Inspection on 20/03/06 for Sebright House

This inspection was carried out on 20th March 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

Sebright House 09/08/06

Sebright House 06/06/05

Sebright House 14/12/04

Sebright House 06/04/04

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

CARE HOMES FOR OLDER PEOPLE Sebright House 10 - 12 Leam Terrace Leamington Spa Warwickshire CV31 1BB Lead Inspector Deborah Shelton Unannounced Inspection 20th March 2006 10:00 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 Sebright House DS0000041396.V286646.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. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sebright House Address 10 - 12 Leam Terrace Leamington Spa Warwickshire CV31 1BB 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) 01926 431141 01926 431326 Interhaze Ltd Care Home 40 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (40) of places Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2005 Brief Description of the Service: Sebright House care home is registered to provide specialist Dementia care to people with dementia and who need nursing care. Sebright House can accommodate up to 40 residents, in single and double room accommodation. The home is staffed by Registered General Nurses and carers some of whom have National Vocational Qualifications at levels 2 and 3. The service provision includes full board and 24 hour nursing care. Sebright House is situated in Leam Terrace, a short walk from the town centre shopping area and picturesque gardens along side the river. The Statement of Purpose and Service Users Guide contains all the information regarding personal, nursing and social care provided by the owners of this care home. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following are the findings of an unannounced inspection visit that took place between the hours of 10.00am and 6.00pm on 20 March 2006. The manager was on duty during this inspection along with two registered general nurses, two adaptation nurses, five care staff, domestic, laundry and catering staff. Thirty-eight people were living at Sebright House. The inspection process involved looking at paperwork, a tour of the building and discussions with the manager, staff on duty and two visitors. Residents were also spoken to about their experiences of life at the Home. Some of the documentation was looked at in the conservatory, this enabled the inspector to see residents in their usual surroundings and see the interaction between staff and residents. What the service does well: What has improved since the last inspection? The new manager has worked hard to improve standards of care. Training programmes have been developed to ensure that staff receive the appropriate training to be able to meet the needs of the people living at Sebright House. New care planning documentation has been introduced. Documentation seen included risk assessments regarding nutrition and hydration. Records demonstrated that a number of residents are now gaining weight. Changes have been made to the environment. No unpleasant odours were noted, carpets have been replaced. Some bedrooms, communal areas and corridors have been decorated. Other areas still require decoration, the manager is aware of this, the handyman will decorate as time allows. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 6 Improvements have been made to the activities available. Residents and visitors spoken to said that there is always something going on. The manager has made a beach hut in the garden, residents said that they enjoy going in to the beach hut and were looking forward to the “pub snug” that the manager is developing. Daily activities include hand massage, games, visits to the public house at the back of the Home and cinema afternoons. During this visit the interaction between staff and residents was good. 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. Sebright House DS0000041396.V286646.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 Sebright House DS0000041396.V286646.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): 4 Staff training organised for 2006 demonstrates that staff now have the opportunity to further develop the skills necessary to meet the assessed and changing needs of residents. EVIDENCE: A schedule showing planned training for 2005 showed that dementia care training was undertaken. The 2006 training schedule has dementia care training planned for March, April, May and June. The manager confirmed that all staff must attend. The cook is also attending “food for thought” training provided by the Alzheimer’s disease society. Some staff have undertaken challenging behaviour training. The manager reported that the staff that undertook this have reported back to their work colleagues. All staff are scheduled to undertake challenging behaviour training in April. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 9 Other training planned for 2006 includes, Parkinson’s disease, diabetes, stroke, continence, protection of vulnerable adults and adult protection as well as other mandatory training. During discussions it was noted that the manager has completed part one of the Alzheimer’s disease society trainers training and is due to commence part two this year. The manager has undertaken in-house sessions regarding dementia care with all staff. An external professional is visiting the Home for two days to undertake dementia care mapping. The manager feels that this will have an impact on the quality of the service provided at Sebright House. Sebright House DS0000041396.V286646.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 and 9 There is a clear, consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service user needs. The healthcare needs of the people living in this home are assessed and recognised with evidence of specialist services being available to them. Systems and practices regarding storage and administration of medicine are good. The Home’s policies and procedures for dealing with medicines protect residents from risk of harm. EVIDENCE: Five care files were chosen at random for review. A new system of care planning was introduced at the Home in November 2005. The manager has been responsible for transferring all information from the old system onto the new documentation. