Inspection on 12/12/07 for Seaview Nursing and Residential Care Home

This inspection was carried out on 12th December 2007.

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

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Turret Villa Retirement Home

Moor House

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Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Seaview Nursing and Residential Care Home 41 Marine Parade Saltburn-by-Sea TS12 1DU Lead Inspector Jackie Herring Key Unannounced Inspection 12 December 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 Seaview Nursing and Residential Care Home DS0000069727.V341823.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. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seaview Nursing and Residential Care Home Address 41 Marine Parade Saltburn-by-Sea TS12 1DU 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) 01287 622 188 01287 622 522 A & R Healthcare Limited Mrs Phillipa Corinne Williams Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability (5) of places Seaview Nursing and Residential Care Home DS0000069727.V341823.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 with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 25 2. Physical Disability - Code PD, maximum number of places: 5 The maximum number of service users who can be accommodated is: 25 This is the first inspection of the service since a change of ownership. Date of last inspection Brief Description of the Service: Seaview Nursing and Residential Home is a care home registered to give nursing and personal care for up to 25 older people. It is situated on the sea front in the seaside town of Saltburn-by-Sea and is close to local amenities and shops. The home is close to the railway station and is accessible by bus. There are four double and seventeen single bedrooms available on three floors. Seven of the single rooms have an en-suite facility with a toilet and a hand basin. A lift enables service users to have access to all areas of the home. A pay phone is available. There are Registered Nurses on duty at all times. The cost of care at the time of the inspection visit ranged from £385 to £569 per week depending on the category of care. Seaview Nursing and Residential Care Home DS0000069727.V341823.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. This is the first time Seaview Nursing and Residential home has been inspected since owned by A and R Healthcare Ltd, which was registered on 25 April 2007. It was an unannounced Key Inspection as such all of the key standards related to older people were looked at. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. The visit to the home was conducted in two inspection days. During the visit to the home, a number of records were looked at, including records of people who use the service, along with medication records, staff records, training records and maintenance information. Time was spent talking to people who use the service, a relative and staff. Time was also spent walking around the home, observing interactions and generally finding out what Seaview Nursing and Residential Care home was like for residents and staff. Discussion also took place with the manager and there was discussion with the provider who visited on the second inspection day and received feedback. It was clear from these discussions that there is a real commitment to making a number of improvements to Seaview. A relative commented that, “The appearance of the home and facilities seem to be improving under the new management, which I think is very necessary for the homes future. Seeing the owner on many occasions now when I visit and his attitude fills me with confidence that he is anxious for further improvement”. The manager has completed a pre inspection questionnaire, some of the detail of which has been used to support judgements made. An action plan was received in respect of the draft report and further discussion took place with the provider. It detailed that a number of the requirements made had been addressed and the others were being attended to. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: A number of areas have been identified as in need of further improvement, some of which related to health and safety. There is the need to ensure the hot water to baths and showers is tested and recorded more frequently. Maintenance and service certificates need to be available within the home and systems in place detailing the ongoing servicing of equipment. Further refurbishment of the home is needed, with further redecoration, replacement of a number of carpets and the repair of a number of windows. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 7 The system for managing the people’s personal allowance needs to be significantly improved, with more detail and supporting receipts and an audit of the existing system needs to take place. A small number of care assessments need to be updated and more detail are needed in one of the risk assessments. The menu and meals need to be reviewed and the system for delivering meals to residents who are not eating in the dining rooms also needs to be improved. Staff recruitment needs to be strengthened in line with the company’s own policies and procedures and further detail is needed with the training records. 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. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 1 and 3 were looked at during this inspection. People who use this service experience good quality outcomes in this area. People have their needs fully assessed prior to being admitted to the service, ensuring their needs are met. People also have good information about the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The statement of purpose and service users guide was looked at during the inspection and contained all of the information needed. Some detail needed to be amended in the complaints contacts, however this was completed during the visit to the service. Consideration should also be given to developing these documents in different formats such as large print. Relative and people who use the service surveys confirmed that contracts are issued to them. Three sets of records of people who use the service were looked at and there was discussion with the manager, people who lived at the home and relatives about how people are/were admitted to Seaview. The manager said that a pre Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 10 admission assessment is always carried out either by her or by one of the qualified nurses. She said that they generally obtain a copy of the care management assessment. People who use the service and relative talked of being able to have a look around the home prior to any decision being made. