Inspection on 19/04/06 for Seaway Nursing Home

This inspection was carried out on 19th April 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 but made no statutory requirements on the home.

Other inspections for this house

Seaway Nursing Home 09/12/08

Seaway Nursing Home 10/01/08

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 Jennie Williams Unannounced Inspection 19th April 2006 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 Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 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.V288354.R01.S.doc Version 5.1 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 01273 730024 Seaway Nursing Home Ltd Dr Leckman Ravi Sumoreeah Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 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 14th October 2005 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. Weekly fees range between £471 and £600. There are additional fees hairdressing (£4 to £25), Chiropody (£9) and newspapers (cost of paper plus delivery charges). This information was provided to the CSCI on the 24 April 2006. There is no parking available at the home. Paid parking is available in adjacent streets and also at the nearby leisure centre. Prospective residents/representatives are provided with a Statement of Purpose and Service User Guide that offer information on the services and facilities provided at the home. A copy of this information is kept within each individual’s room and provides information on how to obtain/view the most recent CSCI inspection report. Residents/relatives know about the service through social service referrals and word of mouth. Information about the home is also obtainable on the CSCI website. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Seaway Nursing Home will be referred to as ‘residents’. This unannounced inspection took place over approximately eight hours on the 19 April 2006. There were 17 residents residing at the home on the day of the inspection. Eleven residents, of both gender and over the age of 65 years, were spoken with during the inspection. The Inspector had limited verbal communication with three residents due to their cognitive impairment. One resident did not wish to speak with the Inspector and their choice was respected. Three residents care plans; two female and one male, were looked at in detail. Specific areas were looked at in two other care plans. The acting manager and six staff; one trained nurse, three carers, the cook and a cleaner were spoken with. A pre inspection questionnaire was received following the site visit at the home. Twenty service user surveys were sent to the home prior to the inspection, of which three have been returned. No contact was made with visiting relatives or visiting specialists. Three staff files were looked at. Previous requirements at the home were assessed to ensure compliance. The environment and some individual rooms were looked at. The lunchtime meal was observed. The Statement of Purpose, Service User Guide, staff rota and activity records were inspected. No health and safety records were viewed as this information has been provided in the pre inspection questionnaire. What the service does well: The home has detailed information available to prospective residents/representatives about the care and facilities available at the home. There is a suitable pre assessment process in place to ensure that only residents whose needs can be met are admitted. The home has a complaints procedure in place and records demonstrate that the home investigates complaints fairly and provides feedback to the complainant. Staff receive training relevant to their roles. Staff spoken with were complimentary about the management structure within the home. Residents spoken with were complimentary about the staff working at the home. Residents confirmed that their lifestyle is their choice within the home environment. One resident commented ‘it is a five star hotel’. The responsible individual is currently the registered manager, however it should be noted that he has not been working within the registered manager capacity since July 2005. There is an acting manager in post who is currently going through the registration process with CSCI. The acting manager facilitated this inspection. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 5 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. EVIDENCE: Three residents admitted since the last inspection, confirmed that they or their representatives obtained information about the home prior to moving in. A copy of the homes’ Statement of Purpose and Service User Guide were observed to be located in every resident’s room. The acting manager confirmed that there was no one residing at the home from any minor ethnic community, social/cultural or religious groups with any specific needs or preferences. Residents/representative are provided with opportunities to visit the home prior to moving in. Three new residents confirmed that they were unable to Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 9 visit the home due to health needs, but all confirmed that a relative/representative visited on their behalf. The acting manager undertakes the pre assessments of all residents and forms completed demonstrate that sufficient information is obtained to demonstrate that the home can meet the assessed needs of an individual. The home does not have dedicated accommodation to provide intermediate care. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” There is a risk of residents’ needs not being met due to lack of clear documentation and guidance in care plans for staff to follow. EVIDENCE: Two residents were not familiar with their care plans. With the individuals’ permission, the Inspector sat with each of them and went through the care plan with the individual. The individuals confirmed the information contained in the care plan to be reasonably accurate. Three care plans were looked at in detail. Two of these care plans were inspected and the information in the daily notes were not consistent. A description of a wound was last recorded on the wound chart in March 2006, inferring that the wound must be healed; however in the daily notes, a month later, the staff were still recording information about the wound. The information for another individual did not provide clear details on where the wound was located. It should be noted that the documentation of wounds has overall improved when the forms are used correctly. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 11 A care plan stated that a resident required assistance with one carer when transferring. The individual informed the Inspector that they were able to independently mobilise short distances. The acting manager also confirmed that this resident is independent. The care plan had not been updated to reflect these changes. There was not clear guidance within a care plan for the correct administration of oxygen. Records demonstrated that a physiotherapist, who left written recommendations for the home to follow, had visited an individual. These specialist instructions had not been reflected into the care plan. Advice from visiting health professionals must be reflected in the care plans. An individual informed the Inspector that they have their sugar levels regularly checked, although unsure how often. The care plan provided no information that this individual required to have their sugar levels tested, or how frequently. One care plan demonstrated that an individual required having a catheter changed every three months. This was now nearly a month overdue. Daily records written on the health care needs of an individual must be expanded. It was noted that some staff are writing, ‘care as per care plan’. This practice is not suitable; particularly as care plans are not accurate documents of the care residents are receiving. There was evidence that residents/representatives were involved in the initial drawing up of the care plan. There was evidence that care plans are being reviewed on a monthly basis, however no evidence that residents/representatives were involved in the reviewing process. At least three residents spoken to were not familiar with their care plans, with some having been admitted for some months. Input from the resident/representative must be sought to ensure that the information provided in the Statement of Purpose and Service User Guide is followed. Staff are advised to use the care plans in conjunction with the pre assessment information. This information is kept in separate folders. Care plans identify any changes in needs and any specialist needs an individual may have that differs from the pre assessment form. It had been recommended at a previous inspection that all information relating to an individual be kept in the one folder. The home had decided to keep the same procedure. Shortfalls in the care planning documentation were discussed in depth with the acting manager, who will be reviewing this process. There is pressure-relieving equipment available at the home and a tissue viability nurse is accessed when needed. A resident observed to be wearing glasses confirmed that she had not had a recent eye check, but was happy with this and a relative would arrange one if they wished. Three comment cards received demonstrated that two residents usually and one always receives the medical support they need. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 12 There was evidence that the personal care for residents had improved, with staff now paying particular attention to eye care. The home must ensure that there are risk assessments and consent forms in place for those residents requiring bed rails. One care plan did not have a consent form signed and a risk assessment for the use of bed rails could not be located in another file. The home receives policies and procedures for medication from their local pharmacist. The content of these documents were not read. Sample signatures are kept of all staff who administer medication. Registered Nurses administer medications. On inspection of Medication Administration Record (MAR) charts, it was noted that one medication had been signed for but was not administered and another given but not signed for. This was discussed with the nurse who made these errors, who will address this. There were some gaps in individuals’ MAR charts. These were pointed out to the acting manager who will be able to track who administered medication on the omitted dates and will address these shortfalls with the individuals involved. The overall signing and administration process was appropriate. The acting manager confirmed that the disposals medication complies with current guidelines. Medication is stored securely within the home. It was made a requirement at the last inspection that steps be implemented to ensure night medication is administered at the correct time. Three residents spoken with confirmed that they received medication at night at a suitable time. Of the residents that were asked, all confirmed that they felt their privacy and dignity are respected. One resident was observed to be assisted to the bath with their privacy and dignity respected. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Residents lifestyle within the home is their own choice, however residents are not provided with sufficient stimulation to fulfil their interests and needs. EVIDENCE: The residents spoken with during the inspection process had mixed feelings about the number of activities provided at the home. Some did not participate by choice, some felt there was enough on offer at the home to keep themselves occupied and some residents felt that there were not enough activities provided. The three comment cards received demonstrated a variety of views on the activities provided. One stated that there was never activities arranged by the home that residents can take part in, one stated usually and one identified there are always activities provided. Three residents spoken with felt that more activities could be provided, with some residents identifying that they would like to go out of the home more frequently. It should be recognised that staff have improved the documentation of activities, however, it is recommended that staff receive guidance on the appropriate activities to be documented. Recording when visited by a physiotherapist is not an activity but forms part of the health care plan. There is no activity person employed at the home, staff on duty provide residents Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 14 with activities. One staff member felt that more activities could be provided. There was no activity programme available at the home on the day of the inspection. It was noted in the activities records that a resident was assisted with sending Easter cards. No activity was observed on the day of the inspection. The Statement of Purpose and Service User Guide reflects what activities are provided at the home. There was no evidence of these activities regularly occurring. One example is bingo. A resident spoken with stated that bingo is played ‘very occasionally’. One resident stated ‘I get bored some days’. It was discussed with the staff and acting manager that a survey, as part of the quality assurance process, be developed to obtain the views of the