Inspection on 04/10/07 for Sedgemoor Care Home

This inspection was carried out on 4th October 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

Sedgemoor Care Home 02/11/09

Sedgemoor Care Home 26/08/09

Sedgemoor Care Home 17/04/08

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 09:00 4 and 5th October 2007 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.V343485.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.V343485.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.V343485.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of thirty (30) adults may be accommodated. Thirty(30) shall be in the category of OP. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. One (1) named female service user under 65 years of age within an overall total of 30 (OP) 21st February 2007 Date of last inspection 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. Each unit has ten single ensuite bedrooms, a selfcontained 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. There is a spacious enclosed garden with patio areas. The weekly fee rate for accommodation is based on an individual financial assessment and the basic fee rate is £85 upwards. Liverpool City Council completes these assessments. Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit took place as part of the unannounced inspection. It was conducted over a two day period for a duration of approximately fourteen hours. Twenty three residents were accommodated at this time. No permanent residents are currently being accepted as Liverpool City Council is looking to close another home and accommodate these residents at Sedgemoor. Residents who receive short term care or respite care are only being admitted 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 nine residents, five staff, and two relatives. The inspection was conducted with Ms Pat Donnellan, Registered Manager and with a senior carer. During the inspection three residents were case tracked (their care files were examined and their views of the service were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. All the key standards were inspected and also previous requirements and recommendations from the last inspection in February 2006 were discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents, relatives, staff and health care professionals prior to and during the site visit. A number of comments included in the report are taken from surveys and from interviews. An AQAA (annual quality assurance assessment) was completed by the 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. What the service does well: Sedgemoor presents with a warm friendly atmosphere and staff were observed to chat freely with residents and visitors. Residents were relaxed in staff company and were being given the necessary support they required. This was observed in relation to assistance with different aspects of personal care and with serving meals. Staff interviewed explained the importance of helping residents to maintain their independence and respecting their wishes and requests. Discussion with staff confirmed that they were knowledgeable regarding residents’ individual Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 6 care needs and their preferred routine. A resident said, “The staff don’t mind what time I get up and will make sure I can make my own decisions”. Residents and relatives were complimentary regarding the care. Comments included: “Very good care” “Lovely staff to help” “The staff will do anything for you like bathing, hair washing” “The care is tip top” “I can go to bed when I want” A full range of social activities is arranged for the residents and a senior carer oversees the programme. Residents have a newsletter, which they confirmed they enjoy reading. In house entertainment includes, music, cake baking, film shows, bowling, social bar and exercises; social nights are also arranged. A resident said, “There is something to join in most days and we have fun”. The home is pleasantly decorated and benefits from a spacious comfortable lounge/atrium in the centre of the building and a number of other lounges, which enable residents to have ‘quiet’ time if they wish. Residents are encouraged to ‘have their say’ regarding the overall service. They are given questionnaires to complete and attend meetings, which are held by the manager. Residents reported that all staff communicate well and that they are informed of what is going on at all times. What has improved since the last inspection? What they could do better: There was no evidence of a plan of care for a resident to ensure their care needs could be met by the staff. Care plans seen could also be more detailed with regard to the level of care and support required. This will ensure staff are fully aware of individual need and are given sufficient instruction on how best to promote the well being of the residents. Residents are supported to administer their own medicines however the manager must complete a risk assessment to ensure they are able to undertake this practice safely. This remains an outstanding requirement from the last inspection, timescale of 21/2/07 not met. Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 7 A number of documents relating to the employment of staff are kept with Liverpool City Council and therefore could not be examined. It would be beneficial to keep copies of staff application forms and CRBs (Criminal Record Bureau) disclosures for the purpose of inspection and for the manager’s information. The details required were obtained from Liverpool City Council however a CRB disclosure could not be located for one member of staff. No employees must commence employment prior to a CRB and/or POVA (Protection of Vulnerable Adult) check being obtained. Recruitment procedures must be robust to protect the residents. Staff must receive training in safe working practice areas to provide them with the skills and knowledge to undertake their work. This must include a rolling programme of training for moving and handling, food hygiene, infection control and first aid. No training has been arranged this year. The manager confirmed that all staff require moving and handling training, as current certificates are out of date. A lack of moving and handling training places residents at risk. A number of other good practice recommendations relating to care, management, health and safety and staffing are made within the report to improve the service and implement best practice. 