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 7, 8, 9, 10 were looked at during this inspection. People who use this service experience good quality outcomes in this area. The health, personal and social care needs of people who use the service are assessed and detailed within care plans, some additional information would enhance these further. People are protected by the home’s policies and procedures for dealing with medicines. People are treated with respect and their right to privacy was upheld. We have made this judgement using a range of evidence, including a visit to this service EVIDENCE: Three sets of records of people who use the service were looked at during this inspection. They contained good information about the individual people. A range of assessment are in place, which then support corresponding care plans that are well written with a good level of detail in terms of goals and interventions. Regular evaluations of the effectiveness of the care take place and the evaluations contain a good level of detail. An area that needs to be improved is in respect of those people who have lived at the home for some time and it was noted that their assessment of need was now out of date and Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 12 needed to be reviewed on a more frequent basis. This was discussed with the qualified staff who agreed that this was necessary. A range of risk assessment tools are being used included moving and handling, risk of falls and nutrition. Where bed rails are used, the assessment needs to be comprehensively completed and the decision made to use this equipment involves key people, such as people who use the service, relative, named nurse, key worker and manager. In all of the files looked at there was clear evidence of other disciplines being involved such as GP’s, district nurses, chiropodist and optician. These were well recorded within the files. One of the surveys stated, “The medical care is very good”. The medication system was discussed with qualified nurses. They described the system and confirmed that currently only qualified nurses are involved in the management of medication. Medication records were looked at and they contained the appropriate information, there were no gaps and where amendments had been made, there were two staff signatures. The manager detailed the ordering system and the storage was observed to be appropriate. It is recommended that an up to date British National Formulary is available and consideration should be given to introducing an audit of the medication system and some ongoing competency assessments should be considered. Discussion took place with staff about care of the people who live at the home. They confirmed that there was a named nurse and key worker system. One care worker said, “It is very important to be a keyworker, it makes the resident feel more important and all residents are individual and have their own needs”. People who were spoken to say their needs were being met. They said, “After losing a lot of weight in hospital I have put a stone and four pounds on in 6 weeks after arriving at the home”, “Happy with my room and happy and content”, “Overall I am happy”. A number of relative surveys were returned and contained very positive comments about the way in which their loved ones were being cared for. Comments received included: • “Going on the experience of a previous home my relative was in prior to Seaview, the residents are treated with respect and needs catered for as and when needed”. • “I have a high regard for the level of nursing care at Seaview. My mother has been close to death on several occasions and their prompt actions and care have in my opinion saved her life”. • “The important criteria for me (patient care) is of a very high standard at Seaveiw and could only be improved with more staff”. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 13 There was some discussion with the manager about developing more personcentred care, the use of certain terminology and about making residents experiences within the home more unique. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 12, 13, 14, 15 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People who use the service have opportunity to take part in activities both on an individual and group basis. They are supported to live in a flexible environment where there is choice of routines and independence. The food provided is of a satisfactory quality and generally meets the dietary and cultural needs of the people who use the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: An activities organiser works in the home approximately three days per week and carries out both group and individual activities. The activities included massage, foot spas, pedicures, manicures, chair exercises, and discussions along with other activities. Staff also said that they people who use the service also had opportunities for their spiritual needs to be met, with visiting clergy. Staff and people who use the service said they thought there was sufficient activities for them and said that they also encouraged people to participate in activities when the organiser was not available. They said that one of the Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 15 events the people who use the service enjoyed more than anything was singa-longs. On the first day of inspection, some people were having massages, one lady was doing her word searches and other people were spending time in their rooms or watching TV. They clearly had a choice about