Inspection on 17/04/08 for Sedgemoor Care Home

This inspection was carried out on 17th April 2008.

CSCI found this care home to be providing an Good service.

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

Sedgemoor Care Home 02/11/09

Sedgemoor Care Home 26/08/09

Sedgemoor Care Home 04/10/07

Sedgemoor Care Home 21/02/07

Sedgemoor Care Home 28/01/06

Sedgemoor Care Home 26/11/05

Sedgemoor Care Home 02/03/05

Sedgemoor Care Home 19/10/04

Sedgemoor Care Home 25/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Sedgemoor Care Home 41 Sedgemoor Road Norris Green Liverpool L11 3BR Lead Inspector Mrs Claire Lee Key Unannounced Inspection 08:45 17 and 18th April 2008 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 Sedgemoor Care Home DS0000035911.V360393.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. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sedgemoor Care Home Address 41 Sedgemoor Road Norris Green Liverpool L11 3BR 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) 0151 256 1810 0151 226 8781 patricia.donnellan@liverpool.gov.uk www.liverpool.gov.uk Liverpool City Council Ms Patricia Donnellan Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 30 Date of last inspection 4th October 2007 Brief Description of the Service: Sedgemoor is registered to provide personal care for thirty people. Residents who require respite care, short-term care as well as permanent residential care are accommodated. Day care can also be provided for people from the local community. Sedgemoor is a purpose built single storey building, which opened in 1993. The home is owned and managed by Liverpool City Council and is located in the Norris Green area of Liverpool. Although the home is some distance from local shops and amenities, they are easily accessible via a bus service that stops directly outside the home. There are three separate units and an administration block which all open out from a central atrium (large spacious communal area). Each unit has ten single ensuite bedrooms, a self-contained kitchen/dining area and two lounges. Residents have the use of a call bell with an alarm facility and moving and handling equipment to assist them. A spacious garden has patio areas. The weekly fee rate for accommodation is based on an individual financial assessment, which is completed by Liverpool City Council. The fee rate is from £98.60 to £359.00 a week. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. A site visit took place as part of the unannounced inspection. It was conducted over two days for a duration of approximately eleven hours. Twenty residents were accommodated on 17th April 2008 and twenty one on 18th April 2008. A partial tour of the premises took place and a number of care, staff and health and safety records were viewed. Discussion took place with eleven residents, one relative, four staff, the deputy manager, assistant manager and the registered manager. The service (senior) manager also visited on the second day. During the inspection two residents were case tracked (their care files were examined and their views of the service were obtained). This was not carried out to the detriment of other residents who also took part in the inspection. All the key and other standards were inspected during the site visit. There have been no permanent admissions to the home since the last key inspection. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents, relatives and staff prior to the inspection. A number of comments received from surveys and interviews that were conducted are stated in this report. An AQAA (annual quality assurance assessment) was completed by the service manager and deputy manager prior to the site visit. The AQAA comprises of two self questionnaires that focus on the outcomes for people. The self assessment provides information as to how the manager and staff are meeting the needs of the current residents and a data set that gives basic facts and figures about the service, including staff numbers and training. Information from the AQAA is included in this report. What the service does well: Residents have a care needs assessment, which is completed by social services prior to their admission. The manager also meets the residents and their family prior to their admission to make sure that the staff only care for those people whose needs they can meet. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 6 Residents have a plan of care and those seen contained important information about what they need help with and how they are to be cared for. Staff who were interviewed were knowledgeable regarding the daily care they need to provide and also the importance of seeking advice from outside health professionals to ensure the resident stays well. Two community based health care professionals said that the staff were good at contacting them and were very polite in their manner with the residents. Residents interviewed were pleased with the care and felt that staff had their best interests at heart. Comments included, “Very good care”, “The staff are lovely” and “It is a nice friendly place to stay”. A relative also commented on the good all round communication and the support the family were receiving. Residents were being offered a varied social programme and an informative newsletter is sent out each month to them. A number of residents were complimentary regarding the activity organiser’s enthusiasm and commitment to making all the events good fun. Resident meals were varied and nutritious and the residents could choose from the menu each day. Comments included, “Lovely food”, “Nice meals” and “I have no complaints”. The accommodation is very spacious and well maintained to ensure residents are comfortable and safe. Areas seen were clean and residents had brought in personal items from home to help make their bedrooms feel special to them. Bedroom doors lock to ensure resident privacy. Staff had been recruited correctly and were also receiving training to provide a care team with the knowledge and skills they need to protect and meet the needs of the residents. This helps to ensure good outcomes for people. The manager is supported by a committed staff team who focus on providing a safe and happy environment for the residents. