Inspection on 11/01/06 for Sedbury Park Care Centre

This inspection was carried out on 11th January 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

Sedbury Park Care Centre 04/07/07

Sedbury Park Care Centre 27/06/06

Sedbury Park Care Centre 23/08/05

Sedbury Park Care Centre 01/02/05

Sedbury Park Care Centre 10/08/04

Sedbury Park Care Centre 10/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Sedbury Park Care Centre Sedbury Park Sedbury Nr Chepstow Monmouthshire NP16 7EY Lead Inspector Mrs Janet Griffiths Unannounced Inspection 11th January 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 Sedbury Park Care Centre DS0000016574.V276337.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. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sedbury Park Care Centre Address Sedbury Park Sedbury Nr Chepstow Monmouthshire NP16 7EY 01291 627127 01291 622327 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) Ashbourne Homes Limited Mrs Lesley Wadsworth Care Home 105 Category(ies) of Dementia (23), Learning disability over 65 years registration, with number of age (5), Old age, not falling within any other of places category (82) Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate 3 Named Service Users with Learning difficulties under 65 years of age 23rd August 2005 Date of last inspection Brief Description of the Service: Sedbury Park Care Centre is a large 19th century Victorian house that stands in its own grounds overlooking the Severn estuary. The care centre consists of three units: the Main House, registered for nursing care, Wye House registered for elderly residential care and The Marlings registered for residential elderly mentally ill. Although the home is registered for 105 beds in total, only 83 beds are operational, as the Company aims to offer single room accommodation only, unless a couple express the wish to share. All rooms offer en suite facilities and there are assisted bathrooms and toilets on all levels. The main catering and laundry facilities are located in Main House. Both Wye and Main House have shaft lifts and there are spacious lounges, a library, a ballroom and activities area (for the use of all the homes service users) and a dining room in Main and a lounge/diner and smaller lounge in Wye. The Marlings has two stair lifts, a lounge and dining area. There are extensive grounds around the home, which the more ambulant residents can access and some paths for wheelchair users. There is a sheltered courtyard and sitting area in the Main House and an enclosed garden for the residents in the Marlins. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Three inspectors carried out this unannounced inspection over seven hours of one day in January 2006. Sedbury Park has recently been taken over by Southern Cross together with all Ashbourne Homes and there was a meeting at Sedbury Park, of the senior management from these two organisations on the day of inspection. The acting manager attended this meeting for most of the day but both she and the Regional Operations Director from Southern Cross spent time with the inspectors during the day and the acting Manager received the inspectors’ de-briefing. One inspector went to each unit to look at the environment, speak to staff, residents and relatives and to examine a selection of records. Fourteen national Minimum Standards for Older People were assessed o this occasion: seven were met, six almost met and one not met. Four requirements were outstanding from the last inspection. What the service does well: Staff throughout the home, were observed maintaining good standards of care for the residents. Both residents and relatives spoken with confirmed this. All of the staff spoken with, including cleaners, the housekeeper, laundry staff, maintenance and catering staff showed a clear understanding of the needs of the residents they were caring for and how to meet those needs. Residents enjoy a very comfortable environment, with a variety of communal rooms to include large comfortable lounges and dining rooms, a library and ballroom where some entertainments are held, large gardens and smaller secure areas out of doors. The home has good induction and training programmes available for the staff. MARLINGS The unit continues to undertake and receive full assessments when service users’ are referred for care. The care team make every effort to keep a calm and stress free environment for confused people. When service users’ are admitted to hospital the unit’s manager and a qualified nurse from the Home undertake further assessments at the hospital before readmission is considered to the Marlings. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Recruitment procedures are still not fully robust and could jeopardise the safety of the residents. Damage to corridors and doors must be addressed and a means to limit further damage found. MARLINGS: Needs to record temperature levels in the medication room so that an audit can be carried out of acceptable heat in this room for storage of tablets and other medications. When carers’ record incidents in daily and night- time records, ensure outcomes and actions to minimise risks are recorded in the care plan and assessment forms. To refurbish the kitchenette (as required in previous inspections). Inspectors were advised that money would now be available to improve this facility for staff and service users. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 7 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. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 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 the following standard(s): 3 Arrangements are in place to ensure that each prospective resident is fully assessed prior to admission and on admission, to ensure that all their particular care needs may be met in the Home. EVIDENCE: Main House: Four care files were examined to include two residents who had been admitted since the last inspection. All had pre-admission and admission assessments completed. One resident spoken with had settled extremely well and had recently moved to a larger room with good views of the gardens and was very happy with the standards of care received, stating that it felt’ just like home’. He’d also told the staff this, which they were very pleased about. His only problem was that he lost his way going down to the lounge and dining room at times, but he was overcoming this problem. A second new resident, a retired farmer, was less settled finding it hard to stay indoors for long periods of time after working outside for years but he also said he was gradually settling. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 10 A third was under review and had been seen by the psychiatric team because her mental health needs were becoming more prevalent than the physical needs she had on admission. Staff are very aware that as needs change, residents need to be referred for reassessment and transferred elsewhere if they feel they can no longer meet their needs. The Marlings: Four care files were examined. One included a service user who had been admitted during the past 6 months. The file had information about the assessed needs from the Community Psychiatric Nurse referring the service user and the unit’s manager through the Home’s assessment model. Remaining files looked at had comprehensive information about the service users’ personal preferences, choices and family history. The assessments also had details of potential risks to support the care plan. Wye House: The Unit Manager confirmed that she normally undertakes an assessment of every prospective resident including those being admitted for respite care; a copy of the completed documentation was seen in one lady’s care file. A very comprehensive assessment form is used although this was not fully completed in the example seen on this occasion. As a result this person’s pressure relief needs were not identified prior to admission to the home. Nevertheless, the necessary equipment was provided very swiftly after her arrival at Wye House. It was reported that there are three residents awaiting beds in alternative accommodation, as Wye House is no longer able to meet their deteriorating health needs. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 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 the following standard(s): 7 ,8, 9 The health needs of the residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication procedures in this home are well managed promoting good health. EVIDENCE: Main House: The records of four residents were examined on this occasion. All had assessments and a variety of risk assessments. If there were risks identified this was used to underpin a care plan. Problems were identified and care planned which reflected the current needs of the service users. For example where someone had a wound to be treated, wound care charts were in place to monitor the healing process. It was reported that the pressure sores of two service users had completely healed. Pressure relieving equipment and turn charts were also seen in place, as were fluid charts. A mixture of core and hand written care plans were in use. Care planning varied; in some cases it was detailed and in others less so, but all showed evidence of review although none were seen to be reviewed with residents or their relatives. It was reported that relatives have been invited to participate but few had responded. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 12 However, there are a number of service users in Main House who would be able to participate in their own reviews and sign them. This should be pursued. The care planning system is under review and a new system may be introduced shortly. Records also confirmed that where required, referrals were made to other disciplines such as the continence advisor, community psychiatric nurses, chiropodist, dentist and optician. Doctor’s visits were also recorded. Medications were not checked on this occasion, as the CSCI pharmacy inspector was due to visit shortly. The Marlings: The records of five service users were examined on this occasion. One had been admitted to the unit recently and the remaining service users had been residing in the unit for a few years, but had lately experienced accidents. There were assessments and care plans set out in the unit’s format. This model has a checklist on the left hand side outlining needs and risks, with written details on the right hand side for care input and minimising risks. All files had indicators that service users’ are reviewed monthly and changes in care needs are identified where required, but although invited, few relatives had become involved in this process to date. Records of accidents and incidents affecting the service users’ case tracked were seen. Each time an accident occurred a record had been made in the unit’s record of Incidents and Accidents in accordance with health and safety requirements. In one case, the local Health and Safety officer had telephoned the unit and provided a letter outlining that that department did not require further action to be taken. Daily records showed details of accidents were clearly written. The risks to two service users had been minimised by the use of sensory mats, which activate the emergency call system whenever the service users’ moved out of bed. The inspector did not note on this occasion if this action had been recorded in the risk assessments or “change in circumstances” section in care plans. Although the accidents were unfortunate, it appeared that sufficient staff were around at the time and service users had not be left at risk. It was seen in the records of one service user that a few days previously they had been displaying stress overnight and banging their bedroom door, later banging their head on the door. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 13 This was clearly recorded but there were no indicators that staff had taken action to minimise the risk to the service user and the care plan had no information to indicate action had been taken, only that it had been observed. For example there was nothing to show a risk assessment either through the unit’s strategies or further assessment by the Community Psychiatric Nurse. Requirements related to medications from the last inspection were followed up. Only one oxygen bottle is stored in the cupboard in the medication room and remaining canisters are stored separately outside. The unit has taken steps to improve conditions in the medication room. During the last inspection the room was too hot for the safe storage of drugs. At the time of this inspection, the room had circulatory fan, which was not in use and a thermometer showing a temperature of 22 degrees centigrade. It is Recommended that a record of temperatures be kept to audit safe heat in the medication room. MAR sheets were not checked on this occasion. Wye House: The Home develops a care plan for each resident based on an assessment of care needs; four examples were read in detail on this visit. In each case, specific care plans had been prepared to address the identified needs; these were clearly written and normally contained the information required for the carers to provide appropriate care. There were examples, however, where this documentation had not been reviewed in a timely fashion and did not reflect the resident’s current condition. Appropriate risk assessments were also completed and usually reviewed, as required. Informative daily records were completed for each person. Clear details about the residents were also conveyed to the care staff at the lunchtime handover meeting. Medications are ordered and stored correctly. The controlled drug cupboard has now been repositioned so that it is secured correctly. The medication records relating to the four selected residents were read in detail. It appeared that drugs had been administered as prescribed for each person. There was one example where the person making the record had signed handwritten entries on the drug administration sheets but these had not been witnessed. Only one person required the administration of controlled drugs at the current time. These records had not been completed correctly. This issue is now being addressed. The Unit Manager was only able to find a copy of the British National Formulary, dated 2004. It is recommended that a recent issue be obtained for reference use. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 14 There was one person who was seriously ill on this occasion. The inspector saw evidence in her records and in other case files which had been selected as part of a case tracking exercise, that service user’s/advocate’s wishes about arrangements following death are clearly documented. The inspector saw that this person was receiving full and appropriate personal care. She appeared relaxed, comfortable and pain free. The lady’s relatives were kept fully informed of her deteriorating condition. Medical assistance was requested and provided as required. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Residents can experience a stimulating and varied life at the home with visitors encouraged, various one to one and group activities made available and entertainments and occasional outings organised. EVIDENCE: Main House: Although a monthly programme of activities was posted in the main reception, with one activities organiser off sick the other was engaged elsewhere on the morning of the inspection. The notice indicated that for the month of January activities would include bingo, the mobile shop, manicures, a film show and baking a chocolate cake. Some of the residents spoken with do join some of the activities and others recounted what they had done over Christmas, visiting relatives, the party in the home and the entertainments organised. A large pile of newspapers are purchased daily and a number of residents were observed enjoying these during the day. Others were either in one of the lounges or their own rooms watching television or listening to music. Several said how they enjoyed walking around the grounds when the weather is warmer. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 16 The Marlings: plans activities for in-house and other entertainment in written and pictorial form ensuring service users have a variety of experiences in their daily lives to include contact with peers in the main home for social interaction. During the inspection, a number of service users were taking part in music and movement. The Home has two activities persons and activities across the Home are advertised in the unit. Daily records of service users’, whose records were closely checked, showed that activities are a regular occurrence in the unit and service users join the Main House for activities. Two relatives were interviewed and expressed that their relative was well cared for and experienced a diverse life style, which kept her occupied. The inspector was also advised by the manager that during afternoons, carers will take service users out for short walks around the grounds and at the time of inspection, one service user was helping a carer take laundry to the nearby laundry room in the Main House. Wye House: In each of the care notes seen on this visit, the inspector read a record of the resident’s background and personal interests. A close relative normally provides these details. Where possible, some of residents are able to pursue these interests while living in the Home. One person particularly enjoys walking in the attractive enclosed garden. Most people had numerous photographs of close family or friends and many had their own radio and television for their private use. Although there was a programme of planned activities displayed on the notice board, nothing was arranged on this day. Nevertheless, residents who were questioned spoke positively about all the festivities over the Christmas holidays. One person also enjoyed the bingo sessions, which are arranged at the home Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The organisation and unit have a clear complaints procedure. EVIDENCE: The Marlings: Relatives interviewed expressed a concern (not complaint) that their relative’s clothing was often mixed up with other service user’s clothing. It was also the case that at times their relative wore other service user’s clothes, which had been left in her dresser. This was discussed with the manager and the inspector was advised the matter would be addressed. Wye House: The clearly written Complaints Procedure is displayed on the notice board. The Manager is reminded that the Commission for Social Care Inspection has been responsible for regulating the home since April 2004 and this must be amended on the procedure. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Residents live in a comfortable and homely environment. The improvements made to the décor and maintenance, greatly benefit the residents but there continue to be a few outstanding requirements, which need to be addressed. Improvements made to the décor at the Marlings benefit the residents but there are other outstanding requirements. EVIDENCE: Main House: A number of rooms and the communal areas of the building were all seen and found to be clean, and decorated and furnished to a high standard. A rolling programme of redecoration and maintenance continues. Two bathrooms are currently out of use for refurbishment and the inspectors were informed that funding for this has been granted. The home still has a number of other assisted bathrooms in use and this did not appear to present any problems. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 19 The only areas noted to still require attention are the worn corridors and lower doors, which have been damaged through the passage of wheelchairs and hoists. It was reported that additional maintenance input would now be available for areas such as corridors and communal rooms. Many of the rooms visited were personalised with items of furniture, pictures and ornaments, which created a cosy and ‘homely’ environment. The Marlings: Bedrooms 17 and 20 still require attention to meet legislation. This was required at the last inspection in September 2005. Room 17 requires replacement to wallpaper in the en-suite facility. Room 20 requires the bath replaced due to ingrained staining. Attention to these rooms must be carried out in accordance with Regulations 13-(3) and 23-(2)(c). A carpet piece is missing to the stair “riser” at the foot of stairway at far end of unit. This requires attention under Regulation 23-(2)(b). The kitchenette has not been refurbished as yet (as required in previous inspections). Inspectors were advised that money would now be available to improve this facility for staff and service users. A second bathroom on the ground floor has been refurbished and inspectors appreciate the work undertaken. The unit was generally clean, free from unpleasant odours and has benefited from continued decoration. A patio facing the front right hand corner facing the unit is being improved to make it safe for service users to walk in a secure setting. Wye House: The unit appeared tidy, warm and reasonably clean. Although a few isolated areas now required decorative attention, it was clear from the records that the maintenance technician, or the gardener, who also takes responsibility for some of the work address any identified maintenance issues promptly. The bedrooms used by each of the residents selected as part of the case tracking exercise were seen on this visit. All were light and airy and furnished in a style to meet the residents’ needs. Each person had the benefit of en suite facilities. The rooms visited showed considerable evidence of personalisation, often with small pieces of residents’ own furniture and other treasured possessions. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 Main House: Rotas indicated that there was sufficient staff to meet the needs of service users in the Unit. The Marlings: Rotas ensure qualified and experience staff are on duty with carers and are trained in specific care, some having NVQ qualifications The procedures for the recruitment of staff are still not robust and do not provide the safeguards to offer protection to the service users. EVIDENCE: Main House: There were two qualified nurses and five care staff on-duty during the morning of inspection to care for 28 residents who require nursing care. One of the qualified nurses was working with the care staff on this occasion, the second being responsible for medications, care plans and any dressings and other treatments required. The staff generally work in pairs across several levels of the building and were observed going about their work in a quiet, unrushed and efficient manner and appeared to be meeting the needs of the residents they were attending. The residents spoken with confirmed this and it was observed that whenever anyone sought attention this was given promptly. Mealtimes still appear to be the most difficult times as there are a large number who require assistance or supervision and not all are in the dining area. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 21 The catering manager did say that at least three days a week a chef does serve the meals in Main House, which helps the staff. Ideally, this practice should continue on a daily basis and would free up staff to help the residents. The Marlings: The duty rota available for inspection showed there is an increase in staff numbers during the morning and afternoon shifts. The manager advised the inspector that the organisation allows a 10 increase in the Home’s budget to have four or five carers on in the morning and when fully staffed, one of the carer’s starts duty at 07:00 a.m. to assist the overnight care staff. During the afternoon there are four on duty including the manager or deputy and overnight there are two carers carrying out awake duties. Training for carers in Marlings was not checked on this occasion. Wye House: There were 28 residents accommodated in Wye House on this day; it was anticipated that the remaining bed would be filled shortly. Many of the residents required high dependency care. Observation of the duty rota showed that there were normally four carers on duty each morning although, where possible, this is increased to five. Three carers are on duty each evening and two people overnight. Although the staff were clearly busy, it was observed that residents were cared for in a sensitive patient fashion. The daughter of one resident was most appreciative of the time devoted to her Mother’s needs. Recruitment: The records of six staff appointed since the last inspection were examined on this occasion. Although some of the requirements from the last inspection have been addressed, there are still gaps in the recruitment process, which should have been noted and pursued prior to staff being interviewed and appointed. These are as follows: 1. Although all files had copies of documents such as birth, marriage certificates and passports and driving licences, any photographs within these are poorly photocopied and could not easily be used to identify staff. 