Inspection on 10/01/08 for Seaway Nursing Home

This inspection was carried out on 10th January 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Seaway Nursing Home 09/12/08

Seaway Nursing Home 19/04/06

Seaway Nursing Home 14/10/05

Seaway Nursing Home 05/05/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Seaway Nursing Home 33 Vallance Gardens Hove East Sussex BN3 2DB Lead Inspector Elizabeth Dudley Unannounced Inspection 10:00 10 January 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Seaway Nursing Home DS0000061313.V350785.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. Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seaway Nursing Home Address 33 Vallance Gardens Hove East Sussex BN3 2DB 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) 01273 730024 F/P 01273 730024 ivar_sum@yahoo.co.uk Seaway Nursing Home Ltd Vacant Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That service users are over 65 years of age on admission and that the numbers of service users accommodated in the home does not exceed 20 15th November 2006 Date of last inspection Brief Description of the Service: Seaway Nursing Home is a care home providing care for up to twenty (20) residents over the age of sixty-five (65). Nursing care is provided at this establishment. It is located in a quiet residential area of Hove. Local amenities and the seafront are within walking distance of the home. There is nearby access to public bus routes. There is a small-concreted garden area at the front of the home and a garden accessible to residents at the rear of the building. Rooms are located over three floors and are accessible by stairs or a passenger shaft lift is available for those unable to independently mobilise. There are six shared rooms of which one has en suite facilities and eight single rooms with one having en suite facilities. There are three assisted bathrooms and two showers that are accessible for wheelchair users. There are six toilet facilities located throughout the home, not including the two en suite facilities. There is one communal lounge/dining area that residents use. There is no parking available at the home. Paid parking is available in adjacent streets and also at the nearby leisure centre. Weekly fees range between £486 and £680. Extra services available from the home including hairdressing and chiropody are not included in the fees and this information is available from the home. Seaway Nursing Home DS0000061313.V350785.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 unannounced inspection took place on the 10th January 2008 over a period of seven hours and was facilitated by Ms Jo Martin, appointed Manager. Ms Martin has been recently appointed and at the time of the inspection had been in post for three weeks. Judgements made at this inspection were reached by methods which included touring the home, examining various records, including care plans, medication records, personnel files, staff training records, health and safety documents and catering documentation. Interaction between staff and residents was observed and ten residents, four visitors and four members of staff were spoken with. Residents’ views on the life at the home were generally good with residents saying that they liked the home and that the staff were ‘ very pleasant and come when you ring your bell’, ‘ staff are very kind’. ‘ I would like to see more people coming in to talk to me and do some activities’. The CSCI requires services to complete and return an Annual Quality Assurance Assessment; this identifies the current status of the home and the achievements of the home in the past twelve months and plans for the future. The Annual Quality Assurance Assessment received reflected the status of the home under the previous manager and gave sufficient information over what was happening in the home at the present time. Prior to the inspection, questionnaires were sent to residents and relatives and three were returned, these provided information about the daily life in the home and whether this was meeting the needs and expectations of the residents in the home. Comments received from relatives were that ‘ my relative is clean and well cared for, the staff are very friendly and helpful and always have a smile’. ‘ My relative is well fed, kept warm and clean’. What the service does well: Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 6 The home provides nursing care to twenty older people and shows a commitment to staff training in the nursing and personal care needs of the older person. Over 50 of the care staff have attained the National Vocational Qualification level 2 in care and registered nurses have access to further training relevant to their role. The home works with a local university to provide mentorship for overseas nurses. The staff turnover in the home is low and staff were described as ‘friendly’, ‘helpful’ and ‘caring’. It is a small home with a homely atmosphere and décor, relatives spoken with said that the ‘care received by the residents was good, the décor and furniture of the home don’t matter as the rest makes up for it’. What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide do not correctly reflect the current management change in the home and also identifies some services that are not being provided at present. During the period of the change of management, staff were not proactive in maintaining some of the care plans to reflect current needs and review. Staff should be made aware of their accountability in this region. Care plans were seen to be individualised and reflect person centred care, but this was not being practised in all areas of the care given, particularly around Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 7 use of bed rails and offering of beverages, which can have implications on residents dignity. Risk assessments did not