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 11 Care plans had some information completed in the wrong area. The manager said that there had been some “teething problems” when the new system was introduced but staff have had training and now fully understand how the system works. The moving and handling assessment in one care file seen had not been fully completed. A waterlow risk assessment had not been reviewed for four months even though previous assessment identified that the resident is at high risk. Care plans contained a great amount of information regarding the resident’s current abilities, the areas that require support and the areas that require staff intervention. Information recorded gave sufficient guidance to staff to enable them to meet the individual needs of residents. Care files had been reviewed up until February and required review for March. The manager was aware of this and plans to complete reviews shortly. There was limited evidence to demonstrate that the resident or their representative is involved in the care planning process. One file contained a sheet that had been signed by a relative. The manager reported that the Home’s policy requires that relatives/representatives are only invited to discuss care issues and sign care files if there has been a change of needs. Standards require that care plans are initially drawn up with the involvement of the resident/representative. The manager must ensure that care plans are also signed when a new resident is admitted to the Home. The oral care plan in one file was not up to date and the toilet regime chart had not been fully completed. Details regarding the contact numbers for dentists, optician and chiropodist were not available in all files. A body chart seen documented that a resident had a red area on the buttocks. Staff were applying cream. There was no further documentation to demonstrate that the red area had gone or whether staff were still applying cream. The manager demonstrated through archived documentation that staff complete a full skin check each week. A body chart is completed if care staff note any areas of concern. This information is reported to the nurse on duty. Other body charts seen for this resident reported that the skin was ok. These records had been archived. This made the current file confusing and appear as if there was still a problem. There was no mention in daily records of any action taken or whether the red area was still apparent the following day. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 12 There was limited evidence in records seen that residents receive regular dental, hearing or sight tests. The manager said that residents receive these tests annually or sooner if required. Due to the changeover of paperwork there was no evidence in current files. The manager demonstrated that other residents had seen optician’s as required and ophthalmic prescriptions were available in their care files. During the last inspection it was noted that a resident was staying in his room as he no longer joined in activities and made annoying noises. The manager reported that she had purchased a specialist recliner chair for this resident. This chair is in the lounge. The gentleman was seen spending some time in the lounge interacting with staff. The manager said that he now spends time in the lounge each day. Records demonstrated that residents are now weighed on a monthly basis. A hydration and a nutritional risk assessment are available for all residents. Where a high risk has been identified residents are weighed on a weekly basis. Four of the files seen demonstrated that residents were gradually gaining weight. One resident was loosing weight, care plans demonstrated that appropriate action is being taken to monitor the situation and provide suitable nutrition. During the inspection process staff were seen to have an excellent relationship with those under their care. Staff were sitting and chatting to residents, completing hand massages, playing games, singing and playing musical instruments. Residents were at ease in their surroundings and showed signs of wellbeing when talking to staff. The systems in place for medication ordering, storage and administration were reviewed and found to be satisfactory. Medication Administration Records (MAR) had been completed in a satisfactory manner. Controlled medications in use where being stored appropriately and records were kept according to legislation. A fridge is available to store any medication that requires refrigeration. A new contract has recently been set up for the disposal of medication. Sebright House DS0000041396.V286646.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, 14 and 15 The lifestyle experience in terms of meals and social/leisure activities has improved and now meets the expectations of residents. Residents still have some control over their lives and choices that they make which improves their sense of wellbeing. EVIDENCE: Since the last inspection the manager has developed life storybooks for each resident. A member of staff sits with the resident and talks about the resident’s history and completes the book. A life storybook is available for each resident, these are being constantly updated. An activity chart was on display in the lounge, activities such as hand massage, nail care, games, cinema afternoon and a trip to the pub are recorded. On the day of the visit staff were seen to complete hand massage, play games and sit and chat to residents. Staff used distraction techniques to reduce anxiety in some residents and played music and sang. A visitor has a “pat-a-dog” and brings the dog to see the residents each time he visits his relative. