Inspection on 06/06/05 for Sebright House

This inspection was carried out on 6th June 2005.

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 20/03/06

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 Suzette Farrelly Unannounced 6 June 2005 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 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 E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sebright House Address 10-12 Leam Terrace Telephone number Fax number Email 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 Interhaze Ltd N Care home with nursing 40 Category(ies) of DE(E) Dementia - over 65 (40) registration, with number DE Dementia (1) of places Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 14 December 2004 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 meals and 24hour 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 E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started at 10:30 am and finished at 5:30 pm enabling a full view of the residents’ day. A tour of the home was carried out looking at a selection of bedrooms, and examining the kitchen, laundry and communal areas. Two staff were formally interviewed and a further six staff were spoken to during the inspection. The inspector met with one relative who reported that they were very pleased with the service and their relative had shown some improvement since admission. The inspector spoke to one relative via the telephone who stated that they were concerned with the care provided by the home, however, they felt that moving their relative might cause more distress. It appears that relatives have various experiences of the care provided by this service and over the past three months there have been relatives and professionals who have made formal complaints and expressed concerns and equally relatives who have praised the service and expressed their delight. Four residents files were examined; information about the resident, care plans, care given and information concerning the long-term care were all seen. The inspector visited the resident’s bedrooms and spent some time with each resident. During the formal interview with the two staff members, they were able to discuss the care required by these four residents. The home requires re-decoration and various items of furniture require cleaning and/or replacement. The home lacks a homely feel and much could be done to use the extensive communal space better. The home has a new manager, who had only been in post for four days at the time of the inspection. She had conducted an audit of the environment, care planning, records and activities and discussed where attention is required. It was noticed that there has been an improvement in the interaction between the residents and staff since the last inspection and more suitable music was playing. The manager discussed her ideas for the future and has put into place systems to deal with concerns she has noted and were also discussed during the inspection. These concerns are dealt with in detail throughout this report. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home’s manager has had a lot of past experience in working with people who have dementia and has already discussed changes she wishes to make. Below is a list of areas of concern and require attention to bring them to an acceptable level. • Staff are not trained in the area of dementia care, managing challenging behaviour and psychological needs. These must be done and the manager must ensure that any training received is followed up with practical application of new skills. The service must ensure that the residents and/or the relatives are involved in the process of assessing and planning care. The service must also ensure that suitable assessments are carried out and changes in care needs are recorded on the evaluation sheets and on the care plans, the resident and/or their relative must be consulted. The service must ensure that all residents have a nutritional and pressure damage risk assessment completed. This should then be carried out monthly to show if there are changes and care must be developed to reduce any risks seen. The service must ensure that a variety of drinks are offered and that residents are given a choice, the process of serving drinks from an uncovered measuring jug is institutional and must stop immediately. (A E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 7 • • • • Sebright House letter of concerning regarding this practice has been forwarded to the provider) • The environment lacks a homely atmosphere, has an unpleasant smell and is in need of redecoration. The residents’ bedrooms are bland, lack personalisation and require re-decoration. The environment does not reflect recent research in design environments for people with dementia, when redecorating the communal and bedroom areas this should be taken into account. There are no structures activities; the new manager has discussed her ideas to meet the needs of this varied group of residents. The records are poorly maintained, disordered and difficult to find the information required. This needs to be sorted out and records must be clear and easy to track. The service must ensure that there are risk assessment completed for the environment for such areas as fire, trips, falls and slips and other risks associated with entering the kitchen and laundry, and managing the stairs. • • • • 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 E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4, 5 All residents have a full assessment of their needs prior to admission ensuring that their needs can be met and that risk of harm is minimised. The home is unable to meet all the assessed needs of the residents particularly those needs associated with dementia. This could result in inappropriate care and