address all the risks relevant to individual residents, and risk assessments were not in place for a particular resident that had specific needs, which could put them at a high risk of harm. Residents who need frequent observation or care should be in a part of the home where staff can monitor them on a regular basis where possible, and staff should be made aware of the risks involved. One resident did not have access to a call bell and call bells were seen to be out of reach of other residents who were in bed. Staff training in the importance of this should be a priority. The stock control of medication is not in line with recognised good practice and medications had not always been signed in when received by the home. The need to risk assess the back stairs relevant to the residents occupying the rooms near to these, or residents who could gain access and the use of one room as a thoroughfare has been discussed at several inspections, this has not yet been addressed by the provider. The Annual Quality Assurance Assessment states that there is a need for redecoration and that a programme has been put in place, this has been stated at previous inspections and should be addressed. This should include the kitchen. The use of the top floor bathroom as storage space rather than as a bathroom should be discontinued, this would ensure that residents on the top floor have access to a bathroom and ensure that the amount of communal bathrooms available meet the National Minimum Standards. A Quality Monitoring programme was in place in 2006, the home was unable to provide evidence that this has been repeated or is continuing. The Annual Quality Assurance Assessment states that surveys have been sent out to residents and their relatives but the manager was unaware of this during the inspection. 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 Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 8 be made available in other formats on request. Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 9 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 Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 10 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): 1,2,3,4,5,6. People who use the service experience adequate quality outcomes in this area. Information given to residents prior to their admission does not reflect the current status of the home in all areas but is sufficient to allow them to decide whether the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which meet the Regulations insomuch that all categories as required by regulation are included, however these have not been reviewed to show recent changes in the home.All residents have a copy of the service user guide. Both documents require amendments to reflect the current management status in the home and to accurately reflect what services the home currently offers. This was discussed with the manager. Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 11 Residents are also provided with a Conditions of Residence, which meets the National Minimum Standards, and residents who are funded by the Local Authority also have a copy of the relevant contract. Residents are assessed prior to their admission to the home either by the manager or a registered nurse. Two assessments were examined and one of these required more detail to be added, assessments should enable the staff on duty to commence a care plan even if the assessing nurse is not on duty at this time. At present prospective residents are informed verbally of whether the home can meet their needs, In order to comply with Regulation 14 (1) (c), the manager must give this information in writing to the prospective residents or their representatives. Residents or their representatives can visit the home prior to admission. The home does not admit residents for intermediate care, only for permanent or respite care. Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10,11 People who use the service experience adequate quality outcomes in this area. Care plans are person centred and show the individuals’ needs, but the actual care carried out is not always reflective of this and consultation with the residents is not evident in some care plans. Changes in the individuals needs are not shown in the care plan and regular reviewing of the care plans has not recently taken place. Medication administration and recording of the medications given, safeguards the residents, but attention is needed in other areas to ensure that the residents are not put at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection 5 (25 ) care plans were examined in depth. These contained preadmission assessments, care plans relating to personal and nursing care, wound care, mobility assessments, general risk assessments Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 13 including those for the use of bedrails, and continence and nutritional assessments. During the period of management change, staff had not updated some care plans to reflect changing needs of the residents or reviewed care plans at the recommended timescales. Registered nurses should be reminded of their ongoing accountability and duty of care. Continence care plans did not identify which type of continence aid was to be used and this could result in incorrect care being given. The implementation of a night care plan would ensure that individualised care is continued throughout the twenty-four hour period. Risk assessments for the use of bedrails were in place but bed rails were not being used according to the relevant guidelines from the Medical Devices Agency, single bedrails were often in use and there was discussion over whether bedrails were being used when not really necessary therefore resulting in lack of dignity and individualised care. There was no risk assessment in place regarding a resident who was found by the inspector