how they wanted to spend their days. The manager said that menu had been reviewed and that there was now clearly a choice for people who use the service. The menu was looked at which was a four-week rolling menu and detailed traditional British cooking. The inspector observed the lunchtime meal being served and delivered. Uncovered plated meals were taken through the home on an open trolley, this included taking the meals upstairs in the lift. There is the need to cover the plates, which will both help to keep the meals warm and safe from any potential contamination. People who use the service said they enjoyed their meals and they also confirmed they had a choice. A number of surveys were returned, they contained the following comments, “If there is something I don’t want they always supply another meal”, “If I get something I am not happy with they will get me something else”. The surveys also contained some dissatisfaction with the pureed food, “I am only able to eat pulverised food which I often find tasteless”, “On pureed meals – not the best tasting”. There was also some concern about the quantity, “Quality is good. Quite sparse at times for anyone with a good appetite”. One person said breakfast at was fine, with lunch at 12noon and tea at 4pm. They did think that supper at 7pm could be improved upon and said that by breakfast the following morning or through the night they were often hungry. Discussion also took place with the manager about the mealtime experience for people who needed assistance with their meals, as currently these people do not go to the dining room. It was agreed that this is an area that could be looked at further. There was again some discussion about the terminology used for people who needed support and the need to move to a more personcentred perspective. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 16 and 18 were looked at. People who use this service experience good quality outcomes in this area. People were generally confident their complaints would be listened to, taken seriously and acted upon. Additional recording would enhance this further. People who use the service were protected from abuse by the home’s policies and procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The complaint procedure was looked at and some slight amendment was made to it during the inspection to detail the local authority contact details. The complaints log was looked at and it contained two complaints since registration. These complaints had been dealt with appropriately. During discussion with staff about complaints it was noted that only formal complaints are recorded, more informal complaints or concerns are not. There is the need to record all issues raised and to include this within the audit system. A number of relative surveys stated that they were aware of whom to contact should they need to and confirmed that they had received a copy of the complaints procedure. A relative who was spoken to said that there had been occasion to raise some minor concerns, which had generally be dealt with. Surveys stated, “I know to speak to someone in charge”, “I know the procedure, it is on the wall in my room”, “My daughter finds the staff easy to discuss problems with if she realises I am unhappy about something”. Staff were clear about the procedure to follow should the need arise. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 17 The manager confirmed that all staff are made aware of protection of vulnerable adults/No Secrets procedures. The manager said that this is covered during induction and then in more detail later. The information was available along with the training information within the office. Staff also confirmed that they had received this training. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 19 and 26 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. The environment is generally appropriate to the specific needs of the people who live there. People are able to personalise their bedrooms and the home is warm, clean and comfortable. There have been improvements to the environment, which are continuing and there is the need to take additional steps to promote people’s health and safety. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Time was spent walking around Seaview to see what the environment was like for the people who live there. People spoke of being very happy with their rooms and there was much evidence of rooms being personalised with resident’s own belongings, ornaments, photographs and pictures. It is acknowledged that a number of improvements had been made to the environment, as detailed by the manager and provider and also noted by the Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 19 inspector who had conducted the previous inspection prior to this change of ownership. This included refurbishment to the dining room, a number of carpets have been replaced, redecoration has taken place to a number of areas and the strip lighting has been replaced in bedrooms by more domestic/homely fittings. The home was looking somewhat tired in areas, some of the furnishings were worn, there was the need to continue with the redecoration programme that was already underway and there was also the need to continue with the programme of replacing carpets. In a number of rooms wallpaper was peeling from the walls. A number of windows were in need of repair as they were worn and letting draughts in. The provider is happy to repair the windows but is currently waiting for permission from the local planning authority, as the home is within a conservation area. Relative surveys also detailed that internal improvement were needed to the home. A number of other areas were identified as in need of improvement, which the provider was well aware of. Care needs to be taken with sluice rooms as they were left open and not locked. The manager said that currently there are no resident who would access these areas. Further detail is needed in respect of monitoring water temperatures within the home. Currently these are not being tested at the required interval and it is essential that the recommendation made by the Health and Safety Executive