Inspection on 04/07/07 for Sedbury Park Care Centre

This inspection was carried out on 4th July 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sedbury Park Care Centre 27/06/06

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 Mr Adam Parker Key Unannounced Inspection 10:00 4th & 5th July 2007 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.V338117.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sedbury Park Care Centre Address Sedbury Park Sedbury Nr Chepstow Monmouthshire NP16 7EY 01291 627127 01291 622327 sedbury.park@ashbourne-homes.co.uk 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 Ms Lynne Evans Care Home 105 Category(ies) of Dementia (23), Dementia - over 65 years of age registration, with number (23), Learning disability over 65 years of age of places (5), Old age, not falling within any other category (82) Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate 3 Named Service Users with Learning difficulties under 65 years of age 27th June 2006 Date of last inspection Brief Description of the Service: Sedbury Park Care Centre is a large Georgian house that stands in its own grounds overlooking the Severn estuary. The care centre consists of three units: the Main House providing nursing care for older people, Wye House providing personal care for older people and The Marlings unit for older people with dementia. 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 residents) 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 £350 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. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was carried out by two inspectors over two days in June 2007 with the inspection on the second day being carried out by one inspector. Seven residents were spoken to during the inspection visit to gain their views on the service provided. The registered manager of the home was present for the both days of the inspection visit which consisted of a tour of the premises and examination of residents’ care files. In addition staff recruitment and training was looked at as well as documents relating to the management and safe running of the home. A sample of residents were selected for inspection against a number of outcome areas as a ‘case tracking’ exercise. Comment cards were received from residents and their relatives. 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. What the service does well: What has improved since the last inspection? Record keeping has improved in relation to admission procedures and meals provided for residents. Air conditioning has been provided to maintain appropriate medication storage temperatures in the Main House and appropriate storage temperatures have been maintained with medication kept in the refrigerator. In addition to this there have been a number of improvements to medication administration. Staff have been provided with training in protecting vulnerable adults as well as training in a number of other areas. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s admission procedure generally ensures that all service users are admitted to the home on the basis of a full assessment of their needs so that they can receive the care that they require. However written information from funding authorities has not always been obtained prior to admission. EVIDENCE: Main House. Assessment documentation for a number of residents was looked at. As well as the pre admission assessment completed by the home, information had been obtained and recorded about the resident from relatives as well as the care plan provided by the funding authority. However in the case of one recent admission the resident had been admitted to the home before the funding authority had provided their written care plan. This was received in the home during the inspection visit and contained information about potential mental Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 9 health needs of the resident that may need further exploration. The supply of pre admission information from funding authorities appeared to vary depending on the social worker allocated to the resident. The Marlings. The assessment documentation for a number of residents recently admitted to the unit was looked at. These had been completed following an assessment of the service user’s needs recorded on an a comprehensive pre-admission assessment document. In addition copies of assessments and care plans produced by funding authorities had been obtained. Wye. Each person had a copy of the Statement of Purpose and Service User Guide in their bedrooms. The care for one new person admitted to Wye was examined confirming that a full assessment of need is completed prior to admission from which care plans are developed. A placement review was scheduled to take place within the first month; the social worker had confirmed their attendance. Good contact had been maintained with the family throughout this period and record kept detailing this. The home does not provide intermediate care and so Standard 6 does not apply. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. Although there are systems in place for planning residents’ personal and health care needs and upholding their privacy and dignity, these have not been applied in all areas in the interests of residents. EVIDENCE: Main House. A number of care plans were looked at as part of a case tracking exercise. Following the pre admission assessment, a dependency assessment is completed as well as risk assessments relating to specific care needs such as pressure area care, moving and handling and nutrition. The home also uses a malnutrition screening tool where they may be problems with weighing a resident. Risk assessments had been reviewed on a regular but not monthly basis. Care plans were written in relation to needs assessments and risk assessments. One resident had a care plan for personal hygiene that indicated that as well as a daily wash they would receive a weekly bath or shower. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 11 However the evaluation of the care plan and a personal hygiene record gave no information whether the resident had been receiving a bath or shower. There was a similar situation with another resident with an evaluation indicating that the care plan had been implemented although no specific record of a bath being given. Through discussion with the registered manager and nursing staff it became apparent that there were various reasons why these residents had not been given a weekly bath or shower. These had however not been documented and the care plans did not reflect the care being given. There was a written record for one resident of a review meeting that had taken place with relatives. Residents were having input from health care professionals such as GPs and Physiotherapists. A recent complaint from a relative of a resident about the Main House was partly concerned with other residents clothes being left in her room. A random selection of rooms were checked for other residents clothes and none were found. The Marlings. Residents in this unit had dementia assessments completed following admission as well as other assessments relating to any physical care needs. One resident had bruising evident on their arm, this had been noted and an accurate record made. One resident selected for ‘case tracking’ exhibited behaviour that required management in the interests of other residents. Although a record had been made of staff interventions in relation to this resident there was no risk assessment or care plan to address this. In contrast another resident who needed similar management had a risk assessment completed and a care plan to direct staff with appropriate interventions. Care plans looked at on this unit had been reviewed on a monthly basis. There were written records of visits to residents by Community Psychiatric Nurses although the home had not been told if Care Programme Approach arrangements were in place from mental health services. It would be beneficial if the home were made aware of any such arrangements in the interests of the residents, mental health. Staff were observed treating residents with respect and up-holding their privacy. It was noted that staff were able to give individual attention to residents where this was needed and this was further commented on in survey forms received from relatives. Wye. One person was case tracked and the care plans for others were sampled. The personal and healthcare needs of each person are identified in a range of care plans that are being frequently monitored and reviewed. Staff maintain daily notes which clearly refer to each person’s assessed needs. For instance one person was observed to be mobilising well using a tripod regularly. Concerns about tissue viability were also noted and could be cross-referenced with a referral for an occupational therapy assessment for a pressure relieving mattress and cushion. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 12 Appointments with healthcare professionals are recorded. Staff confirmed that people have regular access to a General Practitioner. He was observed coming to the unit during one of the visits to see people. Records indicated that people have regular chiropody appointments. The chiropodist was observed providing treatments in communal areas for some people. During the visit the office door was open and confidential information about people living at the home was accessible. Personal information about people’s dietary and fluid intake were left unattended on a table in the dining room. All Units. The arrangements for medication storage, administration and recording were checked in all units in the home. Medication was stored securely and storage temperatures were being monitored with records kept. Regular checks were being recorded on refrigerators used to store medication and showed that temperatures were within the correct range. Air conditioning has been provided in the medication storage room in the main house to maintain appropriate storage temperatures. It was noted that all bottles of liquid medication, and eye drops had been dated on opening. It is generally the practice for two signatures to be used with all handwritten directions on the medication administration charts. This should be extended to all handwritten comments or marks on the administration sheets such as where medication has been stopped or courses of medication completed, to prevent any potential errors. One resident of the main house who had been case tracked had been prescribed a topical cream for a skin condition this was no longer being administered as indicated on the chart although there was no recorded reason given for this decision in the residents notes. There were individual protocols for the administration of medicine on an ‘as required’ basis although in the Main House some of these had very little information on them. The administration of medication had been recorded or where omissions were made, an appropriate code had been entered on the charts. A previous recommendation regarding reviewing the homely remedies list in the Marlings unit has been repeated in this report although the home have had no success in reviewing this with local GPs. Staff who administer medication receive training from the supplying pharmacist. A recommendation from the previous inspection has been partly adopted in that resuscitation protocols are in place although staff have not received training and appropriate equipment has not been provided. A record of weight is kept for residents in each unit. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. The home takes an active role in encouraging residents’ contact with family, friends and parts of the local community. This in conjunction with a varied activities programme provides a good degree of social contact. In addition residents receive a choice of varied and nutritious meals. EVIDENCE: All Units. The home employs 2 activities coordinators and there are plans to recruit a third. Activities are planned and provided for residents in the home as a whole although they setting may be in the individual units. Examples of activities provided in the home are Quizzes, Music and Movement, Film Shows and craft. Residents who do not take part in group activities receive individual visits in their rooms. Activities outside of the home are also organised with links being made and maintained with the local community. Trips out often make use of ‘Dial a Ride’ transport and visits have been made to a Zoo, the local church for coffee mornings and a Garden Centre. Activities schedules were displayed in the units giving information about the week’s activities. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 14 A service is held in the home by the Church of England once a month although there was no information on any contacts with other Christian denominations or other religions should this be needed by residents. It was however reported that a Baptist Minister had visited the home. At Christmas local schools have visited the home to perform Carols. People spoken with said that activities are provided in the unit, in the main house and they occasionally go on day trips. People were observed going to a celebration of the 4th July in the main house and attending a music session. Several people said that they had enjoyed a day trip recently. One person said that the entertainment was marvellous and they enjoyed going to bingo and the quiz. A new communal television had been purchased by family and friends. One relative of a resident commented on a survey form that the home has “a good social activity programme.” Visitors were spoken with and said that they are made to feel welcome. One person said that they pop in frequently and were being given a copy of the weekly activity schedule so that their visits did not clash with this. Another person said that their daughter visits them each week. There is a policy of open visiting in the home. Meetings are held with residents and relatives, the minutes of the most recent in June 2007 were seen. One relative on a survey form commented “Sedbury Park always make myself and family very welcome”. Communication books have been introduced and placed in each bedroom as a way of exchanging information with relatives regarding any issues with the resident. Evidence was seen of service users bringing their own personal possessions into the home including items of furniture. The home has information on advocacy services for residents and it was reported that one resident was being visited by an advocate during the inspection visit. Two choices of main course are given at lunch as well as two choices of dessert. Staff ask residents about their preferences for meals the day before and this was seen during the inspection visit. Meals are taken in dining rooms in the units or in some resident’s individual rooms. Lunch was observed being served in the dining room in the Main House. Some residents who needed help with eating were sitting with staff (who were wearing blue aprons) on one table. Other residents were sitting at tables alone. This appeared slightly unusual and the provider had attempted to address this situation only to find that residents were perfectly happy taking lunch on their own. At the previous inspection a requirement was issued regarding the height of the tables and their use with residents in wheelchairs. New tables were on order and a risk assessment relating to this situation was seen for one resident about the possible risk of injury. The atmosphere at lunch was quiet although staff interacted with residents where needed offering choice and explaining to one resident about a diabetic dessert. In the main house drinks were being provided during the morning with resident preferences confirmed by the staff Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 15 member as they were served. On the second day of the inspection breakfast was seen being served in the Marlings Unit from the unit kitchen. Residents were being given a choice of breakfast served to them after rising. The Menu for the day was displayed on a notice board. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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 this service. Complaints are acted upon in the interests of residents although the information about the complaints procedure could be made clearer in one unit. Staff have been trained in protecting residents from abuse although a written plan to deal with the actions of one resident towards others was lacking. EVIDENCE: All Units. The home has a register for recording complaints, fourteen had been documented since the last full inspection. The procedure for complaints is that on receipt, a letter is sent and following investigation a response is given within 28 days. This is displayed in the entrance to each unit, however in Wye House there are various versions of the complaints procedure in the entrance hall. This could be confusing to anyone wishing to make a complaint. Residents in this unit said that they would feel comfortable expressing any concerns they have to the unit manager or the home’s manager. During the inspection visit a registered manager from another home in the group was present investigating a complaint. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 17 The home has a policy for protecting residents from abuse as well as a ‘whistle blowing’ policy. Training in protecting residents from abuse has been given to the majority of staff. The registered manager was aware of local authority adult protection and had obtained some information from the Gloucestershire County Council in the form of their ‘Alerter’s Guide’. However this was only in the possession of the Registered Manager and should be shared with staff. Staff spoken to during the inspection visit were able to recount what they had learned in training about protecting residents from abuse and about the ‘whistleblowing’ policy. One resident in the Marlings unit had exhibited behaviour that required management in the interests of other residents. There was no risk assessment on file to address how the behaviour would be managed or how to deal with the risk to residents. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More work needs to be done to ensure that all residents benefit from living in a well maintained environment free of odours and with clean bed linen. EVIDENCE: Main House. The home is set in extensive grounds with areas available to residents and their visitors when weather permits. These include covered balconies around the side and front of the main house and a large lawn leading down to a pond where furniture could be provided for residents to take tea. Inside the grand surroundings of the Main House there are a number of large communal rooms including a television lounge a library, a function room and a dining room. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 19 A selection of Residents individual rooms were looked at in the Main House and some beds were found to have been made up with bed linen that was stained and dirty. It was explained by the registered manager that there had been some problems in removing stains during the laundering process and work was needed on the washing machines. This was confirmed with the housekeeper when the laundry was visited. However some of the stains were more recent and it was clear that these items of bed linen had not been removed from the beds for laundering and the beds then made. The registered manager explained that staff were in the habit of making beds and leaving rooms tidy after assisting residents to get up. If this were the case then it would make it difficult for staff revisiting the rooms with a view to providing clean bed linen as beds would then have to be stripped and examined. It was noted however that the problem with bed linen was generally confined to an area on the sixth floor in the Main House. Although the Main House was generally well maintained there had been some damage in a number of areas caused by water entering through the roof. The laundry was spacious, well ordered and clean with hand washing facilities available and easily accessible for staff. Wall and floor surfaces were easily washable providing a hygienic environment. The laundry is also used by the house keeper who undertakes various checks on such things as first aid boxes and cleaning materials. The Marlings. The unit was generally clean and well maintained although the door to the kitchen was badly scratched. Residents individual rooms contained personal items and beds had clean bed linen. In one room on the top floor (room 19) the wall light was working but loose and the extractor fan was not working. Recent work had been carried out on painting bedroom doors in bright colours although door numbers had not yet been replaced. During the inspection visit plans were seen for the extension and improvement of the Marlings unit. Wye. Communal areas in Wye had been redecorated and the manager confirmed that further redecoration was scheduled to take place. Vacant rooms have been totally refurbished and problems in rooms identified in the previous report had been addressed. However there are ongoing problems with damp and water damage to rooms which needs to be resolved. Notably several rooms had unpleasant odours. The unit manager identified that this was an ongoing problem where people have continence issues and that they are thinking of providing non slip washable floors in rooms of concern. She stated that carpets are regularly cleaned. Of particular concern was Room 27 which was odorous. The care plans for the person in this room indicated that they do not have a continence problem. The unit manager confirmed this stating that the smell might be embedded in the carpet. This needs to be resolved. Other issues identified in this unit were:• The fire exit in the lounge was blocked by a chair and small table DS0000016574.V338117.R01.S.doc Version 5.2 Page 20 Sedbury Park Care Centre • • • • • • • • • • Wallpaper in communal areas was peeling off the walls and corridor walls are being damaged by wheelchairs Stairwell is being used to store furniture and other equipment, this needs to be kept clear – it is a fire risk Room 5 – damage to wall by bed needs attention Room 7/9- odorous Room 9 – new pillow needed Room 14 – water damage to wall in the corner of room Room 15 – stained ceiling in the bathroom Room 18 – water damage to en suite ceiling and walls Room 26 – damp patches on ceiling in the en suite Room 29 – pillow needs replacing. Wye unit was clean and tidy at the time of the visit. Personal protective clothing was supplied to staff. Good infection control measures were observed. Staff serve meals and were observed putting on clean tabards and washing their hands prior to serving meals to people. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 21 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. 