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: It would be beneficial to undertake the following assessments to help staff monitor residents’ health and welfare. Firstly, a nutritional assessment for those who are at risk from problems associated with their diet. Secondly, an assessment for monitoring the condition of a resident’s skin if they are at risk of developing pressure sores due to frailty and ill health. The date medicines were received in the building for been entered on the previous month’s medication charts. This was however not the case for the medicine charts seen at the time of the inspection. The manager was reminded Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 8 of this practice, as staff are accountable for all medicines received. This also keeps the medicine charts accurate for the purpose of conducting an audit (check) of medicines administered. The manager should complete a competency assessment for staff who administer medicines. This will ensure the staff have the skills and knowledge to administer medicines in a safe manner. Monthly checks of medicines administered by staff and residents who administer their own medicines should be completed in more detail as to what the check entailed and action taken to resolve any problems. Liquid soap should be placed in the bathrooms to minimise the risk of cross infection for the residents. The training matrix should evidence details of courses offered to staff and dates of attendance. This will help with identifying training needs. Skills for Care Induction Standards should be given to all new staff as these provide good information for the employee when they commence work. 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. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 9 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 Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 10 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): Standards 1,2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had been provided with details of the service and a contract that included terms and conditions of residency. Residents were admitted following an assessment so that the staff were able to ensure that their care needs could be met. EVIDENCE: The Service User Guide and Statement of Purpose were displayed in the main hall for residents and relatives to view. These documents are a brochure, which contain details regarding the service and the care provision. The manager stated that there had been no change to the documents since the last inspection. The new Certificate of Registration was displayed. A care management assessment was seen for a resident who had come to the home for short term care (respite). No long stay (permanent) residents have been placed at the home since the last inspection. The assessment completed Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 11 by social services provided the manager and staff with the information they needed to ensure they could provide the correct level of care and support to the resident. The manager also meets residents prior to their arrival to discuss their care. The assessment covered areas such as, mobility, sight, continence, hearing, dental and personal care, communication, social background, diet, past and current medical history and medicines. Any risk to the resident had also been recorded as this may affect the level of care and support the staff need to give. With regards to the admission process a relative made reference to receiving good information regarding the home and that the staff took lots of interest in sorting out the care needed. On occasions a resident may need to be admitted in an emergency. On the second day of the inspection staff were dealing with an admission of this nature and they were seen to provide plenty of reassurance to the resident and also made contact with social services regarding the resident’s placement at the home. Good communication was evident as staff tried to get further health details to ensure they could provide the necessary care and support to the resident. A resident who was staying at the home for a couple of weeks said, “I could not have better care and am enjoying being here”. Likewise another resident said, “I like it here”. Standard 6 was not assessed, as intermediate care is not provided at the home. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 12 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): Standards 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. Residents’ health care needs were identified in a plan of care and medicines were administered safely to them. Residents were observed to be treated in a respectful manner. EVIDENCE: As part of the case tracking process two resident care files were examined. This included a resident who had been admitted for respite care and a resident who has been accommodated for a long period of time and who needs a lot of care and support from the staff. An individual plan of care was in place for each resident and the information had been collated from the care needs’ assessment and by getting to know them. The care plans had been reviewed each month to reflect any change and the resident had been consulted regarding the care they need. Discussion with the manager and staff confirmed a good understanding and knowledge of the care needs of a number of residents and also the assistance they needed from community based health professionals. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 13 Resident care plans identified health and social care needs, for example, mobility, diet, continence, communication, skin care, medicines, and relevant medical and social history. A person centred plan of care gave a good overview of the resident’s health care to ensure good outcomes for them. The care plans gave the staff information as to what the resident could do for themselves and what level of support they needed. A care plan for a resident who needs specialist input from the staff and a community dietician recorded good detail as to the care and nutritional support being received. Residents are weighed to monitor weight gain or loss however there is no nutritional assessment in place to help staff monitor any dietary risk. The staff looked at and they recorded whether or not there was any risk in relation to a resident’s mobility and what equipment they needed to encourage the resident’s independence. The introduction of an