished with aids and adaptations to suit their needs. In addition the home provides three bathrooms with adapted baths. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 20 The home is well suited to meeting the needs of people who have a physical disability, all accommodation is on ground floor level and doorways are wide enough to accommodate wheelchairs. There are adapted bathing and toilet facilities and overhead tracking and hoists are fitted to help people mobilise. Lounge areas were decorated within the past year and are more homely than in the past. The dining room has been decorated but still appears stark and institutional, with no cloths or condiments on the table and a red lino floor. A Relative commented, ““The home is exceptionally clean.” and all areas of the home were noted to be clean and tidy during the site visit. Equipment is provided for Staff to prevent the possible spread of infection. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service Users are supported by an experienced Staff Team, however Staff do not always take time to ensure Service Users are treated with respect. EVIDENCE: A Relative stated in their comment card that, “my (Relative) receives excellent care and attention from the Staff. They are very kind to him and treat him with love and respect. There is always a pleasant atmosphere when we visit”. Most Relatives said they think there is sufficient Staff working in the home and Service User comment cards, completed by Relatives, said that Staff are available when they are needed. Both professional visitors said in their comment cards, that Staff clearly communicate, act on advice and that they are satisfied with the overall care provided by the service. All members of Staff spoken with during the site visit said that they feel they work well as a team. No agency Staff have worked in the home for some time and a member of Staff commented that this benefited Service Users as they are cared for by people who know them well. Staff were seen to follow the guidelines in care plans for supporting people with their personal care needs. All Staff could explain each persons’ care needs and routines, however one member of Staff had not read all of the care Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 22 plan and was unsure why a Service User needed to rest on their bed daily, although she ensured this was carried out. As identified earlier, the home was short of Staff during the site visit. This clearly impacted on the quality of the support Service Users received, with little interaction between Staff and Service Users taking place on that day. The Staff rota showed that there are usually more Staff working each day. However the evident time restraints on Staff impacted on their work with Service Users, and could lead to Service Users feeling a lack of trust in their Staff Team. Just under half the Staff team hold a qualification in care and a good induction plan is in place for new members of Staff. This includes assigning them an experienced member of Staff as a ‘mentor’ who can introduce them to the unit and provide advice and guidance. There is a varied programme of training for Staff with most having attended basic courses such as fire and moving and handling and a newer member of Staff having undertaken a qualification specific to working with adults with a learning disability. Training in more specialised areas such as abdominal massage has not been formally provided and would ensure that risks to Service Users are identified and addressed. Staff files contained evidence that Criminal Records Bureau (CRB) checks are carried out for all Staff. Two out of the three files also contained copies of references, the Nurse in Charge explained that the third member of Staff’s references were probably with the Manager. Copies of Staff terms and conditions, job application and record of interview are also held on file. These checks help the Manager to ensure Staff are suited to work with Service Users who are often vulnerable. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home is operated by an experienced Manager and there are regular checks carried out on the quality of the service. EVIDENCE: Mrs Jean Pugh is the Registered Manager of Seaview, she holds a learning disabilities nursing qualification and a management qualification and has significant experience of management within a care setting for adults with learning disabilities. The home and organisation have a number of systems in place to audit the quality of the service. Regular unannounced visits are carried out by the organisation and a report of these made. An internal quality audit was carried out by the organisation in September 06 this was based on the national minimum standards of care for adults aged 18 – 65. Surveys had been sent out to Relatives however these had not yet been audited. A report from the Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 24 last Relatives survey in September 05 had been audited and a copy of the findings forwarded to Relatives to keep them informed. An outstanding requirement from previous inspections had not been fully met. This required the home to act on the findings of a security assessment carried out by themselves, in order to ensure Service Users safety. The Nurse in Charge explained that some work had been carried out and the rest is planned. Records and certificates showed that health and safety checks are carried out regularly. The exception to this was testing of the emergency lights, which had not been tested since July 06. These lights are used in the event of a fire in the home and must be regularly tested to ensure they are working safely. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 4 27 3 28 X 29 4 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 2 15 3 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA42 Regulation 13(4) a Requirement The Responsible Person must act on the findings of the security assessment they carried out in order to ensure Service Users safety. This is a previous requirement. 2 YA17 12(4)(a)(b) The Responsible Person must audit arrangements for mealtimes in the home to ensure they do not have a negative affect on Service Users. They must act on the findings of their audit. 3 YA23 13(6) The Responsible Person 28/01/07 must review arrangements for handling Service Users money in the home. This will ensure Service Users are fully protected. 28/01/07 Timescale for action 28/02/07 Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 27 4 YA35 18 (1) (c) The Responsible Person 28/02/07 must ensure before Staff deliver specialist support they have the required training. 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 3 Refer to Standard YA32 YA35 YA20 Good Practice Recommendations The home should continue to support care Staff to obtain an NVQ in care. The home should carry out a training analysis of the Staff team. 1) The responsible Person should provide a thermometer for testing the medication fridge is at a safe temperature. 2) The Responsible Person should stop the practice of using tipex on medication sheets, in order to ensure a permanent record is available. 4 YA34 The Responsible Person should audit Staff files to ensure all contain required safety checks for Staff including references. Seaview DS0000017271.V296439.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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