residents and what activities could be offered at the home to ensure individuals, who choose to be involved, are provided with suitable and fulfilling activities. Visitors are welcomed at the home. There are no time restrictions imposed, but visitors are reminded to be considerate of residents if they visit during busy times or late evening. Residents may see visitors in their own rooms if they wish. Some residents spoken with confirmed that they regularly have friends/relatives visiting them. There is a visitor’s book kept at the entrance of the home that all visitors sign. The activities records identified when friends or family had visited an individual. Residents spoken with confirmed that their lifestyle in the home is their choice. Individuals choose when they go to bed and get up etc. There were mixed feeling about the food provided at the home. Out of the three comment cards received, it was identified that one resident always, one resident usually and one resident sometimes enjoys the food. On speaking to residents, comments received were ‘not good and awful presentation’ to ‘very good’ and there is a ‘choice available’. The menu provided to the Inspector demonstrated that there is a variety offered and often a choice of meals. The majority of residents spoken to were complimentary about the food provided. No requirement has been made in relation to the provision of meals, however it is required that the home undertakes regular surveys as part of their quality assurance monitoring process to obtain views of residents. Individuals that expressed concern about the food did not want to be identified and did not wish the Inspector to discuss their concerns with the chef, they are happy to address the issues themselves. On observation of the lunchtime meal, the Inspector was pleased to note that specialist equipment had been purchased to promote the independence of individuals when eating. Cutlery was noted to have thick handles for easy gripping and plate guards were in place. Staff spoken with confirmed that the Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 15 purchase of this equipment has assisted some individuals to maintain their independence. Staff were observed to demonstrate patience when offering discreet assistance to those residents requiring assistance. Staff were also observed in encouraging and promoting independence at meal times. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” The systems in place protect residents from abuse and residents know how to make a complaint. EVIDENCE: There is a complaints procedure accessible at the home and included in the homes Statement of Purpose and Service User Guide. The home has investigated one complaint since the last inspection. It was concerns raised regarding the discharge process of a resident. Correspondence was kept of all communication. Records demonstrated that the complaint was investigated fairly and an explanation provided for all areas of concerns raised. The three comment cards received demonstrated that the residents always knew how to make a complaint and knew who to speak to if they were not happy. Of the two residents asked, both were happy to express any concerns they may have and knew who to speak to. There have been two allegations investigated by Social Services since the last inspection following the Adult Protection procedures. These were found to be not upheld. Social Services wrote to the home on both occasions advising of additional training and on certain precautions to take to protect residents and staff. The home was co operative throughout these investigations. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 17 The acting manager has recently done Protection of Vulnerable Adults (POVA) training provided by an external company. Staff spoken with confirmed that they have recently received POVA training and are familiar with the procedures to take should an allegation be made whilst they are on duty. The training schedule provided to the Inspector demonstrated that eleven out of nineteen staff have received or will be participating in POVA training. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 & 26 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents live in a clean and comfortable environment whose location and layout is suitable for its stated purpose. EVIDENCE: Eight residents spoken with were happy with the environment and with their individual rooms. There were some areas throughout the home that were in need of redecoration. The acting manager has already identified areas needing improvement and will ensure these areas are addressed. There is no formal maintenance programmed implemented. It is recommended that a maintenance programme be implemented and forwarded to the CSCI. Residents receiving nursing care must provided with an adjustable bed. There has been one additional adjustable bed purchased since the last inspection. The home now has 11 adjustable beds. The type of bed available is taken into account when admitting a new resident. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 19 The home was reasonably clean and free from offensive odours on the day of the site visit. Any minor shortfalls noted on the day were discussed with the cleaner. Two comment cards received showed that the home was always fresh and clean and one felt it was usually fresh and clean. The cleaner confirmed that they are involved in training that is relevant to their role. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Residents’ needs are being met with the number of staff on duty at all times. The recruitment procedure needs to be more robust to safeguard residents. EVIDENCE: Residents spoken to were complimentary about the staff working at the home. The majority felt that there were always sufficient staffing numbers on duty at all times. The rota provided to the Inspector demonstrates that there is always a registered nurse on duty and generally three care staff working in the day time hours and one carer working at night. Staff spoken with felt there were sufficient numbers of staff on duty. Two of the comments cards received confirmed that staff are usually available when needed and one stated staff are always available when needed. Staff informed the Inspector that they are provided with opportunities to attend training sessions. The training schedule provided to the Inspector demonstrated that a variety of courses are provided including; manual handling, fire training and nutrition. Staff were receiving training on record keeping on the day of the inspection. There are additional training sessions provided for the trained nurses, such as pressure area care and wound care. There