Inspection on 27/06/06 for Sedbury Park Care Centre

This inspection was carried out on 27th June 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 11/01/06

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 Sharon Hayward-Wright Key Unannounced Inspection 06:45 27 and 28th June 2006 th 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.V291170.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.V291170.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.V291170.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 11th January 2006 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 service users 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 service users in the Marlings. Information relating to the home is on display in the main entrance, this includes copies of the homes Statement of Purpose and Service Users Guide and results of a recent quality assurance questionnaire. The fees for the home range from £485 to £1000 per week depending on which unit the service user is placed and their needs. Extras that are not included in the fees are hairdressing, chiropody, magazines and newspapers and toiletries. This information was provided to the Commission prior to the site visit. Sedbury Park Care Centre DS0000016574.V291170.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 inspection over two days in June 2006. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The Manager was available during the inspection as were other members of the home team. A total of 24 standards were inspected. Service users were observed and spoken to in order to ascertain their views on the care and services provided. Feedback cards were left at the home and four were returned by relatives following the inspection. The comments received from service users and relatives both at the inspection and from the feedback cards say they are very happy with the care received. All praised the staff for their kindness and helpfulness. The Manager and care staff were spoken with throughout the inspection and were helpful and co-operative. Feedback on the inspection findings was given on completion and was received in a constructive and positive way by the Manager. Two requirements had not been complied with since the last inspection. On this occasion the timescales have been extended as indicated in the requirements made. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale may lead the Commission for Social Care Inspection to consider enforcement action to secure compliance. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home has systems in place to ensure the needs of the service users are assessed prior to admission, however these systems have not always been used. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 7 Inconsistencies in care planning and risk assessments need to be improved to ensure staff have up to date information about service users. This may be due to the home changing format at the time of the inspection. The home must ensure that medication is stored at the correct temperature. Further improvements are needed to ensure that the environment provided is safe and meet the needs of service users. Funds to renovate a bathroom in the Main House are available. This work must be completed as a matter of urgency. Shortages in the numbers of domestic staff employed are impacting on the cleanliness of the environment. Training opportunities are provided for staff to improve their skills but not all staff are up to date with training. 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.V291170.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.V291170.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&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has systems in place to ensure the needs of the service users are assessed prior to admission, however inconsistencies with practice in the three units have meant that these systems have not always been followed. EVIDENCE: Wye House: The care plans for two service users who had recently been admitted were examined. An assessment was completed for one service user but there was no evidence of an assessment for the second service user. One service user said that their son had visited the home before making a decision about whether they wished to move into the home. Care plans were in place for both service users. The Unit Manager must make sure that the assessment of needs is completed for all new admissions and is available for inspection. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 10 Main House The care plans of three recently admitted service users was examined. These assessments took place in hospital prior to the service users being admitted and was continued once admitted. The Care Manager assists with the assessments to ensure the home could meet their needs. The Marlings The care file of a recently admitted service user was examined, this service user had an assessment of needs undertaken and pre admission care plans formulated. The ‘client’ admission information was not signed therefore it is difficult to establish if the staff member completing the assessment has the necessary skills and knowledge. The Manager described the admission procedure to one of the inspectors. Herself and the Unit Manager assess prospective service users. The Care Supervisor is able to assess prospective service users alone. A brochure is sent to them and they are invited to visit the home with their family/representative. Following the assessment and the decision made whether the home can meet the needs of the service users the home is not writing to the service user to confirm they can meet their needs as required by Regulation 14 of the Care Homes Regulations. Each room on the Main House and Wye has a copy of the homes Statement of Purpose and Service Users Guide except for The Marlings, however one is available in the unit if requested by visitors. This home does not provide intermediate care. Sedbury Park Care Centre DS0000016574.V291170.