assessment for assessing the condition of a resident’s skin would also help staff to monitor whether a resident is at risk of developing a pressure sore. The district nurse service is called in when their clinical advice is needed. A community dietician assistant and a district nurse were visiting at the time of the inspection and both were complimentary regarding the care and support the staff gave to the residents. They said that staff were helpful and always explained to the resident the purpose of their visit and any procedure that was needed. Comments included, “Good communication with the residents”, “They take on board what we suggest” and “They monitor the residents carefully”. The care files showed GP and hospital appointments, district nurse and chiropody visits. A resident said, “I can see my GP if I am not well, the staff will always give them a cal. It was evident that the staff were aware of the importance of taking care of resident’s health and accessing outside help at the right time. Residents had aids and equipment to help them with daily living, for example, wheelchairs, walking sticks, walking frames, raised toilet seats and handrails. The home is on one level, which helps residents with their independence. Residents can care for their own laundry if they wish and also make their own breakfast. No resident at this time required special care in relation to his or her cultural or religious beliefs. Staff write up a summary of the care they give each day. Records seen were current and were linked to the plan of care. District nurse notes had been left at the home so that could refer to them at any time. A number of medicine charts were examined and these showed that the medicines were being administered by the staff according to the prescription. A sample of medicines was counted and compared with the records to check that Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 14 they were given at the prescribed dose. The quantity of medicines received in the building and staff signature responsible for their receipt had been recorded however the date the medicines were received had not been entered on the medicine chart. The previous month’s chart had recorded this detail. The manager was reminded of the importance of this practice, as staff are accountable for all medicines received and medicine charts must be kept accurately for the purpose of conducting an audit of medicines administered. Staff had received training in medicine awareness and it is good practice for the manager to complete a competency assessment to ensure all staff have the skills and knowledge for medicine administration. Risk assessments had been completed by the staff to ensure residents could administer their own medicines safely. A number of assessments were also completed at the time of the inspection following a review of this practice. Records were seen of monthly checks of the medicine charts to ensure medicines were being given as prescribed and also that residents were looking after their medicines safely. These could be completed in more detail to evidence the content of the check and action taken to resolve any problems. Residents interviewed were happy with way in which they were spoken to, a resident said, “The staff could not be more polite”. Staff were observed knocking on doors before entering and assisting residents with various aspects of personal care in a professional and kind manner. Resident had keys to their doors and also lockable cabinets in their room to store items safely. There was a pleasant relaxed atmosphere and residents appeared comfortable with the staff. There was plenty of chatter and laughter. Residents made the following comments regarding the care: “Safe and happy here” “Very good indeed” “Quite happy here, pleased with care, home from home” Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards`12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to choose how they wish to spend their day and were seen to be offered a varied activities programme. Residents were served well-balanced meals to meet their nutritional needs. EVIDENCE: Residents interviewed were pleased with the atmosphere in the home and said that staff made it fee like a ‘real home’. Staff were able to sit with residents and relatives to have a chat and spend quality time with then. It was evident that the staff knew each resident well and had a good knowledge of individual need in relation to meals, assistance with personal care, family back ground and social interests. The residents choose to have their meals in the dining rooms on the units and lunch was seen as a social occasion. A resident was having a late breakfast and she said that the staff never minded what time they had to prepare it. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 16 A member of staff is responsible for organising the activity programme and residents said they enjoyed everything that was arranged. Comments included: “They have entertainment laid on for them, singers, play your cards right, deal or no deal, bingo” (relative) “One of the managers, Dave has a good rapport with all of the residents. He is the one who sorts all the entertainment for Sedgemoor. He keeps all the residents spirits up.” (resident) Residents were being offered a good range of activities and this included bingo, ten pin bowling, quizzes, music and carpet bowls. The newsletter for April 2008 was read and this provided residents with lots of information with regard to what is going on. Residents have the use of a bar, sweet shop and two pianos in the atrium. The activities organiser has created a file with information regarding events and a record of resident participation. The hairdresser was visiting and residents were able to enjoy their treatments in the hairdressing salon. Visitors arrived and left at various times of the day and we seen to spend time with residents in their own rooms or in the lounges and/or the atrium. A relative said, “You could not have better, the staff have been so kind.” Meals were served to residents in the dining rooms from heated trolleys. The dining room tables were neatly laid for lunch and approximately six people sit at each table. The menu for the day was displayed in the atrium and an alternative hot meal was available if residents did not want the set meal. Drinks and snacks were seen to be offered throughout the day. The residents said that the food was of a good quality and was served on time. Comments included: “If there is anything you don’t like, they do you something else to eat, always ready to help” “Lovely food” “It is ok, not always what I want” “Very nice food” The kitchen was found to be well stocked with supplies and the cooks offers home baking. Health and safety records relating to management of the kitchen and foods were found to be up to date to help protect the residents. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were confident their complaints would be listened to. Staff had been provided with good information as to what abuse is, thereby reducing the possible risk of harm to residents. EVIDENCE: The complaint policy and procedure was displayed in the home and residents interviewed said they had no worries at this time. Comments from residents included, “Always feel comfortable speaking to any staff member. They are all nice and helpful” and “Not worried about saying I am unhappy”. The complaint log was seen and this showed that one complaint had been received from a resident and one from a relative. The service manager is investigating the complaint by a relative. The resident complaint has been resolved to the satisfaction of all parties. A concern raised by a resident at the time of the inspection was addressed and an agreed plan of action was made with the manager and resident to sort the issues. The Commission are to be informed of the outcome. The staff receive abuse awareness training and staff files viewed evidenced dates of attendance. Staff also have access to Sefton and Liverpool’s Guide to the Protection of Vulnerable Adults. This document provides information on Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 18 how to report an alleged incident of abuse. One allegation came to the attention of the Commission and senior management is investigating this. Staff interviewed were aware of how to report a complaint or alleged incident. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 19 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): Standards 19,20,21,22,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in safe, clean, well maintained comfortable accommodation. EVIDENCE: Sedgemoor is a purpose built home which is divided into three units. It is on one level and residents can get around easily. The home is spacious and was found to be well lit, warm, very clean and pleasantly decorated. A resident said the home was “Very clean, well kept. Bed is kept fresh, towels changed regularly. No smells.” The hall had information regarding the service and CCTV cameras were operational in public areas only. A number of residents sit in the atrium or in the lounges on each unit. All have comfortable armchairs and coffee tables. There is also designated smokers’ lounge. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 20 Each unit also has a dining room with kitchen space. Bedrooms seen showed that residents had brought in items from home and each bedroom had been made personal to the resident. Colour schemes were pleasing and locks to bedroom doors enable residents to maintain their right to privacy and dignity. Residents have a call bell system and residents wore a pendant to call for help when away from their rooms. A resident said that they were happy with their bedroom and that it did not need any changes There were moving and handling hoists and bath hoists available to help the residents who were less independent. The bathrooms were very clean however liquid soap should be provided to reduce the risk of cross infection for residents and staff. Residents spoken with said there was always hot water. A contractor was visiting the home to test the hot water to ensure it was delivered to a safe temperature. The laundry room was well equipped and guidelines were seen to reduce the risk of cross infection. There are laundry facilities for residents who wish to take charge of their own laundry. With regard to fire prevention, emergency lighting was subject to a three monthly test by a contractor and records seen were up to date. There is a large spacious garden to the side of the building and designated patio areas. The gardens would benefit from landscaping and a lot more colour. No work has been done to improve the grounds since the last key inspection. Every day jobs had been completed by a maintenance person to help keep the home safe. The manager stated that plans are in place to paint the atrium and corridors. There is car parking space to the side of the building. Sedgemoor Care Home DS0000035911.V360393.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): Standards 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. Residents received care and support from trained staff who were recruited correctly. EVIDENCE: The staffing rota showed that sufficient numbers of staff were on duty to provide a good standard of care and support to the residents. Relatives made the following comments regarding the staff: “I feel that in Sedgemoor staff are a dedicated team who are hard working and reliable and this is shown by the high standard of all aspects of care given to their residents including my mother” “I believe that the staff are Sedgemoor do a wonderful job. They are all totally committed to their work and are wonderful with the residents” Staff on duty had a good rapport with the residents and were seen to give help to the district nurse and dietician assistant in a professional manner. Staff did not rush residents when helping them and a resident said, “They all take their time.” A number of care staff hold a senior care role and all care staff are supported by a good number of managers. No new staff have been employed since the last inspection. Examination of staff files showed that staff had been recruited safely. There was evidence of a Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 22 CRB (Criminal Record Bureau) disclosure and two written references, which had been obtained prior to appointment. The manager now keeps a list of all CRBs and at the request of Liverpool City Council these are in the process of being updated. New staff receive an induction and this helps to make sure staff understand what is expected of them and that the residents are cared for properly and safely. One file showed that