to be compromised by their medical condition and was unable to summon help when required. Residents who are clearly at risk should be in a part of the home which facilitates frequent staff interaction. Staff had not always ensured that positioning of residents in bed protected them from pressure damage and in one instance a resident was found with legs pressed against a bedrail and no protection offered. Residents were found lying on crumpled bed linen, which could impact on pressure relief. Since the inspection was undertaken, further information has been received about incorrect positioning of a resident and staff not practising safe moving and handling techniques. Care plans showed that consultation and involvement with the wound care specialist nurse was taking place as necessary. Relevant nursing charts had not been correctly completed in some cases, and may not reflect the amount of fluids offered to residents or the nursing intervention taking place, supervision of this should be made a priority. Three residents were not able to reach their call bells and one resident had no call bell, the relative saying that to her knowledge the resident had never had one. This was discussed with the manager who stated that this would be addressed immediately therefore an immediate requirement was not made at this inspection. Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 14 Other health care professionals including the Speech and Language Therapist (SALT), General Practitioners, community psychiatric nurses and the nursing home support team visit the home on a regular basis. Nursing and personal care given to residents was of a satisfactory standard and staff were aware of the individual health care needs of the residents relevant to their medical condition. Residents said that ‘ We are well cared for’ ‘ the staff are always polite’. Relatives spoken with said ‘My mother is clean and well fed and cared for and kept warm’, ‘The care here is very good, I cannot fault it, and everything possible is done for my husband’. Staff interacted in a friendly and comfortable manner with the residents and residents said that the staff treated them in a polite and friendly manner, ‘they are always smiling’. Maintenance of residents dignity was compromised insomuch that drawers were labelled with residents names, giving an institutional air to the home and all residents in their rooms were given their morning drinks in feeding cups and did not appear to have any choice in either this or what beverage they were offered. Medications had been signed for on administration but receipt of medication by the home was not always signed for. Supplement feeds and some external preparations did not have a signature of the registered nurse and this should commence. Handwritten prescriptions were not signed. Good practice recommendations are that two members of staff sign these. Stock control of medication was not taking place and the home was overstocked with medication, some of which was out of date. Registered nurses have attended updated training in the use of syringe drivers. Some members of staff have attended training in end of life care, discussions were held with the manager regarding implementation of the Liverpool care pathway and Gold standards framework (methods to ensure that people at the end of their lives are kept pain free and have a standard of care which is in line with current practice). The home should ensure that any records kept relating to end of life wishes are in line with local and national guidelines. Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People who use the service experience adequate quality outcomes in this area. Residents who stay in their rooms do not benefit from social interaction or the activities offered. The opportunity to take part in activities has increased but could be expanded to include past and present interests of the residents in the home. Presentation of beverages offered does not uphold choice and dignity of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is no formal activities programme but a care staff and a part time activities person provide some activities. These take place in the lounge and some residents who stay in their rooms said that there was little interaction or involvement for them. The activities records had not been completed on a regular basis and it is recommended that a social needs care plan is commenced. Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 16 Residents said that they could choose their times of rising and retiring, but there was no information in the care plans regarding this. The home has recently purchased new televisions both for the lounges and some rooms. Visitors said that they could visit whenever they wished and were made welcome and informed promptly of any concerns affecting the resident. Ministers of religion visit the home with communion being brought in to those who wish for this. Staff said that the cook informs residents of the daily menu, but some residents were not aware of the choices offered and there was no choice for residents on a pureed diet. Residents both in their rooms and in the lounges were seen to be having meals different from the main menu relevant to their choice that day and records are kept of these. Use of feeding cups as identified in the previous section of the report should be restricted and efforts should be made to ensure that beverages are kept hot. Staff were standing up to feed bed bound residents and did not take their bedrails down when meals were in progress, this does not allow residents to relax and enjoy their meals and is not consistent with promoting dignity and nutritional intake. Nutritional assessments were in place and staff were aware of how to use these, it was recommended to the manager that advice is sought from a dietician over maintaining a good nutritional balance for residents, both in the type of food offered and the variety and content of meals available. Wine and other alcoholic beverages are offered to residents before lunch. All staff have completed the food hygiene certificate. Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18. People who use the service experience good quality outcomes in this area Residents are protected by the homes complaints policy and the staff awareness of the need to safeguard those in their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five residents spoken with were aware of how to make a complaint and to whom to go to if they had concerns. The complaints procedure is displayed both in the home and included in the service user guide and any complaints made were recorded and details of the actions taken to address concerns and complaints. There have been three complaints and one adult safeguarding issue in the past year, two complaints were proven and addressed and one complaint and the adult protection issue were unfounded. A concern was received following the inspection regarding the lack of a call bell in one room, positioning of a resident that put them at risk and inappropriate moving and handling by staff. The provider will address this. Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 18 All staff have had training in the safeguarding of those in their care, some staff have not received this for a few years now and residents would benefit if staff received updating in current procedures and protocols. A relative of a resident said that a complaint that they had raised had been appropriately dealt with in a timely manner. Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 19 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): 19,20,21,23,24,25,26. People who use the service experience adequate quality outcomes in this area. Attention to décor, refurbishment and cleanliness in some areas would improve the environment both for the residents and people coming to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The standard of décor and maintenance around the home is adequate, but some areas of the home including the lounge appear cluttered and untidy and one bathroom is used for storage only. Some rooms have been redecorated and the carpets replaced in two rooms, the laundry and the sluice rooms have Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 20 been retiled and a new washing machine purchased. The home now has a regular maintenance person. The home has one lounge/ dining room on the ground floor, leading into the garden and a shaft lift allows access throughout the home. Two of the three bathrooms are currently able to be used, discussions have been held with both the manager and provider on previous inspections about enabling this bathroom to be used by residents on the upper floor, this would also ensure that there are sufficient assisted bathing facilities for all residents but this has not commenced, it is appreciated that storage space in the home is limited but use of this bathroom would benefit the residents living in the home. Individual rooms are reasonably decorated and have a lockable facility; either screens or curtains separate double rooms. A fire door in one bedroom is continually left open; it is recommended that this is kept closed to ensure the privacy of the resident’s room is maintained. Window restrictors and radiator guards are in place. Water temperatures have been checked on a regular basis and are within recommended parameters. Residents and visitors spoken with said that they were not worried about the appearance of the home as the care was good and the staff friendly, however the home would benefit from attention being paid to décor and facilities and general improvement of the environment. There are plans to refurbish the kitchen and this would benefit from receiving attention in the near future. Cleanliness around the home is adequate, more attention is required for the underneath of the bath seats in the assisted baths and staff should be aware that leaving soiled clothes on these can impact on infection control. There were no noticeable odours in the home. There are policies addressing infection control but these were not examined during the inspection. Seaway Nursing Home DS0000061313.V350785.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): 27,28,29,30. People who use the service experience good quality outcomes in this area There are sufficient numbers of suitably trained staff to ensure that resident’s needs and expectations are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas and comments from staff, residents and visitors showed that there are sufficient staff over a twenty-four hour period to meet the needs of the residents in the home, with a registered nurse on duty at every shift. 50 of the care staff have the National Vocational Qualification level 2 in Care, and both care staff and registered nurses attend training sessions and updates relevant to their role. The home provides mentorship for overseas nurses and maintains links with the university. There was no evidence of induction course having been undertaken but staff confirmed that they had done this at commencement of employment, it was unclear as to whether this comprised the nationally recognised course ‘Skills for Care’. Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 22 Two personnel files were examined (20 ) relating to new staff. All other files had been examined at the last random inspection and staff turnover is low. These contained all documentation as required by the regulations and National Minimum Standards. Seaway Nursing Home DS0000061313.V350785.