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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning system provides staff with the majority of the information they need to satisfactorily meet service users’ health and personal needs; fuller recording in some cases would further improve this, as well as consistency with reviewing of assessments of needs and risk assessments. Improvements are evident in the management of medicines in the home. However there are still issues for attention that need addressing to protect the safety and wellbeing of service users. EVIDENCE: Wye House The care of three service users was case tracked. As with the other units staff are introducing new style service user plans. Staff indicated that they have had training in care planning but were unsure about other aspects of the plans including risk assessment. This was evident from the plans examined. There were sections of the plans, which had not been completed, and not all records Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 12 had been signed or dated. Again as mentioned in the standards Choice of Home that if these documents are not signed there is no evidence to prove that a competent and skilled person completed these records. The care planning sections which were completed are being monitored and evaluated at least once a month. It was evident that where necessary monitoring charts are being completed for service users at risk of developing pressure sores and their continence and nutritional needs. One care plan identified that a service user must have a falls risk assessment, which needs to be monitored, and evaluated monthly. This was not in place. The deputy manager indicated that this would be completed immediately. The healthcare needs of service users living at Wye House are clearly identified in their plans and staff spoken with have a good understanding of their needs. Daily records confirm how and when their identified needs are met. Records of appointments with a range of healthcare professionals are also maintained. Main House Three service users had their care examined in detail and it was evident that the social, personal and health needs were documented and individualised. For instance it was noted that one of the service users would benefit from regular walking exercise to enhance his mobility. As the process of changing documentation is not complete it was noticed that not all the information at this time had been transferred to the new format, this could have implications for planning and reviewing of care records. In addition, the risk and dependency assessment for each service user that was being case tracked demonstrated that these assessments were consistent; in that identified risk was recorded well with clear guidance for other members of staff to follow. The dependency assessment is based on how much nursing time is allocated per client and this too provided satisfactory recording. During a random selection of care files, a service user who was on bed rest had evidence that they were having their position changed every four hours to maintain pressure area care. The care manager had said that all service users have access to other healthcare professionals such, as GPs. GP visits occur regularly on a Tuesday. If there were an urgency issue this would be dealt with accordingly. The process the home follows is based on a list, which is supplied to the GP, which is sent on a Tuesday morning at the start of the surgery session in readiness for the GPs visit to the home. This process appears effective. The Marlings The care of two service users was examined in detail. Both an assessment of need, however one of the assessments was not up to date with their continence need as a member of staff spoken with said they need more assistance than what the assessment indicated. This must be updated. All care plans were personalised to each service user and contained sufficient Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 13 detail to manage each assessed need. Both service users had risk assessment scores for pressure areas, moving and handling, falls, nutrition and dependency. An assessment for continence was also seen. One of these service users has had a number falls and evidence was seen of auditing and a plan put in place to try to minimise the risk to this service user. This is excellent and the unit has noticed a big reduction in the falls since they put this plan in place. Consideration should be given to recording this information in the service users care file as it was contained in the homes quality assurance records. This service user had a written risk assessment for falls but it was on the old format used and was yet to be transferred on to their new format. Both service users had fluid charts maintained daily and were weighed on a monthly basis, however the inspector could only find evidence that this had been done since the transfer of documentation, but the unit Manager said this has always been the case. In one-service users file evidence was seen of the unit inviting the family to attend a review of this service users care. The same system for accessing the local GP applies to this unit and they visit every week on Tuesday the same as the Main House unit. A list is maintained of health professional visits. During the inspection of the Main House it was evident that the issue of resuscitation is not discussed with the service user or their family and the Manager said they have no clear guidance on how to manage this. Urgent consideration should be given to devising a protocol on how this will be managed and to ensure the staff are trained and the appropriate equipment is available. Care plans identify the wishes of service users in respect of