the Skills for Care Induction Standards had been completed whereas another file showed a checklist only. The manager is aware that for any news staff the Skills for Care Induction Standards should be introduced. Following the key inspection in 2007 all staff have now received training in moving and handling. Staff are also offered training in food hygiene, first aid, infection control, moving and handling and fire awareness. A date was made available for further infection control training to ensure this is rolled out to all staff. Certificates for courses attended were on file and this also included courses in diabetes, dementia care and Parkinson’s Disease. A staff training matrix is now up in the office and this should be completed with course details and dates of attendance. Dementia training is planned again for this year and also a course on equality and diversity. The AQAA states that over 50 of staff have achieved an NVQ (National Vocational Qualification) in care at Level 2 and above. There was evidence of NVQ certificates in staff files and two staff are currently working towards a qualification. Sedgemoor Care Home DS0000035911.V360393.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): Standards 31,32,33,35,36,37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is competent and adept at ensuring the health and welfare of the residents and making the residents and relatives feel part of the home. EVIDENCE: The registered manager is Ms Patricia Donnellen. Ms Donnellan has many years experience in caring for elderly people and she holds an NVQ Level 4 in Management, which was obtained in January 2008. Ms Donnellan attends mandatory training with the staff and has also undertaken a course in dementia care. Residents, relatives and staff were complimentary regarding the overall management of the service and felt that they could come and see Ms Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 24 Donnellan at any time. It was evident that there was a good management structure with managers in post to support the care staff. The manager and staff were seen to respect residents’ rights to privacy and respect and make the residents’ stay comfortable and happy. Residents had been encouraged to give their opinions of the service and they also attend regular meetings. Resident satisfaction questionnaires from January 2008 were complimentary in all areas. The newsletter is also a good way of telling residents and relatives what is going on in the service and through this letter, residents are reminded that minutes of meetings are available. A service manager undertakes a visit to the home each month and compiles a report of their findings. This involves looking at building, talking to residents and staff and also checking a number of records to ensure they are up to date. Reports were seen for this year. The staff who were interviewed said that the manager holds staff meetings and also that they receive regular supervision and an annual appraisal of their work. This forms an essential part of assessing training needs and looking at personal development. Residents are encouraged to take control of their own money, however the manager is responsible for some monies held on their behalf. The financial records seen provided protection for the residents’ financial interests. The manager and staff have access to a number of policies and procedures. The manager to ensure they are in line with current practice and thinking reviews these. Policies were seen in relation to equality and diversity and staff look at assessing gender, belief, culture, disability and sexuality through the assessment and care planning process. Liverpool City Council are providing training in this area to ensure staff have a good awareness and understanding and continue to provide positive outcomes for the residents. The AQAA provided detail of health and safety checks of equipment and services to ensure the ongoing protection of the residents. A spot check was undertaken of the gas, electric, lifts, moving and handling equipment and these were found to be current. Fire prevention equipment was subject to an annual safety check and fire alarms tested weekly. Staff had received fire training and dates were seen for further training this month for the night staff. Fire drills had also been conducted. It was evident that the manager and staff work hard to provide a comfortable and safe environment for the residents and ensure they receive persona centred care. A staff member reported that it was a friendly and happy home. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It would be beneficial to undertake the following assessments to help staff monitor residents’ health and welfare. Firstly, a nutritional assessment for those who are at risk from problems associated with their diet. Secondly, an assessment for monitoring the condition of a resident’s skin if they are at risk of developing pressure sores due to frailty and ill health. The manager should complete a competency assessment for staff who administer medicines. This will ensure the staff have the skills and knowledge to administer medicines in a safe manner. Monthly checks of medicines administered by staff and residents who administer their own medicines should be completed in more detail as to what the check entailed and action taken to resolve any problems. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 27 2. OP9 The manager was reminded of the importance for entering the dates medicines are received in the building as staff are accountable for medicines received and medicine charts must be kept accurately for the purpose of conducting an audit of medicines administered. 3. 4. 5. 6. OP19 OP26 OP30 OP30 The grounds should be landscaped for the residents to enjoy. Liquid soap should be provided in the bathrooms to reduce the risk of cross infection. The staff training matrix should be completed to evidence course details and dates of attendance. Skills for Care Induction Standards should be given to all new staff as these provide good information for the employee when they commence work. Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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 Sedgemoor Care Home DS0000035911.V360393.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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