Inspection on 22/05/08 for Sedlescombe Park Residential Home

This inspection was carried out on 22nd May 2008.

CSCI found this care home to be providing an Adequate 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

Sedlescombe Park Residential Home 15/05/07

Sedlescombe Park Residential Home 26/06/06

Sedlescombe Park Residential Home 28/12/05

Sedlescombe Park Residential Home 23/09/05

Sedlescombe Park Residential Home 26/08/04

Sedlescombe Park Residential Home 01/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Sedlescombe Park Residential Home 241 Dunchurch Road Rugby Warwickshire CV22 6HP Lead Inspector Michelle McCarthy Unannounced Inspection 09:50 22 and 29th May 2008 nd 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 Sedlescombe Park Residential Home DS0000004295.V365217.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. Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sedlescombe Park Residential Home Address 241 Dunchurch Road Rugby Warwickshire CV22 6HP 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) 01788 813066 01788 813066 sedlescombe@pinnaclecare.co.uk wolston@pinnaclecare.co.uk Pinnacle Care Ltd Mr Darren Yates Care Home 24 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (2) of places Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th May 2007 Brief Description of the Service: Sedlescombe Park is a large detached dwelling set in its own grounds, off the main Dunchurch Road in Rugby. The home is approximately ¾ mile from the town centre. There is a local bus route into the town along Dunchurch Road. A small range of local shops are near by. The Care Home is registered to accommodate up to 24 older persons with dementia. The accommodation is over two floors accessed via a passenger lift. Accommodation is mostly single rooms with some shared rooms. There are 2 lounges and a large conservatory has recently been built to the rear of the property, which serves as a dining room. The corridors throughout the home are narrow which makes it difficult for wheelchair users. The front entrance to the home is via two steps but there is alternative access for wheelchairs from the side and back of the home. Gardens to the front and rear of the property are landscaped. A drop off and turn area for cars with a small parking area is at the front of the property. The services provided for service users at Sedlescombe Park are on a personal care basis only for people with dementia. Nursing care is not provided in this home, nursing needs are met by the district nurse services. Written Information about the cost of accommodation was not available on the day of our inspection visit. Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection visit. This is the most thorough type of inspection when we look at all aspects of the service. We concentrated on how well the service performs against the outcomes for the key national minimum standards and how the users experience the service. Before the inspection, we looked at all the information we have about this service, such as information about: • • • concerns, complaints or allegations incidents previous inspections and reports. We do this to see how well the service has performed in the past and how it has improved. The manager completed the Annual Quality Assurance Audit (AQAA) comprehensively and sent it to us within the timescale we requested. We made two visits the home on 22nd May 2008 between 9.50am and 2pm and 29th May 2008 between 9.45am and 2pm. 23 people were living in the home at the time of our visits. It was the assessment of the home manager that the majority of people living in the home had medium dependency care needs. We used a range of methods to gather evidence about how well the service meets the needs of people who use it. This included talking to people who use the service and observing their interaction with staff where appropriate. We also looked at the environment and facilities provided and checked records such as care plans, risk assessments, staffing rotas and staff files. Three people using the service were identified for case tracking. This is a way of inspecting that helps us to look at services from the point of view some of the people who use them. We track peoples care to see whether the service meets their individual needs. Our assessment of the quality of the service is based on all this information, plus our own observations during our visit. At the end of the visit we discussed our preliminary findings with the home manager. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 6 The home has an ethos of building on a person’s strengths and abilities. This is reflected in the case files of each person where a ‘life history’, interests, important relationships and personal preferences are recorded to assist staff in providing ‘person centred’ care. We observed evidence of well being among the people with dementia living in the home. For example, people engaged with staff and other residents and expressed concern about the well being or feelings of each other. People living in the home are treated respectfully. They each have a plan of care describing what staff have to do to meet their needs. People living in the home are supported to maintain their independence and enduring interests which enhances their quality of life. Mealtimes are celebrated as a social occasion and residents benefit from a varied and nutritious choice of food. People living in the home can be confident that their concerns will be listened to and acted upon. What has improved since the last inspection? What they could do better: Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 7 The needs assessment of prospective residents must identify and record all their needs. This is to make sure the home can meet the needs of prospective residents before they are offered accommodation in the home. Care plans must be reviewed at least monthly so the service can be sure residents’ needs have not changed and the care they give remains appropriate. Residents with an identified risk of poor nutrition or weight loss must have their weight monitored at appropriate intervals to promote their health and well being. Accurate records of changes to the prescribed medication for people using the service must be maintained to protect residents from medication errors and comply with legislation. An accurate audit trail of medicines received into the home must be maintained to protect people from medication error or misuse. Timely requests must be made to the community nursing service when they are required to administer medication, including vitamin injections to make sure people have their prescribed medicine at the correct intervals. The manager must be aware of his role and responsibilities in responding to allegations of abuse in line with joint agency guidelines. This is to ensure that people living in the home are safeguarded from abuse. The ground floor bathroom must cleaned and broken or cracked tiles around the bath must be repaired. This is to protect residents from the risk of infection. Staff who have received a clear POVAFirst check must only be employed subject to induction and supervisory arrangements until a full satisfactory CRB and POVA check is received. This is to ensure that people living in the home are protected from the risk of abuse. 