psychological harm. All residents and relatives are invited to visit the home prior to admission maximising their right to choose and independence. EVIDENCE: Four residents records were examined. A qualified nurse or the manager carries out a full assessment on each resident before admission to the home. An assessment for each resident from the social service care manager was also available. The new manager has carried out an audit and this was discussed, training in dementia care is to be organised and part of the communal area is to be Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 10 converted into a sensory area for residents. The manager will send a full action plan showing when these will be completed. From discussion with staff and relatives it was confirmed that residents and their families are invited to the home prior to admission. It was found that residents who are in hospital are often unable to visit, in these cases the families visit and make the final decision. The home does not formally record these visits. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10 The resident’s health, personal and social care needs are not suitably recorded and information is missing which could result in the risk of harm to the resident. The resident’s health care needs are not completely met which could increase the risk of harm to the resident. The resident’s right to privacy is respected increasing their sense of well being and self worth. EVIDENCE: Four residents records were examined and the assessment and care planning were poor and did not deal well with their needs. In one case it was reported that a male resident was bed bound, the reason given was that he no longer joined in activities and could be verbally aggressive and make annoying noises. In the other three records examined there was a lack of information in the care plans. In one resident’s records it was apparent from the daily reports that the ability to eat had changed, however the care plan had not been up dated. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 12 There was no evidence that the resident or the family were involved in the assessment or the planning of care and there was no information to confirm that there are reviews of the residents care and life at the home. The health records are poorly maintained and it was difficult to tell when the residents last had a full health and medication check by their GP. There is limited information concerning visits by other professionals and follow up information or advice was not seen. The residents are not weighed often enough; even where there is evidence of weight loss the staff do not follow the guidance related to nutrition from the government and health authority. One resident with continual weight loss was last weighed on 7th May 2005; the records showed that he had lost 6 kilograms in five months. The care plan stated that he must be weighed weekly this had not occurred and this resident is at risk of complication of poor nutrition and continual weight loss. The qualified nurses carry out risk assessments concerning the risk of pressure damage to their skin. Where there is a high-risk care plans giving guidance to care staff regarding prevention were not seen. It was found that three residents at the time of the inspection had pressure sores; the qualified staff was treating these. Most residents were seen in the three communal lounge areas in the home. The staff were seen spending time in the conservatory area talking to residents and playing ball games. Other residents were seen sitting alone, sleeping or staring into space. The manager discussed how she is going to change the daily routine to have a more stimulating and interesting environment. It was discovered during discussion with the staff and two relatives that all personal care is conducted in private, the inspector did not see any care being conducted in the communal areas. One agency care staff was seen working one-to-one with a resident, there was no interaction and the carer did not seem aware of her role, the resident was being constantly told to sit down and to return to the main lounge area, it was noted that his aggravation and anxiety were increasing. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 15 The social, cultural, religious and recreational interests are not completely met by the service and therefore the residents’ life experience of the home may not met their expectation. This could result in poor self-esteem and psychological harm to the residents. The service ensures that visitors are made welcome and the residents’ benefit from visits from family and friends. The residents have suitable meals four times a day, the surroundings are drab and not inspiring, and the serving area requires attention this could result in reduced eating and associated health concerns. EVIDENCE: Information concerning the residents’ social, cultural, religious and cultural needs was very varied in the four profiles seen. In two of the residents’ records there was clear information about their lives and the interests and hobbies that they had, this information was not used to develop activities and there were no care plans explaining what hobbies could still be pursued. The home does not have an established activity programme and it appears that all activities are carried out when the staff feel inclined to do so. The manager is aware of this and discussed at length how she is going to develop suitable activities to meet these needs. During the inspection two staff were Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 14 seen playing with a ball with three to four residents. No consideration to other residents in the immediate area had been considered. Residents who have advanced dementia were seen sitting alone in chairs with no stimulation