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.V343485.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 Sedgemoor Care Home DS0000035911.V343485.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): Standards 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information regarding the service and care management assessments help ensure staff can meet residents’ health and social care needs. EVIDENCE: The main hall has information regarding the service for residents and visitors to view. The Service User Guide was available in resident rooms however a copy of this should also be on display in the main hall for prospective residents to see. This document provides comprehensive information regarding the service to enable residents to make an informed choice as to whether they wish to take up residency. A resident who was admitted for respite care said they had been made very welcome by all the staff. Since the last inspection no residents have been accepted for long term placement. Care management assessments completed by social services were on file for residents on short term placement. This information had been received prior to their admission and had been completed in varying detail. The manager confirmed that a staff member visits the resident prior to their Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 10 admission to discuss their care needs. This had not been recorded as part of the assessment process and staff tend to rely on the documents from social services. An assessment record by staff would be beneficial when collating the information to form the basis for a plan of care. Discussion with a resident confirmed that they were happy with the admission arrangements made. Intermediate care is not provided at Sedgemoor and this standard was not assessed. Sedgemoor Care Home DS0000035911.V343485.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): Standards 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s health and social care needs were not identified in a plan of care. A lack of risk management for residents who wish to administer their own medicines places then at risk. EVIDENCE: Residents have an individual file and as part of the case tracking process three care files were viewed. Two residents were receiving short term/respite care and one resident long term care. There was no plan of care for a resident or any risk assessments in place to ensure their care needs were identified an could be met by staff. This was brought to the manager’s attention at this time. The remaining care files included basic information necessary to deliver the resident’s care. Care plans seen had been reviewed but not in detail to reflect the change and there was no evidence of agreement from the resident and/or their relative to this. Care required was recorded in ‘statement form’ and did not identify in full the care needs for each resident, the aim of the care plan or the intervention needed by staff to provide the care delivery. Better recording will help ensure all care needs are met in full. Areas identified included Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 12 communication, mobility, personal care, social back ground, The risk of falls had been identified in relation to a moving and handling assessment however this should include preventative and control measures to address safety issues whilst aiming for a better quality of life. Where any limitation is in place recorded the decision should be made with the resident and be recorded. Management of residents’ nutrition should also be better managed to evidence weight gain or loss. Residents are not routinely weighed however dieticians are approached for their advice when needed. Residents confirmed that they could see their GP when they want and a staff member was seen to accompany a resident for a hospital medical appointment. Good feedback regarding the overall service was received from a health professional and a district nurse stated that staff were pro active in seeking clinical input when needed. Visits by health care professional had been recorded and residents receive regular optical tests. Daily records had been completed by the staff to evidence the care and support given each day. Residents, relatives and a health care professional made the following comments regarding the care: “Good care” (resident) “The care is really good and the staff know what they are doing” (resident) “Have no worries about the care at all” (relative) “Very pleased with everything” (resident) “Always taken on board any suggestions in regards to patient’s medical care” (health care professional) “Very caring and holistic approach” (health care professional) “The care home does look after next of kin” (relative) Medicine administration sheets (MARs) evidenced staff signatures for medicines administered. Advice was given on signing prescribed creams when administered by staff. A list was available of staff signatures for those responsible for medicine administration. The manager and staff had undertaken checks to medicines administered in accordance with the procedure for safe handling, recording and administration of medicines. This means that the manager could guarantee the medicines were given out in a safe and appropriate manner at all times. Staff who administer medicines receive training however there was no evidence of an assessment of competency for staff responsible for this task. Medicines are administered from blister packs and dispensed from two medicine trolleys. The manager provides support to residents who wish to keep their own medicines. A risk assessment is required to ensure the resident is Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 13 capable of undertaking this practice safely and that they are aware that medicines should be kept secure in their rooms. Some medicines were not safely stored. The medicine policy for staff referral was available and since the last inspection this had been deemed as a working policy document. Residents interviewed confirmed that they get their medicines on time. Staff were observed to be respectful in their manner and residents’ preferred name, foods and routine are also discussed on admission. Staff interviewed gave examples of how residents’ privacy should be respected and this included male staff assisting male residents with personal care. Bedroom doors have been fitted with locks and staff in the case of an emergency can open these. Residents can meet their visitors in private or in the communal areas if preferred. Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 14 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 can choose how they wish to spend their day and are given wholesome nutritious meals according to what they would like to eat. EVIDENCE: Sedgemoor presents with a warm welcoming atmosphere and a resident reported, “The home is very nice indeed”. Residents interviewed stated that the routine was relaxed and that they could choose within reason how they would like to spend their day. A number of residents attend the home for short stay only and enjoy the company of other residents and staff. Visitors were seen at various times of the day and those spoken with said that the staff were welcoming at all times. It was reported that, “If any resident do not have a visitor staff will sit down and speak to them about different things”. Residents are able to spend time in their rooms or sit in the lounges, dining rooms or the spacious atrium, which has large screen TV and social bar. A pay phone is available for resident use. Staff accompany residents on shopping trips and outings. Residents are going to the pantomime at Christmas. A senior carer oversees the social programme and residents are able to participate in a good range of activities including, film shows (with ice creams), music, armchair exercises, bowling, sweet shop, cake Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 15 making and social evenings. A monthly newsletter is popular and provides details of forthcoming events, staff achievements, results of competitions and quiz questions. A resident said, “The quiz questions are good and make you think”. A record of residents’ participation for social arrangements should be recorded to evidence their enjoyment. A basic social history is recorded within the plan of care on admission. Members of the clergy visit the residents to enable them to continue with their chosen worship. Holy Communion is also offered. Residents had brought in personal items from home for their bedrooms and they appeared ‘homely’ in appearance to help the residents to settle in. Meals are prepared in the main kitchen and transferred via heated trolley to individual units. Staff assist with the serving of meals and the majority of residents sit in the dining rooms on each unit; tables were laid for lunch. Residents can have meals in their own rooms if preferred and staff were seen to give prescribed nutritional drinks when needed. The menu is rotated every four weeks and also the menu for the day is displayed on a board in the atrium. Residents are offered a choice of hot and cold meals at lunch and tea time. Dietary requirements are noted in the care files and the cook advised of this information. This ensures residents receive the foods they like in accordance with any diet control needed. Staff were observed to serve meals in an unhurried fashion. Resident comments regarding the food include: “Very good food” “The meals are tasty and we get a nice choice” “The portions are fine” “We have plenty to eat” There were good supplies of fresh, frozen and dry goods to ensure the cook provides well balanced meals. Sedgemoor Care Home DS0000035911.V343485.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): 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. Polices and procedures are in place to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. EVIDENCE: A summary of the complaint policy is displayed for residents and/or their relatives to view. Residents and relatives interviewed had no concerns at this time and reported that they would speak to the manager and staff if they were at all unhappy. Discussion with staff confirmed that they would also report any concern or complaint to the management. The Commission has received not any complaints since the last inspection. The AQAA and complaint log evidenced that five complaints had been received ‘in house’. One complaint was upheld and there are no outstanding investigations at this time. An individual record of each complaint should be recorded to ensure records are kept in accordance with Data Protection. The majority of staff received adult protection training last year and a copy of Liverpool and Sefton’s Guide to the Protection of Vulnerable Adults is available. This protocol is used as part of the adult protection training. A staff member described what constitutes abuse, how to report an allegation and how residents’ rights should be protected. This was discussed in relation to care needs, promoting independence and individual choice. Sedgemoor Care Home DS0000035911.V343485.