continue to be shortfalls in the documentation required to be kept on all staff. There was no health check located in a file and an incomplete application form in another. One staff member had not completed an induction Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 21 programme. There have been no new staff members employed since the last inspection. There was evidence that a staff member commenced employment in October 2005 and a Criminal Record Bureau (CRB) was not returned until over a month later, without evidence a POVA first check had been undertaken. Ensuring application forms are fully completed will assist in the home tightening up on recruitment shortfalls. Shortfalls in the recruitment procedure were discussed with the acting manager. The home ensures that all registered nurses are registered with the Nursing and Midwifery Council. The pre inspection questionnaire demonstrates that the home has not been active in achieving the required 50 ratio of staff that have undertaken the National Vocation Qualification (NVQ) level 2 in care training. There is still only one carer with NVQ level 2 qualification. There are two trained nurses from another country who require to be assessed for their NVQ qualifications. Not including the overseas staff, this is equivalent to 9 of staff being NVQ level 2 trained. The training schedule provided demonstrates that an additional two carers will be commencing this training. The home is required to provide the CSCI with a programme identifying their proposals to ensure at least 50 of care staff are NVQ level 2 qualified and the timescale in which they propose to achieve this by. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Residents would benefit from a more robust system of quality assurance and residents will be better protected with improved accessibility to individual finances. EVIDENCE: The acting manager at the home is currently going through the registration process with the CSCI. She is a registered nurse with current registration with the Nursing and Midwifery Council (NMC). She has the relevant skills and experience necessary to manage the home. Staff spoken with were complimentary about the management within the home. The acting manager is currently undertaking the Registered Manager Award (RMA) and should complete these studies this year. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 23 The Statement of Purpose and Service User Guide demonstrates that views from residents/representatives will be undertaken every three months to evaluate the satisfaction of care and services provided at the home. No further questionnaires have been undertaken since the last inspection in September 2005. It is required that the home implements a robust quality assurance and quality monitoring process. A developed and implemented quality assurance and quality monitoring programme would enable management to assess the suitably of services provided at the home and identify areas that can be improved. The Inspector could not inspect individual personal allowance for residents due to finances not being available. It was discussed with the acting manager that action needs to be taken to ensure residents monies are accessible at all times and available for inspection. The acting manager did state that if anyone required money, petty cash was available. The home currently has one trustee bank account where all residents pension cheques and personal allowance is kept. Residents must be provided with individual bank accounts and records kept to clearly demonstrate how much money each individual has. This is the third inspection where it remains an outstanding requirement that individual bank accounts be provided for individuals. The pre inspection questionnaire demonstrates that the registered provider acts as an appointee for three residents. There is a newly devised rota to ensure that all staff receive regular supervision. Staff spoken with confirmed that the supervision process has just been recommenced. The pre inspection questionnaire demonstrates that all relevant health and safety checks are undertaken and staff receive fire training and practice fire drills. Health and safety records were not inspected. This information was provided to the Inspector in the pre inspection questionnaire. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 24 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X 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 X 18 3 3 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 1 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 1 3 X 3 Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 25 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 OP7 Regulation 15 Requirement That evidence be provided of service users involvement in the reviewing of care plans. (Timescale 31.12.05 not met) That care plans reflect actual current practice. (Timescale 31.12.05 not met) That daily records about service users are expanded. That all service users with bed rails in place are risk assessed and have consent forms in place. That service users are provided with suitable and fulfilling activities. (Outstanding from last two inspections) That all service users receiving nursing care are provided with an adjustable bed. This is an ongoing programme. (Timescale 30/06/06 will not be met.) That 50 of staff obtain NVQ level 2 or equivalent qualifications. (Timescale 31.12.05 not met) That a programme is provided to the CSCI with a programme identifying their proposals to DS0000061313.V288354.R01.S.doc Timescale for action 31/05/06 2. 3. 4. 5. OP7 OP7 OP7 OP12 15 Schedule 3 (k) 13(4) (c) 16(2) (m & n) 16(2)(c) 31/05/06 31/05/06 31/05/06 30/06/06 6. OP24 31/12/06 7. OP28 18(1) 31/12/06 8. OP28 18(1) 30/06/06 Seaway Nursing Home Version 5.1 Page 26 9. 10. OP29 OP33 Schedule 2 24 11. OP35 20.1 ensure at least 50 of care staff are qualified and the timescale within this will be met. That staff files comply with Schedule 2. (Outstanding from last two inspections) That the home implements a robust quality assurance and quality monitoring process, as identified in the Statement of Purpose. That individual bank accounts be provided for individuals. That service users monies is accessible at all times. (Outstanding from last two inspections) 30/06/06 30/06/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP19 Good Practice Recommendations That staff receive training on the appropriate activities to be documented. That a maintenance programme be implemented and forwarded to the CSCI. Seaway Nursing Home DS0000061313.V288354.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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