Inspection on 09/08/06 for Sebright House

This inspection was carried out on 9th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 20/03/06

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 Key Unannounced Inspection 9th August 2006 08:45 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.V306931.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 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 Mrs Johanne Catherine Shuker Care Home 40 Category(ies) of Dementia (12), Dementia - over 65 years of age registration, with number (40) of places Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Sebright House may admit up to 40 older people with dementia, 12 of whom can be people with dementia aged 50 years and above. 20th March 2006 Date of last inspection Brief Description of the Service: Sebright House care home is registered to provide specialist Dementia care to people with dementia who also 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 alongside 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. The currently weekly charge for accommodation, board and personal care is £450 - £875. Additional charges are made for private chiropody, which is currently £11 and hairdressing, which is £6 - 20, personal items, toiletries, newspapers and magazines are also paid for separately. This information was provided by the manager. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 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 8.45am and 6.40pm on Wednesday 9 August 2006. The manager was on duty along with three registered general nurses, eight care assistants, two catering, two laundry and two domestic staff. Thirty-eight people were living at Sebright House. Four service users were ‘case tracked’. This involves investigating an individual’s experience of living in the care home by meeting with them, talking to them and their families (where possible) about their experiences, looking at their care files, looking at their environment, discussions with staff on duty and reviewing staff training records to ensure training is provided to meet resident’s needs. Some of the documentation was looked at in the lounge, this enabled the inspector to see residents in their usual surroundings and see the interaction between staff and residents. What the service does well: The atmosphere at Sebright House is relaxed and friendly, staff appeared to be enjoying their work and had a good relationship with those under their care. Staff were seen talking to residents and completing activities with them at various times throughout the inspection. Both residents and visitors appeared at ease and gave positive feedback regarding management and staff. Some of the comments received are detailed below: • • • • • “the staff are lovely, kind, patient and friendly. I want to give special praise to Jo – she is absolutely wonderful”. “everything is fantastic, it is the best thing I could have done” “all you need to do is ask and they get anything for you” “the atmosphere at the Home is relaxed and friendly” “it is good here isn’t it, there is always lots going on” Items related to specialist therapies for those with dementia, such as doll therapy, were available in the conservatory. A wide range of activities and stimulation is provided on a regular basis. The manager is dedicated to provide high quality care for those with dementia and has clear ideas of the action to take to address issues and further improve the quality of the care provided. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 6 Staff were seen to manage any incidents of challenging behaviour in an appropriate way. Staff were able to divert the behaviour and therefore prevent further incidents occurring. 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. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 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.V306931.R01.S.doc Version 5.2 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): 3, 6 is not applicable to this Home. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Pre admission assessments provide staff with the information they need to develop a care plan to meet resident’s individual needs. EVIDENCE: A form is completed upon receiving an initial enquiry about a placement at Sebright House. The manager speaks to the potential resident’s social worker (if applicable) and obtains copies of Social Services care plans and background information. The manager invites relatives to visit the Home prior to any pre-admission assessment taking place. Standardised documentation is used to record relevant details during the pre admission assessment. Discussions are held with those present (either relatives or hospital staff) to obtain further background information. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 9 Pre admission assessments are kept at the front of each care file. Information obtained from these assessments is used to form the initial plan of care. The care plan of the most recently admitted resident demonstrated that sufficient information is gathered prior to agreeing a placement at Sebright House, care plans provided by Social Services were available and formed part of the assessment. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 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 and 10 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. 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, however, some updates are required to information held in care files. The healthcare needs of the people living in this home are assessed and recognised with evidence of specialist services being available to them. Improvements are needed in the management of medication so as to ensure the safety of residents. Personal support is offered in such a way as to maintain the resident’s privacy and dignity. EVIDENCE: Five care files were reviewed, including the file of the most recently admitted resident. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 11 There is documentary evidence in each file to demonstrate that resident’s relatives have been given a copy of the Home’s Service User’s Guide. Consent forms are also available regarding payment for extra items such as hairdressing, chiropody, opticians, consent for the use of restraint, (with the reason for the use of any restraint explained in full), consent for staff to open post etc. Very detailed information is recorded on standardised documentation in care files. Information such as favourite colours, places, music, likes and dislikes, details of GP visits. Assessments regarding the use of call bells, oral health, continence, hydration and nutrition assessments. General risk assessments are available as well as more specific risk assessments regarding moving and handling, pressure areas, fire evacuation, door closures etc. Some risk assessments in one file required reviewing. Instructions record that they are to be reviewed every three months, a majority of the risk assessments were last reviewed at the end of April 2006. The manager stated that staff are in the process of reviewing risk assessments. Relatives sign a document stating that they agree with the contents of initial care plans, currently relatives are not involved in any further review of care plans. Some of the care files were slightly overdue for their monthly review, i.e. date of last review 24 June 2006. Care files contained various documents which record the same information, for example there is an oral hygiene record as well as a daily personal care sheet. Staff are not consistently recording information on these sheets. The manager plans to streamline the documentation in care files. The manager also plans to add more dementia specific information. The systems for the management of residents’ medication were examined. Medicines are stored securely in a locked trolley in a small storage room. Medication is dispensed to the Home every 28 days. There are no residents currently self-medicating. The Home do not have copies of prescriptions and only reference the current medications received back to the previous MAR chart and not a copy of the prescription. Prescriptions are sent direct from the GP to the pharmacy without the Home having sight of the document. This is not safe practice. Medication administration records had not been signed on each occasion to demonstrate that the correct amounts of medication have been received. No other records were available to demonstrate that all medications are counted and dosage strengths checked when they are received at the Home. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 12 Staff had not signed MAR sheets on two occasions to demonstrate how many of a tablet had been administered, for example the GP instructions state give one or two tablets each day. On some occasions the resident was taking one tablet and on others two. Staff had not recorded the amount taken on two occasions. There was therefore no way of auditing that the correct amount of tablets was remaining for the resident. There is no method of auditing the number of tablets held for residents, particularly ‘as required’ medication such as analgesics that are not included in the 28 day dispensing cycle of medication but are ‘carried forward’ to the next month. Controlled medications were audited and found to be correct. Staff had not completed the controlled medications record book on one occasion to say that some tablets had been returned to the pharmacy. The last tablet taken was 2005. The records for all other residents had been completed correctly. MAR sheets showed that one medication for a resident had run out, staff had ordered a new supply from the pharmacy. The medication had not been administered on the previous day and the new supply had not been received by the end of the inspection visit. Staff were seen to have an excellent relationship with those under their care. They chatted to residents, played games, completed manicures and assisted residents in a patient, caring manner. Staff tried hard to provide stimulation for residents by chatting, showing pictures and books and playing games. During this inspection they were seen to respect the privacy and dignity of residents. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 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 and 15 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Various activities are undertaken on a daily basis to provide stimulation for the individuals that live at Sebright House. People living in this home are supported to maintain family links and friendships and continue to be part of the local community in which they live. Residents’ are enabled to make choices about visitors and some daily living routines. Meals provided are varied and menus balanced, residents reported that they enjoy the food. EVIDENCE: Activity programmes are on display on notice boards throughout the Home. Staff were seen to play games such as skittles with residents, give hand massages and manicures and discus topics of interest. During the afternoon age appropriate music was playing and some residents appeared to be enjoying having a dance with staff. One resident was also seen participating in doll therapy. Care files contained details of activities undertaken. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 14 Activities such as trips to the pub, walks in the park, hand massage were recorded on the activity programme. Gardens were well maintained and residents were seen enjoying a walk outside. Each care file contains a copy of the Homes visiting policy. Visitors are allowed at any reasonable time. Visitors spoken to said that they are always made to feel welcome and said that staff are kind and considerate. Family members were seen to be visiting freely and were made welcome. Residents are given as many choices as possible regarding routines of daily living, usual times for getting up and going to bed are obtained from relatives and details are recorded in care files. A choice of two meals is available on a daily basis. Staff take the two meals to show residents who then have a visual choice. Residents are able to choose whether they wish to receive care from a male or female carer as far as possible and there is also the choice of whether to have a bath or shower. Residents spoken to said that the food is good and confirmed that there is a choice. They said that there is always plenty to eat and snacks are offered regularly. Copies of menus were taken for review these demonstrate that residents receive a nutritious balanced diet. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the home. Procedures are in place to ensure that complaints are handled in an appropriate manner. Residents and their relatives are confident that complaints or concerns will be investigated. Systems are in place to protect residents from the risk of abuse, giving them a feeling of safety and wellbeing. EVIDENCE: The manager encourages residents or relatives to approach her to voice concerns. Residents and visitors spoken to during the inspection all felt that the staff and management were approachable. Relatives are asked at meetings whether there are any issues of concern. The manager said that she contacts relatives that she has not seen for some time to ensure that everything is OK. Copies of the complaints procedure and complaint log forms are available at each nurse’s station. The log forms are completed by staff if a resident or relative wishes to make a complaint. The Home keeps a copy of complaint information. Induction training includes training for staff regarding the complaints procedure and the action to take if a complaint is received. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 16 Suggestions forms are available by the entrance door for visitors or residents to complete. The home’s policy for responding to allegations of abuse is available with clear guidance for staff to follow. Records were available to demonstrate that staff have attended training in the protection of vulnerable adults. No adult protection issues have been raised at this Home. All staff have criminal records bureau checks undertaken. Resident’s finances are kept in a satisfactory manner. It was recommended at the last inspection that the whistle blowing procedure be amended to include contact details for those people mentioned in the policy or it should cross-reference where these contact details can be found. The manager confirmed that this had been done but was unable at the time to find the amended policy. The whistle blowing policy should be available with contact details included. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 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 and 26 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the home. The standard of décor and furnishings is good with evidence of ongoing improvement and maintenance. The home presents as a comfortable and safe environment for those living there and visiting. EVIDENCE: A tour of the Home was undertaken. A number of bedrooms and all communal areas were reviewed at this inspection. All furnishings seen were in a good state of repair. No unpleasant odours were noted and all areas were clean and hygienic. Residents appeared at ease in their surroundings and wandered freely around the Home and into the gardens. Work is still continuing on colour zoning bedroom areas. Bathroom doors are all painted blue and have pictorial and written signage. Toilet doors including en suite toilet doors are painted yellow. This aids residents with recognition of certain areas. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 18 Residents whose bedrooms have recently been decorated have chosen the colour for their paint. Bedrooms had been personalised with pictures and ornaments. Rooms seen were light and airy. Communal facilities consist of a conservatory, a dining room and two lounges, all were clean, hygienic and furnishings were in a good state of repair. Brightly coloured cushions and throws provide visual stimulation. The Home is well maintained. Staff were observed wearing disposable gloves and aprons whilst providing personal care to residents and were following the Home’s infection control procedures. All equipment in the laundry was in good working order. Residents reported that laundry staff provide an effective service. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 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 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 and 30 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the home. The number and skill mix of the staff group is sufficient to meet the current needs of the residents. A large number of staff have undertaken National Vocation Qualifications. Good opportunities are available for staff training and development, this ensures that residents are being cared for by qualified staff. The recruitment policy and procedure for this home ensures that service users are supported and protected from harm by the people caring for them. EVIDENCE: The Home is staffed by qualified registered general nurses, staff from overseas undertaking adaptation training and care staff. Adaptation staff work two days per week in a supernumerary capacity completing college work, they are able to work care shifts at the Home if they wish. Duty rotas show that currently the adaptation nurses are working part time shifts at Sebright House. Staffing rotas demonstrate that adequate numbers and skill mix of staff are on duty on a daily basis. Rotas seen do not record the hours that the manager works, these hours must be recorded to demonstrate that sufficient management hours are provided. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 20 On the day of the inspection the Home was adequately staffed. The manager was on duty along with two registered general nurses, one adaptation nurse working a care shift and seven care assistants. Two catering staff, two domestic and two laundry assistants were also on duty. The Home is currently recruiting a new cook. There are no other staff vacancies. A large percentage of care staff have obtained NVQ level 2, some staff have also undertaken NVQ level 3. The Home has in excess of 50 of care staff qualified at NVQ level 2 in care and easily meets this target. All staff undertake the Home’s induction training, this includes the overseas nurses undertaking adaptation training. Copies of partially completed induction records were reviewed. Staff watch videos and have to answer questions as well as receiving copies of relevant policies and procedures and working in a supernumerary capacity for a week. The manager confirmed that the induction training is in line with Skills for Care requirements. Five staff files were reviewed, all contained relevant information as required by standards. Criminal records bureau (CRB) checks are undertaken on all staff. One CRB check had been undertaken at the staff member’s previous place of work. This was another Home owned by the owners of Sebright House. This is not acceptable. The staff member’s current employer must undertake CRB checks. The manager confirmed that this would be addressed immediately. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 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 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 and 38 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the home. 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. Procedures are in place to manage residents’ monies and valuables so their interests are safeguarded. The policies and procedures for safe working practice in this home ensure that resident’s health, safety and welfare is being promoted and protected. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 22 EVIDENCE: The management of this Home is effective, staff work well as a team and issues identified are addressed in a timely manner. The manager has a clear vision of the future of Sebright House and is working hard to make changes to the environment, documentation and staff training to ensure that the environment and care provided meets the needs of those residing at the Home. The manager has an in-depth knowledge of the needs of those with dementia and is continuing her education to gain further knowledge. Dementia care mapping has recently been undertaken and the manager confirmed that she was happy with the results. The findings of the dementia care mapping were recorded and a copy sent to each relative. The manager intends to undertake dementia care mapping on an annual basis. The manager was seen to have a good relationship with staff, residents and visitors to the Home. Visitors spoken to said that the manager is approachable, friendly and works hard. The Home has effective quality assurance systems in place. A satisfaction questionnaire is sent to relatives on an annual basis. The results of the last survey were very positive. Relatives meetings are held on a three monthly basis. Various audits are undertaken such as a kitchen and laundry audit and meetings with the staff. A monthly care plan audit, health and safety, medication and an accident audit are undertaken. Policies and procedures are reviewed on a regular basis and the date of review is recorded on the policy. Residents’ personal monies are held for safekeeping in the home if the requested. Residents have an individually named plastic wallet that contains their funds. Monies are stored appropriately. Receipts are available for all transactions and accurate records are kept of income and expenditure. Personal monies of two residents were audited and found to balance with written records. Records were examined to establish safe working practices. These included servicing documentation for electrical equipment, gas and fire extinguishers. Fire records are up to date. A Fire Safety Officer and an Environmental Health Officer undertook a visit; no issues for action were identified. Monthly records of hot water outlet temperatures are maintained. The Home has a legionella test certificate dated May 2006, water samples have recently been sent off for testing and the Home are awaiting the results. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 23 The Home’s training matrix shows that there are some staff that require moving and handling training updates. The manager confirmed that two staff have recently trained as moving and handling trainers and will now undertake moving and handling updates with all staff. Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 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 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. Risk assessments must be fully completed and reviewed according to the level of risk identified. Care Plans must be reviewed on a monthly basis. 3 OP9 13(2) The registered manager must make arrangements for recording, handling and safe administration of medications received into the care home. The concerns identified in this report on the management and administration of medications must be addressed within a risk management framework 16/09/06 Timescale for action 21/11/06 2. OP7 17 Sch3 30/10/06 Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 26 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 OP7 Good Practice Recommendations The manager must ensure that all charts regarding toileting, personal and oral hygiene are completed by staff as required 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. Moving and handling training should be provided urgently for those staff that require update training. 2. OP18 3. OP38 Sebright House DS0000041396.V306931.R01.S.doc Version 5.2 Page 27 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.V306931.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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