Inspection on 25/06/07 for Seddon Court Elderly Persons Home

This inspection was carried out on 25th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Seddon Court Elderly Persons Home 29/08/06

Seddon Court Elderly Persons Home 30/11/05

Seddon Court Elderly Persons Home 12/04/05

Seddon Court Elderly Persons Home 24/01/05

Seddon Court Elderly Persons Home 18/05/04

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

CARE HOMES FOR OLDER PEOPLE Seddon Court Elderly Persons Home Prescot Road St Helens Merseyside WA10 3UU Lead Inspector John Mullen Key Unannounced Inspection 25th June 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Seddon Court Elderly Persons Home DS0000034059.V338529.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. Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seddon Court Elderly Persons Home Address Prescot Road St Helens Merseyside WA10 3UU 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) 01744 677515 01744 677517 jimphilbin@sthelens.gov.uk St Helens Metropolitan Borough Council Mr James Michael Philbin Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to a maximum of 30 DE(E). The Service may accommodate up to a maximum of 2 service users aged 60 years and over. 29th August 2006 Date of last inspection Brief Description of the Service: Seddon Court is a thirty-bedded home for the accommodation and care of older people with dementia. It is owned and managed by St Helens Council. The registered manager is Mr. James Philbin. The home has twenty-seven permanent beds and three respite ones. Seddon Court is divided into three units of ten, although residents can and do move between units freely. The home does not provide nursing care but calls upon the community nursing services when necessary. The fees charged range from £90.45 per week to £736.00 per week depending on an assessment of residents’ financial means. The premises are purpose-built and were opened in 1988. The area used by residents occupies the ground floor. Here, in addition to the residents units, is located a kitchen, laundry and hairdressing room as well as office accommodation. The first floor is used exclusively by staff and contains a meeting room as well as sleeping-in accommodation. All bedrooms are for single occupancy. The home has a very pleasant communal area as well as a garden facility extensively used by both residents and their families. Appropriate aids and adaptations assist disabled residents manage the premises and the home has a full call system in place. Seddon Court is located within close reach of local facilities and can be easily visited via public transport. Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of Seddon Court which included a site visit. All key standards were assessed in addition to a selection of other standards. This inspection encompassed information received since the last key inspection including an unannounced random inspection which took place on 15th January 2007. In addition it included information provided by the agency through its pre-inspection questionnaire and supporting documents. Interviews took place with the registered manager, two assistant managers, four care workers and a member of the domestic staff. Comment cards were sent out to a random selection of family members and in addition two family members were interviewed by telephone. One family member was interviewed on site. Residents were spoken to and observed. The premises were inspected and a large amount of documentation examined. What the service does well: Seddon Court provides a good level of care for its residents. Those residents who could communicate said they were happy in the home and family members spoken to were generally favourable towards Seddon Court with the exception of one family. Some comments from family members were particularly complimentary including “over the moon” when describing his attitude to Seddon Court. The home recruits staff in accordance with good practice and is employing sufficient and increasing numbers of staff to care for residents. Care staff felt that they had been well trained and that support had improved for them. The premises are spacious to allow residents freedom of movement and provide a safe environment. Meals are of an excellent standard and are served in pleasant surroundings. Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although the care needs assessments are improving this process needs to continue. In terms of documentation, the improvements need to be expanded to include a review of risk assessments, which need to remain under review in view of the illnesses of the residents. Amongst some generally complimentary comments from relatives there were references to lack of communication and this must improve. Activities have improved but would be better organised by staff specialising in this field. There are still some deficits in recordings of medicines taken, particularly at night and training in this area is required. In the area of training generally there appears to have been some shortage in recent training events which means that staff are lacking refresher training in some areas and this needs to be addressed urgently and systematically. Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 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 Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 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. 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 has information on all residents although this is not always comprehensive to ensure a complete picture is obtained. EVIDENCE: An examination of case files found a care needs assessment in each, including one person receiving respite care ,so that the home has information on which to base care. An interview with the registered manager showed that the home had been gradually receiving full assessments as a new format is introduced to provide a fuller assessment. This was shown in the files where there was a variety in the detail of the assessments but all contained the basic information on which to base the work. Interviews with staff found them well aware of the Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 10 needs of residents and families were generally satisfied that their relatives’ needs were known and being met. Comments received included “I feel they know the people they care for as individuals and treat them as individuals”. In interview, the registered manager did say that he would accept residents without a care needs assessment because this was a local authority home which had responsibilities to safeguard adults and so provide urgent accommodation. Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is provided to a good standard but some improvements to the recording and training are required to fully meet best practice. EVIDENCE: A random inspection of 15th January 2007 found there had been improvements to the care planning process although deficits still existed, particularly in the area of people receiving respite care. This key inspection found that this had been corrected. An examination of files found an up to date care plan in each, including one who was receiving respite care, where a shortened, agreed version was in place to give guidance to staff. In each case also there was a risk assessment in place but one was dated July 2005 and another April 2006 and neither had any evidence of review to confirm its relevance. An Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 12 interview with the registered manager confirmed that he felt that these needed to be reviewed more regulary to confirm usefulness. Contact with other staff found them aware of the needs and risks of individual residents and families contacted had no concern about the safety of their relatives. Interviews with the registered manager and other staff found no particular problems with the accessing of health care provision with the exception of chiropody which is a national problem. In the past, there has been some concern about the psychiatric overview of residents but now the home is being assisted by three consultant psychiatrists and a senior registrar and, therefore, this is no longer is a problem. Evidence from the files confirmed that residents are being regularly weighed and that health care needs are being attended to regularly to confirm this remains a high priority. One relative commented “I feel that although we have had scares regarding her health on several occasions I think if she had not been at Seddon Court she would not be with us now”. The home has full procedures for the administration of medicines to support and guide staff. An examination of medication records found them generally correct although there were some slight problems at night which staff said related to residents going to bed prior to the medication being given and, therefore, the recording was not complete. There is still a deficit in further training in medicines which remains an outstanding issue from the last key inspection. The registered manager said that St Helens Council has formed a working party, of which he is a member, and had submitted proposals to the Commission on this subject but this has not yet reached the latter so that this cannot be progressed. Interviews with care staff did not find any anxiety about medication and those interviewed were experienced in this field and appeared quite confident. Observations during the inspection confirmed that residents were being cared for in a respectful and dignified manner reflecting good practice. All residents have individual clothing and all looked well cared for to confirm this point. All contact with relatives found no concern about the physical care of their relative which they felt was generally of a good standard. The elements of privacy and dignity are contained in the induction programme but there has been no induction to this home for four to five years which has prevented its implementation. However, there has been an increase in vocational training which does also emphasise correct personal care to underline practice in this area. Seddon Court Elderly Persons Home DS0000034059.V338529.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good level of social contact and activities so that residents can have a more fulfilling experience. EVIDENCE: The home has seriously considered the issue of activities since the last key inspection and this was confirmed both by the random and this key inspection. Activities are now listed on the units and there has been a, possibly temporary, increase of staff, which means that three members of staff are regularly available on units to promote activities. In addition, an interview with the registered manager confirmed that they had an agreement with a local school to provide volunteers to further promote activities. Interviews with staff confirmed that residents were being taken out of the home more frequently as well as activities on the units. Families had a mixed response to the issue of activities. One family commented that there is a “lack of Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 14 stimulating activities” although this was not the opinion of other family members contacted. The registered manager still felt it would be better if he could have designated activity organisers rather than the, perhaps temporary, extra care staff so that future activities could be more planned. Contact with families revealed no problems in visits to the home which confirmed an open access policy. All said they were well received and were able to contact their relatives as necessary. The home has a pleasant central area where families tend to congregate although they can see relatives in other areas if they so wish, so maintaining privacy. Staff interviewed confirmed an open visiting policy and reported no difficulty in relationships with families in this area. Observations during the inspection found relatives and residents meeting in a friendly and relaxed manner so that family ties are promoted. The pre-inspection questionnaire contained details of menus available and they confirmed a nourishing and appropriate diet. Observation of the midday meal found it highly attractive in appearance and residents clearly enjoying the experience. There was a very pleasant atmosphere during the meal and residents spoken to said they were enjoying it. In one lounge two residents were having a separate, diabetic meal to confirm the home’s ability to meet individual need. An interview with the registered manager, confirmed by the cook, showed that the home is to move to a new menu planner which will calculate nutritional value and, therefore, reinforce good practice. The cook also has a book which lists both the dietary requirements and the likes and dislikes of individual residents so that these can be met. Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home protects its residents through thorough processes and procedures. EVIDENCE: The home has had one complaint in the last twelve months about a resident who has now left the home which confirms a generally high level of satisfaction. Generally, families said they knew how to make a complaint but there was one exception to this which detracts from these arrangements. However, families contacted on this occasion revealed a high level of satisfaction which included “complaint, you must be joking no complaint whatsoever”. The home has a full complaints’ procedure which is of a good standard to show the home’s commitment to an open approach. Experience with this home shows that they inform the Commission where appropriate and manage complaints properly for the safety of residents and staff alike. The home has a full prevention of abuse policy which conforms to good practice and, therefore, provides full guidance to staff. There has been no recent incident of alleged abuse to underpin the good practice of the home. There was a comment from one family that her mother had been pushed by Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 16 another resident and that the home failed to inform her of this. The registered manager said that training in the prevention of abuse is behind schedule which was confirmed by examination of training records. Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Seddon Court is a suitable, hygenic home which offers a comfortable home for residents. EVIDENCE: There has been no change to the premises of the home which remains suitable for its purpose. There has been some decoration since the last inspection and the home presents as a pleasant and comfortable environment for the care of residents. Residents spoken to were happy with their bedrooms which are all for single occupancy and therefore promote privacy. Relatives contacted had Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 18 no concern about the premises of the home which they felt was suitable for the care of their relatives. Since the last key inspection there has been a random inspection as well as this key inspection to consider the arrangements for the cleanliness of the home. The last key inspection found only one member of the domestic staff on duty whereas more were on duty on this occasion to maintain levels of cleanliness. The registered manager confirmed that extra domestic staff have been redeployed as a result of home closures and there are now a total of ten, which he felt sufficient for the needs of the home. An interview with one of the domestic staff confirmed that she felt that the numbers of staff were no longer a problem. In addition, she said the cleaning materials were of a good standard and stock levels high so that standards can be maintained. A tour of the premises found them clean and hygienic with only a minimum of offensive odour which reflects a high standard given the disabilities of residents. Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home recruits, employs and generally trains staff to a standard that ensures that residents are well cared for. EVIDENCE: An interview with the registered manager confirmed that there had been an increase in staffing levels since the last inspection due to the transfer of staff so that, in particular, more activities could be provided. The home now employs four night staff instead of three, two cooks instead of one and extra domestic staff all of which means that the home is now well resourced. This is in addition to the extra care staff previously mentioned. However, the service manager has pointed out that this is the result of redeployment to meet temporary circumstances and does not mean that staffing ratios have been permanently increased. Interviews with care staff confirmed that the extra staff had assisted in expanding activities in particular so that residents could be more stimulated. Staff felt that the home was progressing and that ratios of staff to residents was sufficient to enable full care to be given. Relatives contacted were generally happy with the staff ratio but there were exceptions Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 20 to this reflecting concern in one case about the home’s ability to meet individual needs. The pre-inspection questionnaire stated that the home has 62 of its staff vocationally qualified which is higher than that which is required and provides a good basis of qualified staff. In addition, the staffing complement tends to be experienced and mature which ensures a stable staff group to the benefit of residents. The home does not employ agency staff. There was a trainee nurse on placement and she was being employed appropriately for the benefit of both herself and the residents. The Human Resources Section of the Council has now made its recruitment and selection process available to the registered manager on computer so that he can check progress. The examination of the file of one, randomly selected, staff member confirmed that full police checks are in place and that references are also being appropriately taken so ensuring a correct approach to recruitment. Contact with other St Helens’s agencies confirmed that full and correct procedures are in place for the safety of residents. This includes full policies on equal opportunities and equality and diversity so that there is an individual approach