2. One application form had a blank career history. All must contain a full career history and where there are any gaps these must be explored, recorded and signed. The majority had a full career history, some with CV’s provided. 3. All had CRB and POVA checks, with the exception of one newly appointed carer, who had a POVA First but who’s CRB was not yet back and was working unsupervised; Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 22 the second, a qualified nurse, had apparently had a CRB completed as the disclosure number was written on a piece of paper in the records, but it also indicated that this had been shredded the same day it had arrived. CRB disclosures must be kept until seen by CSCI at the next inspection. 4. One file had one written character reference and a verbal reference from the last employer; a second had one reference given on behalf of the two named referees from the last employment; a third had only one reference. These gaps in employment records must be more robust to ensure that all necessary checks and documentation is in place prior to appointment and to ensure the safety of the residents. This requirement is outstanding from the last inspection. All had records of interviews, medical questionnaires and confirmation of mental and physical fitness, copies of relevant certificates and full records of induction and mandatory training given. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,38 The home has systems for resident consultation to indicate that their views are sought but these needs further development to ensure views given are acted upon and published. Residents’ financial interests are safeguarded. The health, safety and welfare of both residents and staff are promoted and protected. EVIDENCE: The Marlings: The manager is attempting to elicit the views of relatives and advocates for service users through meetings. It is hoped that their input can improve care plans and risk assessments. There are in-house audits carried out by the Home to assist with its statistics. However, the inspector advised that for the Home and unit at the Marlings to fully meet criteria in Standard 33.1, 33.4 and 33.7; the unit share input for all stakeholders in accordance with Regulation 24(1)-(4) and input this for the Home’s main Quality Assurance report for the CSCI. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 24 Wye House: The General Manager audited care plans in Wye House earlier in the month; the staff are now addressing any identified issues arising from this process. The supplying pharmacist audits the medications annually. There has been no written quality improvement report produced for the home in recent months. Staff in Wye house do not look after money for any of the residents accommodated there. There appears to be a good focus on Health and Safety in this home. Staff receive training on these issues and the dedicated notice board provides information on these topics. Ashbourne carried out a number of in-house audits by collecting data such as numbers of pressure sores, falls, deaths etc, on a monthly basis. Environmental audits and others mentioned above were also completed. It is anticipated that Southern Cross will continue this quality assurance programme and it was reported that a satisfaction survey would be circulated shortly. The home holds personal money securely for a number of residents at either their families or their own request. Individual records of each resident’s financial transactions are held, together with any receipts collected. These were seen. A copy of these records can be provided for the resident/ their family on request. The home is only able to hold a certain amount of money, after which they either encourage families to bank this money or with their consent it is banked in a separate interest free residents account, until an individual requires some more. Records seen and observations made during the inspection confirmed that regular servicing and maintenance of equipment is carried out. Fire alarms were tested during the inspection. Work was also being carried out to modify the boiler compressor. Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 26 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 14 Requirement Timescale for action 28/02/06 2. OP7 15 3. OP16 22 4. OP19 23 The registered person shall not provide accommodation to a service user at the care home, unless the needs of the service user have been fully assessed and the home has ensured that they can meet that persons needs. Ensure that care plans reflect the 28/02/06 current needs of residents and that they are reviewed regularly with the resident/their representative where possible (Timescale of 30/9/05 not met in full). The copy of the complaints 28/02/06 procedure shall include the name, address and telephone number if the Commission for Social Care Inspection. Repair damaged corridor walls 31/07/06 and doors, Main house; Redecorate room 17, replace bath (timescale given at last inspection not met) and replace carpeting in The Marlings Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 27 5. OP29 19 Ensure that all documentation required by Schedules 2 and 4 of the Care Standards Regulations are in place within staff files (timescale of 10/10/04 and 1/3/05 not met). The registered person shall ensure that any unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. 28/02/06 6 OP38 13 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Monitor the temperature of the room where medication is stored to ensure that correct temperatures are maintained; Renew British National Formulary (BNF) at least annually; Handwritten entries on MAR charts to be signed and countersigned as correct by two authorised staff. Risk assessments to be carried out for all safe working practice topics and significant findings are to be recorded. 2. OP38 Sedbury Park Care Centre DS0000016574.V276337.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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