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 14 The manager has made vast improvements to the level and type of activities provided. A 1950’s beach hut has been put up in the garden. A shed has been painted in the style of a beach hut and is filled with the sights, sounds and smells of the sea. The manager is also developing a pub snug in another shed in the garden. The public house at the rear of Sebright House has donated some fittings to make the room authentic. Some of the residents visit the public house at the back of the Home on a Friday evening. A cinema afternoon also takes place and residents can eat ice cream and popcorn. The Home have purchased a 1950’s Silver Cross pram. This pram is used as a reminiscence tool. The era that this pram came from reflects the age group of the current residents. Some resident’s benefit from doll therapy. Visitors spoken to said that there is always something going on and that those who do not wish to join in seem to enjoy watching. When an activity such as a craft is taking place a table is set up and residents are free to complete as little or as much as they wish. The manager has taken photographs of residents completing activities and is going to display them. The photographs showed residents painting large plant pots and tasks such as drying dishes. The manager reported that residents have also planted spring bulbs in tubs in the garden. A quarterly newsletter has been developed to send to residents and relatives. The newsletter gives an update regarding issues such as staff training, what is happening at the Home and asks for input from relatives. An advocacy service provides assistance to those residents who have no family. Some residents also have their financial affairs handled by solicitors. One resident spoken to said that you have a choice in the things that you do, you can stay in your room or go to the lounge, but there is always someone there to help if you need it. The manager is encouraging family members to bring personal possessions for residents to make their bedrooms more homely. Some bedrooms had been personalised with pictures and ornaments. The manager has tried to introduce various types of stimulation in the bedrooms of those residents who remain in their room. Visual stimulation in the form of lights, colours and shapes, auditory stimulation by playing favourite music and stimulation of the sense of smell with the use of aromatherapy fans. One resident who remains in her room all day was spoken to. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 15 This resident’s family and the manager have introduced pictures and brightly coloured ornaments, pillows, bed throws to the room. Appropriate music was playing. An issue identified at the last inspection regarding the conservatory door not closing properly and residents wandering in the garden in the cold was discussed. The manager reported that the door to the rear garden is now fixed. This door is still left open during the day to enable residents to go into the gardens if they wish. When a resident goes into the garden staff go outside and offer a coat. During the inspection a resident went into the garden for a short walk. Staff persuaded the resident to come back inside and ensured that the resident was warm when she came back into the lounge. The inspector did not dine with residents on this occasion. This issue raised at the last inspection was reviewed to identify whether the required action had been taken. New dining furniture has been purchased and the dining area was clean and hygienic. The manager has put pictures and ornaments that relate to food and eating in this room. She has also put a wallpaper border which has words associated with eating such as meal, snack etc. The room has been re-decorated and is fresh and inviting. Perspex covering has been put over the chipped woodwork in the food serving area. During the last visit the inspector noted that drinks were being served from a jug and that residents were not being offered a choice of drink. A drinks trolley now provides tea, coffee, juice or milkshake. The cook said that she makes the milkshake using milk, fresh fruit and ice cream and that this is a favourite for residents. During the afternoon staff were seen giving out drinks to residents and visitors and were offering a choice of drink and biscuit. The menu available is not available in large print. The manager feels that a large print menu would not benefit those living at Sebright House. Instead staff take out the two meals that are available each day and offer a visual choice to residents. Sebright House DS0000041396.V286646.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): 18 There are policies and procedures in place to ensure that service users are protected from harm. Effective systems are in place for listening and responding to issues raised by residents or their representatives. EVIDENCE: There have been no allegations of abuse since the last inspection. Staff have undertaken in-house protection of vulnerable adults training. More training is planned for 2006. The whistle blowing procedure gives step-by-step guidance on whom to contact if there are concerns regarding any aspect of care/practices at the Home. The policy gives the names of people who may be contacted for example the manager, the group care director but does not give any contact details i.e. telephone or address. These contact details are available in a company telephone book. A copy of the telephone book is kept in the manager’s office and another on the nurses’ station. The policy does not inform staff where these phone numbers can be located. Various policies and procedures are available regarding adult protection and prevention of abuse, these policies have been reviewed on a regular basis. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 17 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, 20, 24, 25 and 26 The appearance of this home has significantly improved since the last inspection creating a comfortable and safe environment for those living there and visiting. Further improvements are still required to certain areas. EVIDENCE: The strong smells identified during the last inspection have been removed. New carpets or laminate flooring has been put down in communal areas and in some bedrooms. New chairs and settees have been purchased for lounges, cushions, throws and ornaments have also been purchased. Lounges were homely, clean and hygienic. The manager has replaced some of the pictures in lounges and dining rooms. These were all issues identified during the last inspection, which have now been addressed. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 18 Other issues identified at the last inspection are recorded below, the action taken to address each issue is recorded underneath: Unpleasant smells in bedrooms, untidy bedrooms. • The manager has employed three domestics. Bedrooms seen during this visit were clean and tidy and no unpleasant smells were noted. A call bell system is available but there are no bell cords in any bedrooms. • The manager has completed an assessment to identify whether residents would be able to use the call bell. This assessment is reviewed every three months. No record of maintenance, various small repairs are required. • Staff/the manager report maintenance issues to the handyman. The handyman works between 9am – 2pm for five days per week. The handyman was present during the inspection and was undertaking routine maintenance and repairs. The staff room was dirty and there were no lockers for storage of personal belongings. • The staff room has been painted. The manager reported that it is the responsibility of staff to tidy up after themselves in the staff room. Lockers are available at either side of the building for storage of personal items. A box of pants, tights and socks was seen in the laundry. • Net bags have been purchased. The pants, socks tights etc of a resident is laundered in their individual named bag. These items are then returned to their room in these bags. The lighting in the bathroom is dim and visibility is poor. • New lampshades have been fitted to increase lighting levels. Centrally heated rooms are warm and cannot be individually controlled. • The problem identified with the boiler has been addressed. Thermostatic controls are available on radiators. A number of items were stored in an unused bathroom. • Storage remains a problem. Items were still being stored in this bathroom. The bath is not of the assisted type and the manager said that none of the current residents would be able to use the bath. However, the toilet could still be used by residents if they had access. Resident’s hair and fingernails were not clean and some male residents needed their hair cutting. • The hairdresser had visited and cut resident’s hair. Ladies spoken to had had their nails manicured and were wearing nail varnish. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 19 The manager has started re-painting toilet doors in a distinctive bright yellow colour; new pictorial and written signage is in place on bathroom and bedroom doors. The manager intends to paint all en suite toilet doors in the same colour. Bathroom doors have been painted blue with new signs in place. Some of the corridors and bedrooms have been painted. Residents have been able to choose the colour of the paint for their bedroom. The manager is colour zoning areas of the Home to make areas more easily identifiable to residents. Bedroom and corridor doors and grab rails are being painted to match. Pictures, hats, photographs are on display in corridors. The manager has attached these with Velcro so that they can be removed by residents and easily replaced. Work is still required to update some bedrooms that have magnolia walls, and which have not been personalised. The handyman is responsible for painting and is doing this as time allows. A large amount of rooms have already been decorated and personalised. One bathroom viewed had been painted and the manager had put pictures on the walls related to bathing/showering. The room was bright, fresh and cheerful. Work will start on the other bathrooms shortly. The rear garden was well maintained. Residents have planted brightly coloured flowers in large tubs which are pleasant to look at. All bedroom doors are lockable. The manager and qualified staff hold master keys to open bedroom doors. Currently none of the residents choose to lock their doors. Windows seen were fitted with restraints. The handyman checks window restraints every three months to ensure they are in good working order. Sebright House DS0000041396.V286646.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): 28 and 30 A large number of staff have undertaken National Vocation Qualifications. Good opportunities are now available for staff training and development, this ensures that residents are being cared for by qualified staff. EVIDENCE: The Home is staffed by qualified registered general nurses, staff from overseas undertaking adaptation training and care staff. Currently 82.35 of care staff have obtained NVQ level 2 training, some staff have also undertaken NVQ level 3. Staff vacancies include a part time cook and a kitchen assistant. Agency cooks are used most weekends. There are no vacancies for care staff currently. On the day of the inspection the Home was adequately staffed. The manager was on duty along with two registered general nurses, two adaptation nurses and five care assistants. The cook, kitchen assistant, laundry and domestic assistant’s were also on duty. Staff had a good relationship with those under their care, they were patient and caring. Staff were seen to encourage residents and were chatting and joking with residents and visitors. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 21 Corporate induction training information is available. The manager reported that the induction training meets TOPSS requirements. Staff work in a supernumerary capacity for one week whilst starting the induction process and must complete the induction process during the next five weeks whilst working as part of the staffing establishment. Although a large majority of care staff have NVQ training, staff have not undertaken any training regarding dementia. Training has been booked for 2006 and all staff must attend. However, until this training has taken place this standard remains unmet. Staff must also undertake fire training, there was no evidence that staff had undertaken any fire training within the last twelve months. Sebright House DS0000041396.V286646.