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): Standards 19,20,21,22,25,25 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 comfortable, clean, and safe accommodation. EVIDENCE: Sedgemoor is a purpose built home with three units. The entrance hall has information regarding the service to welcome residents and visitors. All areas seen were pleasantly decorated and subject to a rolling programme of maintenance and refurbishment. Each unit has two lounges, a dining room and bathing/toileting facilities. The lounges and dining rooms are comfortably furnished and a large lounge/atrium, which is the central point of the home, also presents as a pleasant area to sit in. This room has a social bar, piano, widescreen TV and billiards table. A hairdressing salon enables residents to have their hair done in comfort. Accommodation is based on a single level and does not restrict access for the residents. Hand rails are in place in the corridors and the bathrooms are equipped with moving and handling equipment to assist those less able. A Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 18 shower facility is available in the ensuite bathrooms to offer residents a choice of bathing facilities. There is a smokers’ lounge which, has been risk assessed as providing suitable space. Residents have the use of a call bell with an alarm facility. Residents carry a pendant, which can be activated when help is required. Bedrooms seen were individual and bright and airy. Residents can lock their doors if they wish to provide privacy. Residents interviewed said, “My room is fine”, “I like my room”, “Am happy with the colour” and “It is pleasant”. The self-contained kitchens enable residents to make their own hot drinks thus encouraging independence. For health and safety, hot water temperatures had been checked by a contracted engineer to ensure the hot water was delivered to a safe temperature. A spot check should also be undertaken prior to bathing residents to ensure the correct temperature is maintained daily. Emergency lighting had been tested monthly in accordance with fire prevention checks for the safety of people in the building. The laundry was well equipped and staff had access to gloves and aprons in accordance with infection control guidelines. These were seen to be used at the appropriate time. The home was clean and there were no unpleasant odours. The gardens are enclosed and there are designated patio areas with garden furniture for the residents. The garden would benefit from planting flowers to provide colour and enjoyment for the residents. Sedgemoor Care Home DS0000035911.V343485.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): Standards 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A lack of robust recruitment procedures and staff training place residents at risk. EVIDENCE: The staffing rota evidenced sufficient numbers of staff on duty to provide care and support to the residents. Agency staff are occasionally used when a permanent member of staff cannot work a shift. Residents and relatives reported that they were pleased with the attitude and professionalism of the staff and comments included, “Nice staff”, “Very good people”, “The staff are lovely and very good” and “Nothing is too much trouble for the staff. No new staff have been employed since the last inspection and the residents are cared for by a stable work force. Staff application forms are kept at Liverpool City Council and it is recommended that for new staff employed a copy of the application form should be kept at the home for the purpose of inspection and for the manager to evidence past employment and experience. A record of CRB disclosures was not on file for three employees and Liverpool City Council was only able to verify that two had been obtained. A CRB is required for all staff members to ensure the ongoing protection of the residents. As CRBs are kept centrally it is also recommended that a list of CRB disclosures be kept at the home for the purpose of inspection. References are obtained for new staff from referees of past employers and they receive a job description and contract of employment. Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 20 The AQAA evidenced that the majority of staff have achieved an NVQ Level 2 or above and staff interviewed confirmed their qualification. NVQ training records should be kept accurately and evidence the level of training and date of achievement. The manager stated that NVQ certificates were not on file for all staff. A training matrix evidenced that all staff require moving and handling training. This training as last given in June 2006 and staff must receive this training to ensure residents are protected when transferred by staff. Food hygiene and first aid were given in 2006 however a number of staff require infection control training. The manager confirmed that no training has been arranged so far this year and a number of files did not evidence any certificates for training previously attended. The manager should conduct a review of the training programme to ensure staff attend courses in safe working practices. A staff member who started in 2006 attended a Skills for Care Induction Standards training day; a certificate was on file for this course. These standards help employees to work safely, effectively and prepare for Health and Social Care National Vocational Qualification (NVQ). No documents relating to the Skills for Care Induction Standards were available and this information should be obtained. This will help the manager ensure staff are competent in each outcome area and are capable of working ‘safely’. Sedgemoor Care Home DS0000035911.V343485.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): Standards 31,32,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensures residents and staff feel valued and health and safety policies and procedures help protect people. EVIDENCE: The registered manager is Ms Patricia Donnellan and Ms Donnellan has many years experience in caring for elderly people. Ms Donnellan holds an NVQ Manager’s Award and first aid certificate. Ms Donnellan attended a recent course on dementia care and wishes to attend the moving and handling course when arranged. Residents, staff and relatives were complimentary regarding her management skills and said that Ms Donnellan was “Fair”, “Approachable” and “Willing to do anything for the residents”. A good management team and senior care staff support Ms Donnellan in her role. Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 22 The manager and staff use a variety of methods to seek the views of the residents. Questionnaires are sent out and resident meetings are held. Residents are therefore able to give their opinion of the service. Surveys seen evidenced satisfaction in all areas. An annual government quality assurance review is also carried out. Senior management undertake a monthly visit to the home and complete a report of their findings. This includes meeting with staff and residents to ensure the service is running well. A report was seen for August 2007. Staff meetings are held and staff receive supervision. Supervision sessions enable staff to discuss training needs, care practices and general management of the home. Records were seen of supervision dates and staff confirmed that they could meet with the manager at any time. Ms Donnellan was described as being “Very supportive”. Residents are encouraged and assisted to look after their own money. The manager also maintains financial records on their behalf. Records seen were kept in good order to protect residents’ financial interests. Staff have access to a number of policies and procedures, which provide guidance for them in health and safety matters. Policy documents were seen for privacy, dignity and confidentiality; staff interviewed reported that these were discussed when commencing employment. Equality and diversity were discussed in relation to providing care on an individual basis thus providing positive outcomes for people. The manager is ware of taking into account gender, belief and culture and a booklet is made available for staff regarding expressing sexuality for elderly people. Records are kept of accidents that affect the resident however not all had been recoded using an official Health and Safety Accident Book. The manager was advised that the other record is to be kept in accordance with Data Protection. A spot check was undertaken of the gas and electric certificates to ensure the ongoing safety of people in the building. These were valid. Evidence was seen to confirm that moving and handling equipment was examined in June 07 however there was no safety certificate on file to evidence this. Once obtained a copy must be forwarded to the Commission. Fire instruction is given to staff when fire drills are conducted however the training matrix did not evidence any fire training since August 06. Formal fire prevention training is booked for November 2007 and must be given every six months to ensure staff know how to act in the event of a fire. The training matrix should be updated with the most recent fire training to evidence staff attendance. Fire alarms are checked weekly and fire prevention equipment is Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 23 subject to an annual maintenance contract. A fire risk assessment of the building is in place and it was reviewed in August 2007 to comply with the changes in the fire regulations. Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 24 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 X 3 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 (1) Requirement The registered manager must ensure all people using the service must have an up to date, detailed care plan. This will ensure that they receive person centred support and care that meets their needs. The registered manager must complete a risk assessment for those residents who wish to administer their own medicines to ensure they can undertake this practice safely. This remains an outstanding requirement from the last inspection, timescale of 21/2/07 not met. The registered manager must obtain a CRB disclosure and/or POVA (Protection of Vulnerable Adult) check prior to an employee commencing employment. This will ensure recruitment procedures are robust to protect the residents. The registered manager must provide training for staff in moving and handling to ensure residents are protected whilst DS0000035911.V343485.R01.S.doc Timescale for action 05/11/07 2. OP9 13 (2) 19/11/07 3. OP29 Schedule 2 19 (1-6) 19/11/07 4. OP30 18 (1) (c) (i) 13 (1) (5) 19/11/07 Sedgemoor Care Home Version 5.2 Page 26 5. OP30 18 (1) (c) (i) 6. OP38 23 (2) (c) being transferred. The registered manager must provide training in infection control to ensure residents are protected against the spread of infection. The registered manager must obtain the safety/maintenance certificate for the moving and handling equipment to ensure it is safe to use for transferring residents. 19/11/07 19/11/07 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. 3. 4. Refer to Standard OP1 OP3 OP7 Good Practice Recommendations The Statement of Purpose and Service User Guide should be displayed in the main hall for prospective residents to view. Staff should complete an assessment of need to accompany the care management assessments to assist with the plan of care The plan of care should include more detail to ensure health care needs are recorded in full. Resident and/or relative consent should be obtained to the plan of care where possible. Risk management for residents should include preventative and control measures to address safety issues whilst aiming for a better quality of life. Nutritional screening should be better managed to include resident weight gain or loss. There should be a record of an assessment of competency for staff responsible for medicine administration An activity record should be maintained to evidence resident participation and enjoyment. An individual record should be kept of complaints received in line with data protection guidance. Hot water checks should be carried out prior to bathing residents each day to ensure it is delivered to a safe temperature. DS0000035911.V343485.R01.S.doc Version 5.2 Page 27 5. 6. 7. 8. 9. 10. OP8 OP8 OP9 OP12 OP16 OP25 Sedgemoor Care Home 11. 12. 13. 14. OP29 OP30 OP30 OP30 A copy of staff application forms and CRBs should be kept on file to evidenced robust recruitment procedures. Skills for Care Induction Standards information should be obtained to assist the manager with them implementation. NVQ records should be maintained accurately to evidence course details. The manager should conduct a review of the staff training programme to ensure staff receive training in safe working practices. Sedgemoor Care Home DS0000035911.V343485.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Merseyside Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo L22 0LG 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 Sedgemoor Care Home DS0000035911.V343485.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. Re-publishing this information is in breach of the terms of use of that website. 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