is followed. It was agreed that baths and shower temperatures would be recorded on a weekly basis. Of the ones checked, two of the extractor fans were not working. Care is also needed in the use of portable heaters, these need to comply with local fire authority guidance, must only be for short term use until more permanent solutions have taken place and have corresponding risk assessments in place. Other areas identified, as needed some improvement are: • TV in top floor lounge is broken and needs repair, care is needed when using extension cable to ensure they do not present as a tripping hazard. • A number of light-shades need replacing. • A number of new lounge chairs are needed. • Some of the bedrooms furniture is in need of replacement. • A window in the top floor lounge needs to have a restrictor, as this could be a potential risk. • Where the strip lighting has been removed, some remedial redecoration is needed. • A number of carpets need to be replaced. • Redecoration of bedrooms where wallpaper is peeling off the walls. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 20 There was also some discussion with the provider about improving the lounge by creating a larger and more pleasing space, this would most certainly be an improvement to this area, which is a bit cramped and a bit of a walkway. It was confirmed that there had been some housekeeping vacancies and more staff had recently been appointed. There is the need to improve the housekeeping of the home; a number of carpets needed more thorough cleaning and more thorough cleaning of other areas within the home. One of the surveys stated, “The home is not to my personal standard, dust on pictures etc. Decoration and carpets leave a lot to be desired”. A further survey stated, “I would appreciate a new bed that could perhaps be raised for me to see out of the window. I spend all day in bed this may enable me to enjoy a better view”. A relative also commented that their loved ones life would be enhance further from being in a hospital type bed for comfort and also for the benefit of the carers. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 21 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): Standards: 27, 28, 29 & 30 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People are very satisfied with the care they receive. There is some shortfall in the recruitment procedures and this does not fully ensure that people are protected. The manager recognises the need to ensure all staff are well trained although records to support this need further development. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Three sets of staff files were looked at, two of which were newly appointed staff and one was a qualified nurse who had been in post for a number of years. Two staff commenced employment prior to full checks being carried out CRB for one staff POVA First was in place but no detail as to how this person was supervised pending CRB. The other staff member completed induction within the home prior to CRB and POVA First. The proprietor outlined the recruitment procedure and said that they would always follow the correct systems and gave an explanation about the two staff members, which related to the delays caused by Royal Mail. He insisted that they had seen a copy of the CRB, which the staff member had brought in. A system for updating qualified nurses Personal Identification Numbers confirmed their eligibility to practise was in place and was a good system. The manager confirmed that any new care staff who are not qualified to NVQ level 2 or above would complete the Skills for Care Induction. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 22 The manager and key training organiser said that they were making headway with the training programme and records but that there was still a way to go. In the records looked at there were gaps in mandatory training for a number of staff. The manager said she was in the process of updating the matrix to increase the level of detail and also looking at ways to ensure that all staff attend the training. Staff did confirm they had received mandatory training and in the past more resident specific training such as Palliative Care and End of Life Pathways. The pre inspection questionnaire detailed that 75 were qualified to NVQ level 2, which is good. During discussion with both people who use the service and staff they believed there was sufficient staff on duty to meet the needs of the residents. Staff believed that one of the strengths of Seaview was the staff team. They said, “There is a good team of people, we are like a family, we can go to each other and it is a team that pulls together”. Relatives said, “The majority of carers have been at the home a long time and seem very experienced”, “I have found all of the staff very caring and loving towards my sister”. “They provide a friendly atmosphere for the resident and family is welcome at any time”. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 23 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): Standards: 31, 33, 35 & 38 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. The manager has the required qualification and experience to manage Seaview Nursing and Residential home. A number of areas require further development to ensure good management systems are in place to protect the residents and that health and safety is fully promoted. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager is registered with CSCI and has the relevant qualifications and experience to manage Seaview Nursing and Care Home. People who were spoken to thought the home was well run and could approach both the manager and proprietor if necessary. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 24 A relative survey detailed the following comment, “The appearance of the home and facilities seem to be improving under the new management, which I think is very necessary for the homes future. Seeing the owner on many occasions now when I visit and his attitude fills me with confidence that he is anxious for further improvement”. As discussed with the manager and provider, further development is needed to a number of systems to strengthen the management and management systems within the home. This includes more auditing of the systems such as recruitment and selection and the recording of concerns and complaints. This would also tie into an improved quality assurance system. Customer satisfaction was also discussed and currently the outcomes of these are feedback on an individual basis. It was recommended to develop this further and to produce a brief summary report that would be available to people. Other areas described below also need to be improved upon. The way in which people’s personal allowances are recorded is not good enough, more detail is needed, debits needs to detail the corresponding receipts and accurate balances must be recorded which also show change from personal shopping. A full audit of the current systems needs to take place. The system for managing the maintenance and service arrangement needs to be further developed and it is essential that details of servicing are easily available. The fire system maintenance and servicing certificate needs to be available within the home to show that it is up to date. The recommendations made by the fire authority need to be fully addressed. It was also recommended that there is a more robust recording system in place for detailing the servicing and maintenance of equipment so that people would know when equipment had been last serviced and when it was next due as well as who carries out this work. The provider said that the intention was to develop a matrix to record this information. Staff need to attend mandatory training and records needs to be fully completed to demonstrate this. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 OP19 Regulation 23 Requirement The planned refurbishment must take place. This needs to include: • Some of the bedrooms furniture is in need of replacement. • Replacement of a number of windows. • A window in the top floor lounge needs to have a restrictor, as this could be a potential risk. • Where the strip lighting has been removed, some remedial redecoration is needed. • A number of carpets need to be replaced. • Extractor fans need to be repaired. • Redecoration of bedrooms where there is peeling wallpaper. Bath and shower water temperatures must be checked and recorded in line with the Health and Safety Executives recommendations ensuring more safety in these areas for people who use the service. DS0000069727.V341823.R01.S.doc Timescale for action 30/04/08 2. OP19 13/23 10/01/08 Seaview Nursing and Residential Care Home Version 5.2 Page 27 3. OP29 19(1) 4. OP35 17 (2) New staff must not commence employment until all of the employment checks have been completed as specified within Schedule 2. These records must be available within the care home. This will ensure protection to people who use the service. The systems for managing people’s personal allowances must be developed further with more detailed recordings and corresponding receipts. There is the need to ensure these records are updated on a regular basis and must detail accurate and up to date information. The system must to be in accordance with Schedule 4. This will ensure the safeguarding and protection of people’s money. 10/01/08 20/02/08 5. OP38 13/23 A full audit of peoples personal allowances must take place, details of which must be forwarded to CSCI. The registered provider must 31/01/08 ensure that the maintenance and service of equipment is up to date and copies of certificates available within the service. There must be a system in place to show when this servicing needs to be carried out. This will ensure that people are provided with a safe place to live and work. The work that has commence to ensure that all staff undertake mandatory training needs to continue and records needs to fully detail this. The recommendation made by the local fire authority must be Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 28 addressed and appropriate action taken. 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 OP8 Good Practice Recommendations Risk assessment tools should be fully completed by appropriate individual, such as bed rails assessments. Ongoing assessment should take place so that they are current and accurately reflect the care needs of the individual residents. An up to date BNF should be obtained. An audit system should be developed and the full medication system should be audited. Consideration should be given to developing ongoing competency assessment for the administration of medication. The menu should be reviewed with particular attention to pureed diets. The system for delivering meals to residents in their own rooms also needs to be improved. People’s views need to be sought to ensure satisfaction with the meals. Consideration should be given to more detailed recording of concerns or more informal complaints that are made in the home. Care should be taken with sluice rooms as these are currently not locked when not in use and could present some potential risk to the safety of people who use the service. The use of portable heaters should be reviewed, these need to comply with local fire authority guidance, only be used on a short term basis until more permanent solutions have taken place and have corresponding risk assessments in place. A number of chairs need to be replaced, as do some lampshades. There should be an effective system in place for the housekeeping arrangements. A number of areas including DS0000069727.V341823.R01.S.doc Version 5.2 Page 29 2. OP9 3. OP15 4. 5. OP16 OP19 6. OP26 Seaview Nursing and Residential Care Home 7. 8. OP30 OP33 carpets need more thorough cleaning. There should be an up to date programme that details the training in place for staff. Quality assurance systems should be developed further and need to show that the home is run in the best of interests of the people who live there. Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 30 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 Seaview Nursing and Residential Care Home DS0000069727.V341823.R01.S.doc Version 5.2 Page 31 - 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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