and one resident seen in bed had no music, pictures she could see or any other form of stimulation. Various books, magazines and games were seen and three residents were observed reading a newspaper. The residents were able to go into the garden from the conservatory, on the day of the inspection it was quite cold and the door to the conservatory does not close well leaving residents in this area cold. Residents who went into the garden did not have enough clothes on and one complained of feeling ‘really cold’ when they returned to the conservatory. During the inspection a number of relatives were seen visiting. One relative told the inspector that he was very pleased with the service and his relative has improved since coming to the home. He had praise for the staff and stated that they were always friendly. From discussion it was confirmed that there are no restrictions to friends and relatives visiting the home. The kitchen area was seen and the cook gave an explanation on how the kitchen area is kept clean and showed the inspector the menus and other records kept in the kitchen. There is a serving area, which contains a hot trolley and surrounding area for plates and utensils; this had chipped paintwork and was sticky to touch. The wall behind the serving area had the menus in very; the writing is very small and could not be read with ease. There were no menus that could be used with residents who have dementia. The morning drink was served in a large measuring jug with no lid, there was no choice offered and when asked if there was sugar for anyone who wished it the inspector was told that ‘no one need sugar with hot chocolate.’ The cups also had no saucers. This has been raised before with the service and discussion took place concerning the lack of choice and institutional aspect of serving drinks in this way. The dining area lack comfort and the pictures on the walls were very small and not appropriate for this area. The table and chairs were old and need replacement. The manager said that new table and chairs were to be delivered the following day, the home have informed the inspector that these have now arrived. Many residents were seen eating their main meals while sitting in the lounge areas, the residents’ records did not show why this was and the staff could not give a reasonable explanation. From discussion, records and an Adult Protection it was found that the home has poor practice when dealing with weight loss in the residents, and action taken at the early stages of weight loss is not carried out. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 16, 18 The home has dealt with complaints in a confident and professional manner therefore the residents and their families may have confidence that their concerns will be listened to. The home has appropriate policies, procedures and good employment procedures to protect residents from abuse. Other polices and procedures are not always adhered to and this could put the residents at risk of harm. EVIDENCE: The home has dealt with two complaints since the last inspection, records were seen which demonstrated that the home had dealt with these according to the policies and procedures. Copies of all investigations and letters sent to the complainant were seen. The Commission had received two complaints since January 2005. These were dealt with after discussion with the home management at that time and reports sent to the complainants. All complaints received concerned poor practice in delivering care and surrounded issues related to weight loss, injury and sores to skin and lack of general care. There is no evidence that the qualified and care staff have received suitable training in dealing with complaints in an appropriate way. There is evidence from discussion and records that concerns raised are not dealt with and this then escalates into a complaint. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 16 The policies and procedures for adult protection were not seen at the time of this inspection, as the manager could not locate them as she has only been in post for four days. Discussions with the manager concerning the protection of vulnerable adults took place this demonstrated her awareness of issues related to this area. There is some concern that some staff have a minimal awareness of issues related to protection of vulnerable adults and this puts the residents at risk. One resident was very distressed during a visit from a relative, the staff failed to intervene and there was not suitable information to guide staff. Another resident was found to spend all there time isolated in there room, the care plan stated that they did not want to join activities and was noisy and disruptive. Records concerning changes in health and action taken by the home and other professionals are very poor and there is a risk that serious changes to health will be missed. There had been an Adult Protection related to a resident with weight loss, poor physical condition and reddening pressure areas. The investigation showed that risk assessments had not been completed for nutrition and pressure sore development. Equipment needed was not available and there were no care plans to demonstrate care prescribed or carried out. Information has been given to the home and new risk assessments, at the time of the inspection these had not been implemented. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 23, 24, 25, 26 The general and private areas of the home accessible to the residents require some repairs, redecoration and cleaning, some areas were untidy and lacked a homely feel reducing the quality of life for the residents. EVIDENCE: On entering the home there is a strong unpleasant smell of stale food and urine. The carpets are stained and tape is visible in a number of areas presumably to reduce the risk of tripping. The manager stated that new carpets had been ordered; a date for delivery and fitting had not been agreed. Chairs seen in the lounge areas had dirty armrests and a number of chairs lacked the correct cushion or failed to have a cushion at all. There was a scarcity of other furnishings such as occasional tables, ornaments, cushions and so on that would make the service more homely. The pictures on the wall were crooked and in some case too small or inappropriate for the needs of the residents. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 18 There is no record of maintenance and various small repairs throughout the home are required. There is a full call bell system in the home, there are no bell cords in any of the bedrooms, and the manager stated that the residents did not know how to use them. A full assessment has not been conducted and it could not be confirmed that residents had been given the opportunity to use this facility. Most bedrooms were visited and some have a very unpleasant smell and were untidy. It was noted that in some cases the bed linen was stained, the rooms were bland, uninteresting and lacked personalisation and a homely feel. All bedroom doors have locks, it was noticed that at least two of these are broken and there was a lack of individual locked facilities in the bedrooms for the residents to use for personal items. There is nowhere in the home to store equipment and a number of items were seen in an unused bathroom. There are a further two assisted bathrooms and two shower rooms available for residents. It was noted that the residents’ hair and fingernails were not clean and the some male residents needed their hair cutting. The manager stated that the service was looking to employ a new hairdresser. All rooms are central heated, it was very warm in some areas and the temperature could not be controlled individually. The manager stated that this is due to a fault with the boiler and this was being looked at to try to solve the problem. The lighting in the bathrooms is very dim and visibility is poor, which may result in residents sustaining an injury or falling. The laundry is situated in the cellar; there are separate areas for the dirty linen, clean linen and dry linen. The laundry person appropriately discussed control of infection and care of residents’ clothes. A box was seen with socks, tights and pants with no names, the laundry person stated that residents use these if they do not have any or run out of these items, it was discussed that this is poor practice. The staff room is also situated in the cellar, this area was visited and found to be untidy and dirty; also the staff do not have any lockers for personal items. The fridge was dirty and the temperature is not checked to ensure that it is working properly. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 Although there are sufficient numbers of staff on duty, the skill mix requires attention to ensure that the level of care required is met reducing the risk of harm to residents due to oversight of care. Most of the care staff are trained to NVQ level II and there are qualified nurses on duty at all times, however, practice observed and documentation demonstrated that the care is poor putting residents at risk. The recruitment policies and procedures ensure that residents are protected from harm. EVIDENCE: It was seen from the duty rosters and the number of staff on duty on the day of the inspection that there are sufficient qualified and cares staff available. It was confirmed through records and discussion that the qualified staff have relatively little practical or theoretical knowledge of working with individuals who have dementia. Despite the high level of training in National Vocational Qualification to level 2 in Care it was confirmed from records, complaints and adult protection that the basic health care needs are not consistently met and residents are at risk due to an oversight of care. It was found when interviewing two qualified staff that they have had not training in the specialist care of individuals with dementia and at times found it Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 20 hard to recognise the psychological needs and how to deal with challenging behaviour. Five employment records were seen and it was confirmed that all staff have full checks prior to employment to ensure that they are suitable to work with vulnerable adults. There was not information to show that staff had received the Codes of Conduct from the General Social Care Council. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 37, 38 The manager has only been in post for four days and it was not possible to assess this fully during this inspection. The residents’ person monies are handled appropriately and they are safeguarded from financial harm. Records are poorly maintained and are disorganised and not easily accessible therefore the residents’ rights and bests interests might not be safeguarded and they are at risk from harm. 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. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 22 EVIDENCE: The manager has only been in post for four day at the time of the inspection. She was able to demonstrate that she had conducted an audit of the communal areas and activities that occur on a daily basis. The manager discussed her plans for the future of the home. She has nine years experience of working with people with dementia and has managed a similar service previously. She was able to discuss new research concerning dementia and her vision for a specialist provision of care, also addressing staff training and dealing with attitudes, behaviours and beliefs. The residents’ personal monies were seen and checked, records related to this have been properly maintained and receipts are kept. Storage is appropriate and the manager and senior staff have access only. Records of the home are varied, there is some disorganisation and the manager is aware of this and has begun sorting out this problem. Records of maintenance were seen and examined, all checks on equipment are up to date and staff training is ongoing. There are no risk assessments for the environment and the home was unable to show where risks may exist and the actions it would take to reduce them. Safety notice were seen around the home in bathrooms, the laundry and toilet areas. A Health and Safety Poster was also seen. Staff spoken to during the inspection had varying levels of knowledge and understanding of health and safety, this could result in an increased risk of harm to the residents. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 x COMPLAINTS AND PROTECTION 2 2 x x 3 2 2 2 STAFFING Standard No Score 27 2 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x x x 3 x 2 2 Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? 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 OP4 Regulation Requirement Timescale for action 31.08.05 2. OP7 3. OP7 4. OP7 16(1)(a)(c The regiatered provider and ) manager must ensure that the staff are able to meet the physical and psychologicla needs of the residents at all times through appropriate training. Residents and relatives must be informed in writing of the initial assessment and care plans. 15(1) The registered provider and registered manager must ensure that the care plans are appropriate and address the assessed physical and psychological needs of the residents. 14(2)(a)( The registered provider and the b), manager must ensure that the SChedule evaluation of care and that 3 changes in care needs are recorded and care plans up dated accordingly. 12(2), The registered provider and 14(d) manager must ensure that the 15(d) residents and/or their relatives are involved in the process of assesment, planning and evaluation of care. When changes in care are made residents and/or their relatives must be informed. E53 s41396 Sebright v231746 060605 Stage 4.doc 31.07.05 31.08.05 31.08.05 Sebright House Version 1.30 Page 25 5. OP8 12(3), 13(4)(c) Schedule 3 6. OP8 7. OP8 8. OP12 9. OP15 10. OP19 11. OP20 the registered provider and manager must ensure that the results from risk assesments for nutrition are acted upon and suitable care is devised to minimise the risk and complications of malnutrition and dehydration. 12(3), The registered provider and 13(4)(c) manager must ensure that risk Schedule assessments for pressure 3 damage is carried out and appropriately completed. Care must be prescribed to reduce the risk of the development of pressure damage. 13(1)(a)( More complete records must be b) maintained of visits made by the Schedule GP and other health 3 professionals, this must included reason for vist, action taken follow up. 1692)(m)( The service must ensure that n) there are structured activities. Residents and/or relatives must be made aware of this and given a choice as to their participation. This must be available to all residents and/or their relatives in a suitable format. 16(2)(g)(i The registered provider and ) manager must ensure that residents have a choice when drinks are served. Hot liquids must also be served in a suitable container that is recognisable for drinks. 16(2)(c) The registered provider and 23(2)(b)( manager must ensure that there d) is a programme of renewal and redecoration of the home organised on a yearly basis. This must address the need to refurbish/replace fixtures and fittings to meet an acceptable standard. 16(2)(c) The registered provider and 23(2)(b)( manager must ensure that the E53 s41396 Sebright v231746 060605 Stage 4.doc 31.07.05 31.07.05 31.07.05 31.08.05 31.07.05 31.08.05 31.08.05 Page 26 Sebright House Version 1.30 d) 12. OP24 16(2)(c) 23(2)(b)( d) 16(2)(i) 13. OP24 14. OP25 23(2)(p) 15. OP25 23(2)(p) 16. OP27 18(1)(a) 17. OP28 18(1)(c) 18. OP37 19. OP38 17 Schedule 3 Schedule 4 13(4)(a)(c The registered provider and ) registered manager must ensure that there are generic risk assessments available and that E53 s41396 Sebright v231746 060605 Stage 4.doc communal areas are redecorated taking research in to suitable environments for those with dementis ito account. Suitable fixtures and fittings appropriate for the client group must also be available. 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 manager must ensure that there are locked facilities in all bedrooms for each resident and the locks to bedroom doors must be suitable and working. The registered provider and manager must ensure that the radiator covers throughout the home are in good repair, and that the temperature in each part of the home is appropriate. The lighting in the bathrooms must be suitable to enable residents to see clearly and to avoid accidents. The registered provider and manager must assess the skills mix of staff on duty and ensure that the physical and psychological needs of the residents can be met. The registered provider and manager must ensure that qualified and care staff receive training in the specialist care for people with dementia. The records in the home must be organised and available at all times for inspection. 31.08.05 31.07.05 31.08.05 31.07.05 31.07.05 31.07.05 31.08.05 30.09.05 Sebright House Version 1.30 Page 27 these are re-assessed yearly. 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 OP19 Good Practice Recommendations 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. Sebright House E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 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 E53 s41396 Sebright v231746 060605 Stage 4.doc Version 1.30 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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