resuscitation on Wye unit. A care plan for ‘dying’ was seen on the Marlings unit. Care plans identify the wishes of service users in respect of resuscitation on Wye unit. Medication, Wye Unit Medication administration systems at Wye House are mostly satisfactory. A drug round was observed and records were examined. All liquids and most of the creams were labelled with the date of opening. One cream was not marked with the date of opening. A new copy of the British National Formula has been obtained. Controlled drugs are not being used. Main House The home’s medication records were documented well. Records of receipt and disposal of unwanted medication were clear and accurate creating a satisfactory medication audit trail. Recent photographs of each client within the home were available and attached to individual MAR sheets. The administration of medication was satisfactory and no gaps on the client’s Mar sheet were detected. Controlled drugs were safely stored and were additionally accurate and correctly recorded. This was evident during a mock controlled drug check of service users who were on controlled drugs. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 14 The unit has met the requirements issued at the last inspection, with the medications being stored in a storage medicine room. However, the documents show that the temperatures were inconsistent and at times higher than the recognised temperature that the medications should be stored at, which is particularly important, as some of the peg feeds are sensitive to temperature changes. This must be addressed as a matter of urgency. The Marlings The morning medication round was observed. Only senior staff administer medication after receiving training and observed practise. A trolley is used for this purpose; however as there is no lift to the next floor the trolley cannot be used upstairs. The Deputy Manager for this unit said that nearly all of the service users are downstairs at medication times, however the home must undertake a risk assessment for when service users need to have their medication administered upstairs to ensure the safety of the medication. The unit may have to consider purchasing a lockable facility for this purpose. Night sedation is also administered whilst service users are downstairs, again this practice must be risk assessed for each service user to ensure they are not at risk as they climb up the stairs after taking it. All medication is stored in the trolley and this includes creams and eye medication that does not have to be stored in the fridge. Creams are stored next to eye medication and this could potentially be an infection control risk and storage must be reviewed. One solution that the unit is looking at is that lockable facilities are provided in service users rooms so the creams can be stored in there with a record sheet for staff to sign once they have been applied. Records were seen for medication received, administered and for returns of medication. The Medication Administration Record (MAR) sheets were examined and no gaps in the recording were seen. The home has a front sheet for each service user that includes a photograph and a list of allergies. The room used for storing medication was seen and room temperatures are taken and recorded as well as fridge temperatures. Drug reference sheets and an up to date drug reference book were seen along with a staff signature and initials list. One service user is receiving oxygen therapy and the appropriate signage was on display. A care plan for ‘prn’ medication was seen and this is stored with service users MAR sheets. The unit has a homely remedy list signed by the local GP that is dated 2003, consideration should be given to obtaining an up date list. Staff were observed treating service users with respect and sensitivity during the visit. They referred to service users by name and responded to their personal needs discreetly. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 15 Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A stimulating and varied programme of events is in place, which meet the social and recreational interests of service users. The religious needs of service users are recognised and provided for. Further thought needs to be given to how the cultural needs of service users can be met. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: Two activities co-ordinators are employed to organise a range of social and leisure activities. A monthly diary is produced outlining plans for the month. June’s diary included regular activities such as skittles, bingo and afternoon teas as well as music and movement and beauty treatments. The coordinators said that they have arranged two trips out in July and that as part of the Chepstow Festival a brass band and theatre company are performing in the grounds of the home. On the day of the visits service users had access to a hairdresser and the opportunity to take part in afternoon tea in the library in the Main House. Musical movement sessions were held in each unit and an impromptu sing Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 17 along took place in Wye House. Newspapers are delivered daily and service users were observed helping staff to deliver these. Service users in the Main House and Wye House said that they enjoy the activities, which are arranged. Some said that they like to go for walks in the grounds. The Marlings On the first day of the visit no structured activities were taking place on this unit, however service users were enjoying reading the daily newspapers. It was evident that the hairdresser had visited the previous day. One service user said how much she enjoyed feeding the birds and service users can go out into the secure garden area. After lunch a number of service users were seated in the other lounge and appeared to be enjoying sat talking and having