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): 31,32,33,34,35,36,37,38, People who use the service experience adequate quality outcomes in this area There was no evidence of systems in place to ensure that the services offered by the home meet the expectations of the residents and the manager is yet to become familiar with other issues in the home. Staff training in health and safety safeguards residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post for four weeks, and prior to this was the deputy manager at the sister home, she has previous experience as a senior staff Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 24 nurse in the NHS working in stroke rehabilitation. She is a Registered General Nurse and is commencing the Registered Managers award and applying for registration with the CSCI. Having only just taken up post, she is at present, a little unsure of systems around the home. During the period between managers there was no consistency in the home and some records and other practices relating to residents dignity and discussed in the report, previously seen in the home and reported on in positive manner, were not kept up. This was discussed with the current manager who will address these issues. Five members of staff were spoken with and positive comments were received about the new management of the home and the ethos in the home. All staff said that they had opportunity for updating knowledge, received supervision and induction, and found the home friendly. Residents and their relatives commented on the friendliness of the home. There was no evidence to show that the quality monitoring programme commenced in the home has been continued or taken forward, this should be recommenced and practised on a continuing basis. The home does not act as appointee for any residents or keep any money in the home for them. Staff are receiving supervision at intervals recommended by the National Minimum Standards and records of these were seen. Regulation 26 visits (provider visits as required monthly by the CSCI) have been undertaken but were not examined at this inspection. The Annual Quality Assurance Assessment stated that all utilities and equipment had received recent service, and examination of these documents showed that these were satisfactory. All staff have undertaken mandatory training. Fire risk and other risk assessments are in place around the home but risk assessments relating to individual residents require to be put in place. Risk assessments should be put in place regarding the access of residents to the back stairs, which could put some residents at risk. Accident records were up to date and Reg 37 reports have been sent to the CSCI as required. Seaway Nursing Home DS0000061313.V350785.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 2 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 3 x 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 x x 3 2 2 Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 26 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 OP1 OP2 Regulation Reg 4 (1) Reg 5 Requirement Timescale for action 30/03/08 2 OP3 Reg 14 (1)(c) 3 OP7 Reg 15 (2) 4 OP8 Reg 13(4) That the statement of purpose and service user guide accurately reflect both the current status of the home and the services offered by the home That the preadmission 30/03/08 assessment is comprehensive and addresses all the needs of the service user and that the homes ability to meet these needs is confirmed in writing. That the service user plans are 01/03/08 reviewed at regular intervals, as directed by the National Minimum Standards, and show the current and changing needs of the service users and evidence is shown of consultation with the service user at both the formation and review of the care plan. Documentation relevant to nursing intervention and kept in service users rooms must record all nursing intervention in an accurate manner and must be monitored to ensure adequate intervention is taking place. That all service users are 30/03/08 DS0000061313.V350785.R01.S.doc Version 5.2 Seaway Nursing Home Page 27 5 OP8 OP12 OP15 6 7 OP20 OP26 8 OP33 9 OP38 provided with a call bell and that these are kept within reach of the service user. That individual service users are risk assessed and the appropriate measures taken to ensure risks are minimised. That risk assessments for bedrails are person centred and in line with the relevant national guidelines. That the safe positioning of the service users is monitored by the responsible person. Reg That the individual choices and 12(2)(3)( wishes of service users in all 4) areas including health and personal care, activities, daily living and choice and presentation of food are identified and met. Reg That the top floor assisted 23(2)(j) bathroom is restored for the use of service users. Reg That the standard of cleanliness 23(2)(d) in the home is improved particularly regarding bathroom areas. Reg 24 That a system of monitoring and evaluating the services offered to service users is commenced or recommenced and that this is undertaken at regular intervals and includes the views of stakeholders visiting the home. Reg 13(4) That risk assessments are put in place for the back stairway. 30/03/08 30/03/08 01/03/08 01/08/08 01/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 28 1 OP9 2 3 OP19 OP24 That the receipt of medication, handwritten prescriptions and stock control is in line with good practice guidelines of the Nursing and Midwifery Council and Pharmaceutical Regulations. That the home, especially lounge and corridor areas, are kept in a tidy condition to ensure the comfort of residents and to maintain their safety. That the doors to the room on the top floor are kept shut to maintain the privacy of the residents private accommodation and the dignity of the resident. Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Seaway Nursing Home DS0000061313.V350785.R01.S.doc Version 5.2 Page 30 - 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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