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, 37 and 38 The manager has a clear vision for the home and a good understanding of the areas in which the home needs to improve. The quality management systems in place ensure that the home is run in the best interests of the residents. Some areas related to the health, safety and welfare of the residents have been promoted, however there are areas that raise concerns, this lack of attention may result in harm. EVIDENCE: The manager started work at Sebright House on 31 May 2005. Since she started working at the Home she has undertaken in-house training. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 23 The manager is starting a diploma in dementia studies in June 2006 and has applied to undertake the Registered Manager’s Award. The manager has yet to become registered with the Commission for Social Care Inspection. Visitors spoken to said that the new manager has made many changes that have improved the quality of life for the people who live at Sebright House. Throughout the inspection the manager was enthusiastic about her work. She has a vision of the type of service that should be provided at Sebright House and clear ideas of how she will achieve this. The manager had a good relationship with staff, residents and visitors to the Home. There have been no changes to the quality assurance system in place. Quality assurance questionnaires are sent to residents and relatives on an annual basis. These are due again in June 2006. The manager said that she assisted residents to complete the questionnaires last year. A suggestions box is available at the front of the Home. As mentioned earlier in this report, the manager has developed a quarterly newsletter to give to residents and visitors. Residents/relatives meetings are held every three months, during these meetings discussions are held regarding the quality of service provided. The manager undertakes various audits to assess the quality of the service. During the last inspection various pieces of documentary evidence could not be found. All information required was available at this inspection. Changes to the care planning systems in place have ensured that documentation is easy to read and understand and in good order. The standard relating to health and safety was audited to identify whether the issues raised during the last inspection have been addressed. It was noted at the last inspection that there are no risk assessments for the environment and the Home were unable to show where risks may exist. The manager produced health and safety policies and procedures and information regarding COSHH. However, there was still no risk assessment regarding the working environment in general i.e. a risk assessment for laundry or catering staff or care staff whilst undertaking certain duties. Records demonstrated that fire training is arranged for May and July 2006. A few staff have not undertaken any fire training within the last twelve months. Training is planned for May and July 2006. The manager confirmed that any staff that require update training will attend. Sebright House DS0000041396.V286646.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 X X X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 X X X 2 3 3 STAFFING Standard No Score 27 X 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 3 2 Sebright House DS0000041396.V286646.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 OP3 Regulation 13 Requirement Risk assessments must be fully completed and reviewed according to the level of risk identified. The registered provider and manager must ensure that the residents and/or their relatives are involved in the process of assessment, planning and evaluation of care. When changes in care are made residents and/or their relatives must be informed. Timescale for action 15/05/06 2 OP7 12(2), 14(d) 15(d) 28/04/06 3 OP8 12(3), 13(4)(c) 3 The registered provider and 28/04/06 manager must ensure that the action recorded in care plans regarding pressure area care must be completed by staff, for example if the care plan requests dressings to be changed every three days this must be undertaken as recorded, also photographs must be taken of pressure areas if the care plan requires this. Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 26 4 OP8 12(1) 13(1) The manager must ensure that all charts regarding toileting, personal and oral hygiene are completed by staff as required. The registered provider and manager must ensure that all bedrooms are suitably decorated and that all fixtures and fittings are in good repair. The registered provider and registered manager must ensure that there are generic risk assessments available and that these are re-assessed yearly. (Outstanding since June 2005) 28/04/06 5 OP24 16,2,c, 23,2,b, d 15/05/06 6 OP38 13(4)(a) (c) 15/05/06 Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 27 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 The manager should transfer the information from the old care planning system regarding optical and dental tests undertaken to demonstrate that regular routine checks are made regarding oral and visual health. The Home’s whistle blowing policy should contain contact details for those people mentioned in the policy or should cross-reference where these contact details can be found. It is recommended that the management policies and procedures related to the guidance from the Department of Health on Protection of Vulnerable Adults. This should include the role of the service and the individual employee. 2 OP18 3 OP18 Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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. Extracts may not be used or reproduced without the express permission of CSCI Sebright House DS0000041396.V286646.R01.S.doc Version 5.1 Page 29 - 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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