an afternoon nap. On the second day of the visit a number of service users were seen at the activities taking place in the Main House. Visitors were observed during their visits. Some saw relatives in their rooms; others joined them in activities or sat with them in the lounges or library. The spiritual needs of service users are addressed by regular visits to the home by a Roman Catholic Priest and a Vicar. The activities co-ordinators confirmed that ‘Churches Together’ also visit the home at least twice a year to hold services. Meals are cooked in the main kitchen next to Wye House. They are then delivered to the Main House and The Marlings. A roll over menu is in operation repeating the menu over a four-week period. Alternatives are provided to each main meal. Staff ask service users for their preferences and record these on menu sheets. At present these are the only record of meals provided for service users. These must be kept in ‘sufficient detail that any person inspecting the record would be able to determine whether the diet is satisfactory’. Nutritional records are also kept. Examination of the kitchen confirmed that a range of fresh ingredients is used including fresh vegetables, fruit and meat. A lunch of Roast Beef and vegetables was sampled during one of the visits. Most people said they are happy with the quality of the food. A few people said that they were not happy with the meals offered and one person felt that their cultural needs were not recognised. However despite being aware of the complaints procedure they had not expressed these feelings to the management of the home. Breakfast, lunch and afternoon tea were observed during the visits. Service users also had access to drinks and snacks in between meals. Mealtimes were unrushed, staff support being provided where needed. Some people chose to eat in their rooms. Soft diets were provided for service users at the Main Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 18 House and Wye House. These meals looked appetising and ingredients were liquidised separately. The Marlings Service users were offered a choice at both breakfast and lunchtime meal. Three service users said how much they enjoyed the food but could not remember what they had. Service users are able to eat and drink as much as they like without any restrictions and this was evident during breakfast. The Main House Records being maintained in relation to service users’ nutrition, food and fluid intake and elimination were kept on a table in the dining room. These records must be stored securely. Wye House One of the service users said that they would like to have smoked sausages on the menu. This had been discussed with the assistant chef prior to the second visit. The inspectors joined the service users in the Main House for lunch on the second day of the visit. The meal was appetising and this was also expressed by a number of service users in the dining room. A number of service users sit at the table whilst in wheelchairs and it was noticed that the height of the table is too high and the service users had to reach along way to the table. Footrests were also not in place on at least two service users wheelchairs. Consideration should be given to providing tables at a suitable height for service users to eat their meals and footrests should be on wheelchairs. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The home has a satisfactory complaints procedure in place with evidence that views of service users and visitors are listen to and acted upon. Arrangements for protecting service users are satisfactory, however there is a possible risk that service users could be placed at risk or harm without staff receiving the appropriate training and information. EVIDENCE: The home has now adopted Southern Cross’s complaint procedure, which contains the required contact numbers and timescale. Copies of this procedure are available at different locations in the home, however the complaint procedure on Wye unit is out of date and needs altering to the new complaints procedure. Records are kept of complaints received and the action taken. Relatives and service users said that if they had a concern they would approach a member of staff on their unit or the Manager. One relative said that they feel able to approach the staff with any concerns, however they feel that the staff do not always feed back to them without them having to approach them again. The home is in the process of adopting Southern Cross policies and procedures. Staff spoken with were aware of the procedure to follow if an allegation of abuse is made and had a fair understanding of the whistle blowing Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 20 policy. One member of staff said they were not told about this policy until they asked to see a copy. The Manager said that the majority of staff have received training in adult protection, however it is imperative that all staff receive this training and are aware of the whistle blowing policy. Copies of policies and procedures are stored in the main entrance to the home. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 21 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A homely and comfortable environment is provided which will benefit from further improvements to ensure that it is safe and continues to meet the needs of service users. Additional domestic staff would significantly improve the cleanliness of the home. EVIDENCE: Main House All communal areas and individual rooms in the Main House were inspected. A rolling programme of maintenance and redecoration is in place. Southern Cross employs a maintenance person and a gardener. Parts of the house on the ground floor have been redecorated but other areas are in need of Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 22 attention. On the sixth floor some of the carpet is frayed and will need replacing. As rooms become vacant they are being redecorated and one has been fitted with a new en suite. Hallways throughout the house are damaged in parts and need redecorating. In addition the following issues need addressing: • • • • • • • The light pull in the downstairs toilet needs changing The walls in several toilets need washing where soap is dripping from the soap dispensers Throughout the house, taps in rooms and en suites were dripping. This need addressing The contents of the first aid boxes in the servery and kitchen need to be checked and refilled Some hazardous chemicals are being kept under the sink in the kitchen – these must be stored securely The carpet in the dining room near the servery needs cleaning or replacing – these are cleaned regularly but this carpet continues to be sticky underfoot There is one assisted bathroom on the second floor – according to staff this is the only bathroom being used. The plastic covering on the bath chair needs replacing. The manager confirmed that there is funding to upgrade one bathroom. This needs to be done urgently. Wye House Communal areas in this house are pleasantly decorated. The registered manager confirmed that the servery is due to be refurbished. A selection of rooms were examined of these the following need urgent attention: • • • • Room 9 – paper is peeling in the en suite, which is odorous. The curtains were hanging off the curtain rail Room 14 – paper is peeling in the corner of the room due to water damage Room 15 – damage to the bathroom ceiling needs investigating and repairing Room 22 – damp walls in the en suite need investigating. Paper is peeling and stained. The Marlings This unit consists of a ground floor and first floor with all communal areas downstairs. A tour of both floors took place. The first floor is separated in to two areas and separate staircases access both. Each area has six service users’ bedrooms. Following an incident involving a service user fallings down the last step of the stair case the home has added keypads with the agreement of the Fire Service. This means service users are not able to come down from their rooms without a member of staff opening the door. This environment is Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 23 not the best for supervising service users with dementia, however the home is keen to minimise any risks to service users and is looking to add pressure pads by these doorways to alert staff pagers when a service user is wanting to come down stairs. As Southern Cross have only recently taken over the running of this home they have inherited this situation, a consideration would be to fit a lift into the stairwell space to improve the situation. The overall impression of the environment is that the décor is tired in places and the cleanliness again in places is poor. The following observations were made relating to the upkeep of the environment and must be addressed: The communal room downstairs that incorporates the dining area had areas where the wallpaper had been pulled off the walls, damaged to the paintwork especially to the serving area. The door to the kitchenette area is damaged in places. A number of window catches in this room were loose. The call bell in room 10 en-suite area was tied around the light fitting so could not be used by a service user. In room 21 the radiator guard was damaged and had come away from the radiator. All extractor fans seen needed cleaning out, as they were all full of what appeared to be dust. A requirement issued at the last inspection to renew a bath in room 17 has not been addressed as all service users have a bath in the assisted bathrooms. The cleanliness of the environment as previously mentioned was in places poor and could potential put service users at risk and the following observations were made and must also be addressed: Rooms 3, 4, 5, 12 and 15 all had an odour. The new bathroom downstairs had no waste bin, soap dispenser or hand towels The light shades in the communal lounge/dining room were dirty and this was also the case for light shades in corridors. The window frames in the communal lounge/dining room, other lounge and toilet near this lounge were all dirty and had cobwebs. The dining room chair had food debris on them and stains. Cobwebs were visible in a number of rooms and these were shown to the unit manager. The kitchenette area was very dirty with visible food debris on the floor, in between the fridge and bin and on the worktops. The lid was off the bin. The window has cobwebs around it. The sink tiles had visible dirt on them and the same for the storage cupboard. The overall cleanliness of this room was poor considering service users food is prepared in this room. This was addressed on the days of the inspection, however the unit manager and home manager must ensure that food preparation areas are clean and hygienic at all times. The inspector was informed by Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 24 the last inspector that funding had been granted for this area to be upgraded, as there is damage to work surfaces and the flooring. Discussions with the housekeeper indicated that the team of domestics are not at full strength and this was evident in parts of the home. The hallway between the Main House and the kitchen is presently the dual responsibility of the kitchen staff and domestics, but this area is in need of urgent attention. Staff confirmed attendance at infection control training. Parts of the Main House were clean and tidy, although areas in the dining room required springcleaning. Staff said that personal protective equipment is provided for their use although none was evident around the home apart from the office in the Main House. The manager confirmed that staff have access to gloves and aprons but have been requested to use these discreetly and to dispose of them before leaving bathrooms, toilets and service users’ rooms. There was evidence in one service user’s room that this equipment had been used but had not been appropriately removed. This was also the case on the Marlings unit. During the inspection it was found that one service user was awaiting results from tests following treatment for MRSA. The inspectors were not informed of this to the end of the inspection. Whilst all staff including professional visitors should ensure they follow good hand washing procedures, however it is good practice to inform people. There was also no visible protective clothing in this service user’s room but the manager said as before they like to keep it discreet. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff have a good understanding of service users support needs and this was evident from the positive relationships, which have been formed between the staff and service users. Training opportunities have been provided for staff to improve their skills but there are inconsistencies with not all staff receiving training. Since the last inspection the standard of vetting and recruitment practices has improved with all the appropriate checks being carried out to minimise any risks to service users. EVIDENCE: Each unit has an agreed number of staff on duty and the manager for the home has a copy of the duty records in the front office. The number of night staff on Wye had been increased from two waking staff to three waking staff, however on a number of occasions this unit has only had two staff on duty. This must be addressed to ensure the safety of service users. During the inspection the Marlings unit worked with three staff on a late shift instead of four. The manager of the home must ensure that a review of the needs of the service users and staffing levels is undertaken in all three units to ensure the safety of the service users and that their needs are being met. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 26 The home is using agency staff and staff provided from other Southern Cross homes to fill any gaps. Since the last inspection seven staff members have left the home. Comments received about staff were positive from service users and visitors to the home. Staff confirmed it is a nice place to work with a good team spirit. A number of staff felt they need more staff on duty to meet the needs of the service users but all staff did not share this. Staff spoken with had a good understanding of the needs of the service users and how to manage them. The home is working towards the 50 of staff trained to NVQ 2. A number of staff have sent off their course work but to date have not received a reply to inform them if they have passed. Four staff have NVQ 3 and eight staff are qualified nurses. Four personnel files of recently appointed staff were examined. All contained the required checks. This is a big improvement on the previous inspections. Consideration should be given to obtaining a new photograph on one member of staff, as it is not very clear in place. Two files did not contain interview records but the manager said this unusual as they always maintain records of interviews. The home has four in house trainers to train the staff. A tracking system has been devised to show where the training gaps are. The majority of staff are up to date with their training but the manager said they are gaps where staff need training and this must be addressed. Southern Cross provides a training programme for staff. The manager did say that all new staff are up to date with their training. The unit manager on the Marlings said nearly all staff have received training in dementia and some staff members are booked on course. Staff confirmed that training opportunities are provided. The home has now adopted Southern Cross’s induction booklet and each new member of staff has a mentor for six weeks induction period. The inspector did not see an induction booklet as the staff member holds these. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 27 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, 32, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager is supported well by her senior staff, who demonstrate a good awareness of their roles and responsibilities. Staff are able to approach the management of the home to discuss any concerns. The Manager also has a supportive, open approach to running the home, which benefits the service users, staff and relatives. However there are areas that need improvement to meet the standards. Service users’ monies are safe The home regularly reviews aspects of its performance through a programme of self-review and consultations, which include seeking the views of relatives, staff and where able service users. As far as is reasonably practicable the health, welfare and safety of service users are promoted and protected. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 28 EVIDENCE: There have been no changes to the management of the home since the last inspection. The manager is waiting for her interview with the Commission to be considered for registration. From discussions with service users, staff and visitors to the home they all said they could approach the manager with any concerns they might have. The manager operates an evening surgery where anyone can see her to discuss any issues. The home has recently sent out quality assurance questionnaires and the results are displayed in the main entrance and in the Marlings unit. A plan is in place to address any outstanding issues raised. The manager and area manager undertakes audits on the home bi-monthly. Audits are in place for medication and accidents as discussed in standard 7. Systems are in place to manage service users monies. The home has detailed records of each service users money with receipts kept and two staff signs all withdrawals and deposits. The home is able to audit each service users funds. The manager said staff supervision is not up to date with the recommended six times per year for care staff, however the manager is looking at ways of addressing this as some supervision sessions are taking place but not being recorded. Supervision sessions are undertaken on individual units. Records were seen of some sessions undertaken. Information sent to the Commission prior to the inspection listed servicing of equipment to include boilers, fire equipment and electrical testing. Monthly checks of equipment and water were seen at the inspection. The home has completed their fire risk assessment. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 29 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 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 X 3 Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 30 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 Requirement Timescale for action 10/08/06 2. OP3 3. OP7 4. OP7 5. OP9 14(1)(b) The registered person must 17(1)(a) make sure that an assessment is Sch 3.1(a) completed for service users and that the assessment is kept in the home. This requirement has been repeated from the last inspection. 14(1)(d.) The registered persons must confirm in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in respect of their health and welfare. 13(4) The registered person must ensure that a falls risk assessment is put in place as identified in the standard. 14(2) The registered person must ensure that service users’ assessments are revised and updated with any changes in their condition. 13 Action must be taken to ensure that all medicines in the medicine storage room in the Main House are stored at the DS0000016574.V291170.R01.S.doc 10/08/06 10/08/06 20/08/06 20/08/06 Sedbury Park Care Centre Version 5.1 Page 31 6. OP9 13(2) 7. OP9 13(2) 8. OP9 13(2) & 13(4)(c) 9. OP12 16(2)(I) 10. 11. OP15 OP15 17(1)(b) 17(2) Sch 4.13 22 12. OP16 13. OP18 13(6) 14. OP19 23(2) correct temperature (below 25°C for room temperature). This requirement has been repeated from the last inspection. The registered persons must complete a documented risk assessment to determine the risk for the safety of medication if staff have to transport it upstairs as The Marlings unit does not have a lift. The registered persons must review the storage of creams next to eye medication, as it is a potential infection control risk. This relates to The Marling unit. The registered persons must complete documented risk assessments for all service users that receive their night sedation downstairs to ensure they are put at risk. This relates to The Marlings unit. The registered persons must ensure that the cultural and dietary needs of service users are met. The registered persons must ensure that records are stored securely. The registered persons must ensure that records of meals are kept as indicated in the standard. The registered persons must ensure the complaints procedure in Wye unit is updated with the information required in this regulation. The registered persons must ensure that staff receive training in the protection of vulnerable adults and are aware of the whistle blowing policy. The registered persons must ensure that the environmental issues identified in this section of DS0000016574.V291170.R01.S.doc 31/08/06 31/08/06 31/08/06 20/08/06 20/08/06 20/08/06 20/08/06 30/10/06 31/12/06 Sedbury Park Care Centre Version 5.1 Page 32 15. OP26 23(2)(d.) 16. OP27 18(1)(a) 17. OP27 12(1)(b) 18(1)(a) standards are addressed. The registered persons must 30/08/06 ensure that the cleanliness of the home is improved and the areas identified in this section of the report are addressed. The registered person must 20/08/06 ensure that the staffing levels are Wye unit are maintained as per there off duty. The Registered Persons must 01/09/06 monitor the staffing levels to ensure the health; welfare and safety of service users are being met. The Home must demonstrate that this is an ongoing process. The registered person must ensure that all staff receive training appropriate to the work they are to perform. The registered person must ensure that all staff are appropriately supervised. 30/10/06 18. OP30 18(1)(ci) 19. OP36 18(2) 30/10/06 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 OP3 Good Practice Recommendations The home should ensure that all care records are signed and dated to provide evidence that a suitably skilled and competent person completed them. Dating assessments and care documentation will assist with reviewing of service users care. The home should add a copy of the auditing and plan of action of how they managed one service users falls, and how the plan was implemented to reduce the number of falls (This relates to The Marling unit). The home should ensure that protocols are in place with regards to resuscitation and the appropriate equipment DS0000016574.V291170.R01.S.doc Version 5.1 Page 33 2. OP7 3. OP8 Sedbury Park Care Centre 4. 5. OP9 OP15 6. 7. OP19 OP26 and staff training are provided. The home should review their homely remedy list with the local GPs as the last review was 2003. (This relates to The Marlings unit). The home should review the arrangements for the dining area as the tables are at the wrong height for service users in wheelchairs and to ensure that footrests are used when service users are sat at the table. A lift should be fitted on the Marlings unit. The home should inform visiting professionals if service users have MRSA. Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 34 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. Extracts may not be used or reproduced without the express permission of CSCI Sedbury Park Care Centre DS0000016574.V291170.R01.S.doc Version 5.1 Page 35 - 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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