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. Residents are cared for by a staff team that is generally well trained and competent although in one unit staff numbers are insufficient for residents needs. In addition recruitment must be more robust to protect residents. EVIDENCE: Main House. The Staffing for the main house is 2 Registered Nurses and 5 Carers in the morning and 1 registered nurse and 3 carers in the afternoon although this was due to be increased with more residents being admitted to the home. The Marlings. Normal staffing for the unit is 4 care staff in the morning, 3 in the afternoon and 2 at night. There is one cleaner working in the unit during the day. Wye. Staffing levels have recently been reduced on Wye Unit due to a number of vacancies. Staff were observed struggling to meet the day to day needs of people living there. Staff stated that the needs of people living in this unit have changed increasing their dependency on staff to support them. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 22 Lunchtime was observed when there were four staff on duty. Normally three staff would be on duty but a team leader had come in to help the Doctor with their round. Despite this the unit manager was trying to serve lunch whilst responding to the telephone. She ignored the phone four times so that people could have their meals. Some people choose to have their meals in their rooms (including one person who needs help to eat their meal), others in the lounge or dining room. In the middle of this a person asked to go to the toilet that meant two staff had to go and support them. At mealtimes a number of people need help with their meals and staff did this at their pace despite the obvious pressures on them. In addition to this staff working a long day are entitled to a break which they are to take between 12.00 – 13.30. This is obviously a very busy time for the unit to be depleted of staff with no additional cover being provided. All units. Staff records were examined for four new members of staff. The Human Resources department manages recruitment and selection centrally and copies of staff records are forwarded to the home. Each person has an application form and there was some evidence that gaps in employment history are being investigated. However several applications had gaps that were not followed up. Two references are obtained prior to employment. Although one person had two references one of these was not from the last employer in Care. There was evidence that PoVA first checks are being completed. The manager described the systems that are put in place until the Criminal Records Bureau check is received, although no formal risk assessment was in place. Copies of training certificates are kept on files as well as a health questionnaire. Records confirmed that a NVQ programme is in place and staff verified that they were working towards their awards. Copies of training certificates on files confirmed access to moving and handling, slips, trips and falls, English language, dementia, protection of vulnerable adults, abuse, whistle blowing and carer/resident relationship courses are provided. Mandatory training is also provided. The level of care staff trained to a minimum level of NVQ 2 is 51 . Staff receive induction training with this being recorded in an induction training document. A new document has recently been supplied to the home reflecting the most recent changes to induction training nationally. Some staff in the Marlings unit have received training in Dementia Awareness which includes dealing with challenging behaviour although others have not. A number of staff from overseas had been attending English lessons. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there are a variety of quality assurance audits in place, these and the Management of the home have failed to identify a number of shortfalls. Nevertheless the home has worked to provide a safe environment for residents. EVIDENCE: All Units. The registered manager is a registered general nurse with previous experience in district nursing and nine years in care home management. She is currently undertaking the NVQ 4 registered managers award and has attended recent training in fire safety, dementia and care planning. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 24 A quality audit is carried out in the home every month, this is either a home manager’ audit or a validation audit. Other audits take place concentrating on accidents, care plans, environment, pressure area care, and residents’ weights. The use of a new care plan audit was being considered and this may prove useful taking into account some of the findings around care planning in this report. Unannounced visits by a representative of the registered provider also take place and a short report is produced and copied to the registered manager and the commission. In addition questionnaires are sent out to residents and relatives The finances for three people being case tracked were examined and other people’s records sampled. Staff explained that these records were due to be centralised and accessible on the computer system. Receipts are kept for any outgoings and could be cross-referenced with the financial records. Balances kept in the home were correct. Bank statements were also cross-referenced with the financial records and these were satisfactory. Records are checked each month and a reconciliation is also done monthly. Some people had large amounts of money that are being kept in a current account with no option to earn interest. Schedules for supervision indicate that this will be held every two months but supervision records indicate that some staff in the Wye unit have had only one supervision this year with others having three. In the main House and Marlings units supervision sessions were taking place on a regular basis. It was noted that in all three units residents records were not stored securely but kept in unlocked rooms. Staff have received training in fire awareness and fire safety as well as moving and handling, health and safety and food hygiene. First aid