to recruitment. The Council has taken the decision to renew police checks when staff are transferred which is good practice and reinforces these policies. St Helens Council has a full staff training and development plan available for staff so they are encouraged to develop. An interview with an assistant manager confirmed that training is identified through the supervision process and this was confirmed by an examination of supervision and appraisal records. This manager also confirmed that all managers in the home are having equality and diversity training which they will impart to staff so that all are familiar with these ideas. However, an examination of training records in the home found that training has been minimal in the recent past and therefore some subjects need refreshing. Moving and handling training has been provided last year for all staff in-house and particularly related to people with dementia and therefore more relevant. However, medication training needs to be renewed as does the protection of vulnerable adults training to ensure staff remain up to date in these important areas. Interviews with care staff found them generally happy with the training available although one would welcome training in palliative care and others confirmed the need for some refresher training to remain up to date. Relatives spoken to were happy with the staff although one felt more training was required so that the more specialist needs of residents would be met. Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed well resulting in a supported workforce and safe environment for the protection of residents. EVIDENCE: There has been no change to the registered manager who has been in the post for a number of years and is fully qualified in terms of experience and qualifications. Previous inspections have confirmed that the manager meets all the standards required for this post so that he is capable of fulfilling his role. Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 22 The home has expanded its quality assurance process to include a number of specific areas within the home as part of an overall process. An interview with an assistant manager confirmed a new quality assurance approach to room cleanliness and personal clothing care so that standards can be improved and maintained in these areas. Interviews with managers confirmed that surveys have been undertaken to assess opinion from families. In addition, a performance management framework has been put in place to consider specific targets including appraisals, supervision and cleanliness so that a targeted approach is developed. An examination of records in the home confirmed that residents’ monies are managed appropriately and are fully recorded for the protection of residents and staff alike. Essentially, families manage their relatives’ finances due to their incapacity. Where this is not possible, the Council acts as appointee and this was the case for four residents at the time of the inspection. The random inspection was mainly concerned to assess the supervision of staff and found there had been a distinct improvement in this area following communication between the Commission and the Council. This was confirmed in this key inspection by an examination of staff files which showed that supervisions and appraisals are taking place much more regularly to assist staff; this includes both care and domestic staff. Interviews with care staff found them happy with the level of support generally and confirmed that they could seek help as required. There is still some difficulty in one unit where both the manager and staff are part time which causes difficulty when arranging contact. However, this was the exception and other care staff interviewed reported a significant improvement in this area. Interviews with managers confirmed that they were being supervised on a monthly basis which confirmed these improvements. A tour of the premises found it a safe environment for the care of residents. The home has a full health and safety folder underpinning practice. A risk assessment of the premises had taken place in February 2007 and a new fire book showed that appropriate checks and drills are being undertaken to ensure safety. A check of bathroom water temperature found it 43º C which is the recommended level to prevent accidents. An interview with the registered manager confirmed that gas, electricity and other tests had been undertaken to further underpin safe working. Relatives contacted had no concerns about the safety of their relatives which they thought Seddon Court protected. Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 3 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement The registered manager to ensure that full assessment documentation is provided on all residents, including those receiving respite care so that full information is available. (Previous timescale of 1st November 2006 not met). The registered manager to ensure that regular reviews of risk assessments are undertaken so that the safety of residents is ensured. The registered manager to ensure that all medicines are recorded and that training in this area is provided to relevant staff so that practices are safe. The registered manager to review training to ensure that all staff receive mandatory and refresher training so that they remain up to date. Timescale for action 01/08/07 2. OP7 13(4) 01/09/07 3. OP9 13(2) 01/10/07 4. OP30 18(1) 01/12/07 Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 25 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. 2. OP12 Refer to Standard OP18 Good Practice Recommendations The registered manager to review communication so that families are informed of significant incidents. The registered provider to consider using dedicated staff to promote activities so that they can be more fully planned Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Seddon Court Elderly Persons Home DS0000034059.V338529.R01.S.doc Version 5.2 Page 27 - 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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