training was due to be arranged. Regular maintenance checks are carried out and recorded on equipment in the home such as hoists, lifts, bed rails and wheelchairs and window restrictors. As a result of the checks 2 wheelchairs had been scrapped. Bed rails are only used in the Main house subject to a risk assessment. In addition temperatures from hot water outlets are checked and recorded and the cleaning and disinfection of shower heads is carried out in line with reducing the risk of Legionella at the home and following an audit by a specialist consultant. Central heating boilers had been serviced and the electrical wiring in the home has been checked as well as portable electrical appliances. Cleaning materials are stored securely in all units however it was noted that one bottle of disinfectant in use in the Marlings unit was not adequately labelled although it is accepted that this was not the general practice in the home. This was remedied during the inspection. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 25 It was noted that there was no immediate control over people entering the home through the main entrance in the Main House and this situation should be risk assessed from a security point of view. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 26 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 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 2 3 Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (2) (c) Requirement Where the care that a resident receives is different from the written care plan, the care plan must be revised. Where a resident exhibits behaviour that affects others then a care plan must be drawn up to guide staff in appropriate and safe interventions. Where a plan is made in relation to stopping medication administration to a resident is made then this and the reasons for the decision must be recorded. Treatments for people must respect their privacy and dignity and be provided in privacy A risk assessment must be completed in relation to how the behaviour of one resident in the Marlings Unit affects other residents. In areas where rainwater has leaked into the home and damage has occurred then this must be attended to along with other maintenance issues so that residents can live in a safe and DS0000016574.V338117.R01.S.doc Timescale for action 30/09/07 2 OP7 15 (1) 30/09/07 3 OP9 17 (1) (a) Schedule 3 Paragraph 3 (m) 12(4)(a) 13 (4) (c) 30/09/07 4 5 OP10 OP18 30/09/07 31/08/07 6 OP19 23 (2) (b) 31/10/07 Sedbury Park Care Centre Version 5.2 Page 28 7 OP24 16 (2) (c) & (e) 8 OP26 16 (2) (k) 9 OP27 18(1)(a) 10 OP29 19(1)(c) Sch 2.3,4 11 OP30 18 (1) (c) (i) 12 OP37 17(1)(b) well maintained environment. Where residents bed clothes have been stained beds should be changed and the bed linen laundered so that residents can have the benefit of clean bed linen. Odours within the home must be addressed and if necessary carpets replaced or an alternative floor covering provided. There must be sufficient staff on duty in the Wye Unit at all times to safeguard the safety and wellbeing of residents. Records must be obtained for staff which confirm their full employment history including a reference from their last period of employment which involved working with adults or children. All staff working in the Marlings unit must receive training in dementia awareness so that residents receive consistent care from competent staff. Resident’s records must be securely stored to protect their interests. 31/08/07 31/10/07 31/10/07 30/09/07 31/10/07 30/09/07 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 So that a full assessment of care needs can be made. The home should insist on receiving written information from funding authorities relating to a resident’s needs prior to admission to the home. Where residents are receiving input from mental health services, the home should check if Care Programme DS0000016574.V338117.R01.S.doc Version 5.2 Page 29 2 OP7 Sedbury Park Care Centre 3 4 5 6 OP8 OP9 OP9 OP9 7 OP12 8 9 10 11 12 13 14 15 OP16 OP18 OP19 OP31 OP33 OP35 OP36 OP38 Approach arrangements are in place and request any relevant information. The home should ensure that staff training in resuscitation takes place and appropriate equipment is 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). There should be a review of individual protocols for medication administration in the Main House as some contain very brief information. The practice of signing, dating and checking handwritten directions on the medication administration charts should also be used when any medication is stopped and the chart is marked accordingly. There should be more information in the home about how to contact representatives of various Christian denominations or other religions and a check should made if this information is needed by current residents. In Wye unit the most recent complaints procedure should be displayed and others disposed of, so that people have access to current information. Information from the local authority about protecting vulnerable adults should be made available to staff. The practices observed in Wye unit in relation to fire safety should be checked to ensure that they are in line with the home’s fire risk assessment. The registered manager should complete the NVQ 4 registered managers award. The quality audit of care planning should be more robust. People should be supported to transfer large balances from current accounts to interest earning accounts. Supervision sessions for staff in Wye unit should increase. A risk assessment should be carried out relating to the security of the premises with particular attention to the main entrance in the Main House. Sedbury Park Care Centre DS0000016574.V338117.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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