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. Sedlescombe Park Residential Home DS0000004295.V365217.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 Sedlescombe Park Residential Home DS0000004295.V365217.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): Standard 3 was assessed. Quality in this outcome area is adequate. A pre admission assessment of needs is made before people move into the home. Some needs are not identified during the pre admission assessment which leaves people at risk of not having their needs met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager told us it was usual practice for the manager or deputy to visit prospective residents to make an assessment of their needs before they are admitted to the home. We examined the case files of two people admitted since the last inspection. Both files contained evidence of a pre admission assessment of needs. Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 10 One file identified all the needs and abilities of the person. For example, ‘XXXX has no awareness of the time or day and does not recognise people’. The assessment in the other file failed to record that the person had dementia and any needs associated with this. This leaves this person at risk of not having their needs met. Sedlescombe Park Residential Home DS0000004295.V365217.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 were assessed. Quality in this outcome area is adequate. People living in the home are treated respectfully. They each have a plan of care describing what staff have to do to meet their needs. The home does not consistently manage medicines safely which puts people at risk of harm from medication errors. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was evident from observation that the personal care needs of people living in the home are met Three people, with varying levels of needs and abilities, were identified for case tracking. The home operates a ‘Best Friend’ system in which each resident has a member of care staff allocated to them as a key worker. We spoke to the ‘Best Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 12 Friend’ of one resident identified for case tracking and they were able to tell us about the person’s needs, enduring relationships, interests and life history. Each person had a care plan, daily records and monitoring records. Care plans were based on information secured during the initial care needs assessment. The ethos of the home is to build on the strengths and abilities of each individual. Each case file contained a summary of the strengths and abilities of the person and identified ‘requirements to assist daily living’. This gives staff information about the actions they need to take to meet the care needs of residents. For example, the care plan of one person with pressure sores identified that ‘staff must turn XXXX from left to right every hour’. A chart was available in this person’s room recording that the person was re-positioned as directed in the care plan. The care plan of another resident identified the person ‘requires observation and encouragement with bathing’ and included directions to staff ‘to assist her to the bath and stay with her to ensure her safety’. The psychological needs of people are considered. For example, a risk assessment for one resident with an identified potential for demonstrating challenging behaviour recorded that the person might ‘communicate by physical means’. The care plan documented signs that staff should be aware of and information about how to deal with challenging behaviour; ‘XXXX may express herself physically if she has become very frustrated. Some signs to look for are pacing or vigorous tugging at clothing and other people. Responds well to comfort, care and distraction eg offering a hand to hold’. This detailed care plan means that staff know how to reduce feelings of anxiety for this person which should improve her quality of life. There was evidence that care plans were reviewed with relatives and they had signed to indicate their agreement with plans of care. There was no evidence that care plans had been discussed or agreed with the residents themselves. There was some evidence that care plans are reviewed when there is a change in need. For example, the care plan for meeting one person’s nutritional needs was updated when a review of the person’s needs identified an improvement in their nutritional state. There was no evidence to demonstrate that care plans are regularly reviewed each month. Care plans should be reviewed each month so the home can be sure residents’ needs have not changed and the care they give remains appropriate. Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 13 Risk assessments were available for falls, nutrition and moving and handling. A risk assessment tool for identifying people at risk of developing pressure sores has been implemented since the last inspection. Records were available to demonstrate that when a decision is made to use bed rails it is in the best interests of the resident and risk assessments were in place to minimise the risk of entrapment. This complies with the requirement made at the last inspection to minimise the risk of harm from entrapment or restraint. Care plans are developed to minimise identified risks but the directions are not are not consistently followed. For example, a nutritional risk assessment for one person with a history of weight loss prior to their admission identified a moderate risk requiring that they should be weighed each week. The person was admitted in February and their weight had only been recorded once. This puts this person at risk of not having their healthcare needs met. Access to other healthcare professionals such as the district nurse, GP and optician are recorded in the case files of people living in the home. The systems for the management of medicines in the home were examined. Medicines are administered by senior care staff that have undertaken training provided by the local pharmacist in the safe administration of medicines. Medicines are stored in a dedicated, locked store room. The manager told us that the room is kept locked and medicine keys are kept on the person in charge of each shift. All the controlled drug (CD) balances were correct, accurately recorded in the CD register and stored correctly. The home has no trolley to transport the medicines to the people who live in the home. This increases the risk to the residents because there is nowhere to secure to the medicines in the event of an emergency. The manager told us that staff dispense and administer medication to one person at a time and lock the door in between to maintain the security of medicines. We examined the medicine administration records (MAR) of the people involved in case tracking and audited the amount of medicine remaining against the signatures recorded on the MAR. There were discrepancies in the audits sampled that demonstrate that the service does not consistently manage medication safely. MAR charts had a facing page with an identification photograph of the person and a list describing the action of each of their prescribed medicines. Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 14 One person’s records indicated that medicines had been given as prescribed. On another person’s MAR chart it was evident that a telephone instruction had been taken from the GP to reduce the dosage of Quietiapine (a sedating medicine) by omitting the morning tablet. The MAR chart had been amended by a member of staff. It is not safe practice to accept telephone instructions to alter the medication of residents without maintaining detailed and accurate records, or requesting written instruction using a fax machine. This puts residents at risk of harm from medication errors. When we examined ‘blister packs’ the morning tablets had not been dispensed from the packaging, as per instructions, except for one occasion when the tablet had been dispensed from the ‘blister pack’ but had not been signed for. We cannot be certain whether this tablet was given or disposed of as there was no explanatory code or notes recorded on the MAR chart. The third MAR chart examined recorded the person was prescribed a Vitamin injection every 3 months. The MAR chart did not record the date of the last dose given or the due date of the next dose. The manager told us that a system was in place to confirm when the district nurse is due to administer medicines and a separate record of this was maintained. When we examined this record it was evident that this person’s vitamin injection had not been given when it was due one month previously. This puts this person’s health at risk because they have not received their medicine as prescribed. People living in the home were observed to be treated with respect and their dignity maintained; for example, personal care was provided in private and residents were spoken to respectfully. During observation of working practice it was evident that staff are knowledgeable about the likes and dislikes of people living in the home and were kind, caring and attentive towards them. Sedlescombe Park Residential Home DS0000004295.V365217.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 were assessed. Quality in this outcome area is good. People living in the home are supported to maintain their independence and enduring interests which enhances their quality of life. Mealtimes are celebrated as a social occasion and residents benefit from a varied and nutritious choice of food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an ethos of building on a person’s strengths and abilities. This is reflected in the case files of each person where a ‘life history’, interests, important relationships and personal preferences are recorded to assist staff in providing ‘person centred’ care. We observed evidence of well being among the people with dementia living in the home. For example, people engaged with staff and other residents and expressed concern about the well being or feelings of each other. Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 16 The home does not have a planned programme of activities but staff support people living in the home to participate in activities and plan how to spend their time on a day to day basis, depending on their preferences for that day. It is recommended that the home maintain a record of group or individual activities to demonstrate how they meet peoples’ social and recreational needs. Residents ‘pottered’ around the home freely, making use of the communal space. Staff spoken to were familiar with the preferences of residents and the type of activities that might engage and stimulate each individual. The home has an open visiting policy. People are encouraged to maintain links with their family, friends and local community. Residents told us their visitors are made welcome. At 12.30pm staff invited residents to have their three course midday meal in the bright, pleasant surroundings of the conservatory dining area but some chose to remain in the lounge area or their own rooms. Tables were beautifully set with linen tablecloths and slip cloths which lent a ‘restaurant type experience’ to the social occasion of people coming together to enjoy their meal. Residents were offered a starter of soup or fruit juice followed by a choice from sausage plait, vegetable pasta bake or fish pie accompanied by broccoli, new and mashed potatoes and gravy. Dessert was a choice of pavlova or peaches and cream. Staff offered each resident a choice of meal at the table; those people who found it difficult to choose were assisted by staff who brought the meal to them as a visual prompt. The meal was served from a heated trolley from the kitchen and was beautifully presented, nutritious and tasty The most recent Environmental Health Officer’s inspection of the home’s kitchen awarded a Silver Standard for Food Hygiene in August 2007. Sedlescombe Park Residential Home DS0000004295.V365217.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 were assessed. Quality in this outcome area is adequate. People living in the home can be confident that their concerns will be listened to and acted upon. The manager’s lack of awareness of his responsibilities in responding to allegation or suspicion of abuse does not safeguard people from potential harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a formal complaints policy which is accessible to people living in the home and their families. People are encouraged to raise their concerns with the manager. Residents were observed to be familiar with the senior staff on duty and felt confident to make requests. This suggests residents would be confident in raising concerns with staff. The home maintains a record of complaints and their response. They have recorded one complaint since the last inspection regarding a resident being dressed in clothes that belonged to another resident. Evidence was available of a timely and objective response; the complaint was investigated, upheld and resolved. Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 18 There has been no information shared with us since the last key inspection that raised any concerns about this service. Staff training matrix records that the majority of staff have had recent training in abuse awareness. This should mean that staff can recognise symptoms of abuse and know what action they should take. This should safeguard people living in the home from harm and complies with the requirement made during the last key inspection for staff to have abuse awareness training. It was evident through discussion with the manager that he is not fully aware of his responsibilities in responding to allegations of abuse. He was not aware of joint agency (including police and social services) guidelines and was not confident about the appropriate agencies to contact or in which priority. The manager is required to know his role and responsibilities in responding to allegations of abuse to safeguard people from harm. We recommended that a copy of the local joint agency guidelines is obtained for reference in the home. Sedlescombe Park Residential Home DS0000004295.V365217.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 and 26 were assessed. Quality in this outcome area is adequate. Residents benefit from homely and ‘lived in’ surroundings but some working practices do not protect people from the risk of infection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Accommodation is provided over two floors with lots of narrow corridors and ‘nooks and crannies’ which a person with dementia may find difficult to navigate. Two communal lounges are available on the ground floor along with a bright and inviting conservatory dining area. All of the bedroom doors are painted and numbered and residents were given a choice of ‘door knocker’ for their bedroom door. This should help residents who have dementia to identify their own rooms more easily. In addition, some of Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 20 the rooms have a photograph of the occupant on the door to further identify who the room belongs to. There are pictures on each communal toilet to enable residents to identify where they are, but there is no further signage throughout the home. The communal lounges of the home are homely and lived in; there are lots of items such as games, dolls, magazines, books and soft furnishings available and easily accessible to residents. Independently mobile residents ‘pottered’ around the home freely. Decoration in corridors is tired and worn in places. Bedrooms varied in the quality of decoration and furnishings provided. Some contained matching furniture with carpets and soft furnishings to match the décor; other rooms were more sparse. Information in the AQAA told us that two rooms have been redecorated since the last inspection and one with new carpets and light shades to enhance them. Residents are encouraged to personalise their rooms with their own belongings such as photos, small items of furniture and ornaments. Single use hand towels have been placed into communal toilets and bathrooms so people can dry their hands on clean hand towels each time; these are then laundered appropriately. Commode pans are washed in the sink in the laundry room. Instructions were available to describe how commode pans should be cleaned. Washing commode pans in the laundry room continues to present a risk of contamination of clean laundry in the small area allocated as a laundry room. The service employs domestic cleaning staff for 25 hours each week, Monday to Friday. Some parts of the home were not clean. For example, one bedroom had an unpleasant odour and the armchair in this room was grubby, stained and smelly. The bath in the ground floor bathroom was dirty and some of the tiles around it were cracked and broken. This presents a risk of infection and is not pleasant for people to use. Sedlescombe Park Residential Home DS0000004295.V365217.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 were assessed. Quality in this outcome area is poor. There are sufficient numbers of staff on duty most of the time to meet the needs of people living in the home. Recruitment practices are not sufficiently robust to safeguard residents. Further training is needed to make sure people are cared for by competent staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager confirmed that the usual staffing complement for the home is: 7.30am – 2.30pm 2.30pm – 9.30pm 9.30pm – 7.30am 3 care Staff (sometimes 4 staff till 11am) 3 care Staff 2 care staff (who are awake throughout the night) Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 22 The manager’s hours are mostly supernumerary; he ‘works the floor’ to cover unplanned absence such as sickness. The home does not use agency staff to cover unplanned absence but relies on permanent staff working overtime. There is a member of catering staff in the kitchen between 8am and 2pm each day to prepare breakfast and the main midday meal. Kitchen staff prepare the evening meal but it is heated and served by care staff. The home has one person undertaking cleaning duties between 9am and 2pm from Monday to Friday; care staff undertake essential housekeeping duties at the weekends. Care staff undertake laundry duties. Three weeks of the home’s duty rota between 3rd May and 23rd May 2008 was examined and demonstrated that the staffing levels set by the home (in the table above) are usually achieved. Absence due to sickness was not covered on five early shifts in the three week period examined. This reduced the number of care staff from four to three. The manager was on duty for each of these shifts. The manager told us that staffing levels are ‘decided by head office’ and depend upon the occupancy levels of the home. No evidence was available to confirm that the needs and abilities of residents are considered when deciding how many staff are needed on each shift. One member of care told us, ‘Doing the laundry isn’t really a problem. We all pop in to the laundry room when we’re passing and put things in the washer or dryer. It doesn’t take up a great deal of our time.’ Five of the 12 care staff employed in the home have a National Vocational Qualification in Care (NVQ) at level 2 which, at 33 , is below the National Minimum Standard for 50 of staff to be qualified. However, a further six members of care staff are currently working towards this award which should mean that people living in the home are cared for by competent staff. The personnel files of two recently recruited staff were examined and both contained evidence of satisfactory checks such as Criminal Record Bureau (CRB), Protection of Vulnerable Adult (PoVA) and references. However, records evidenced that both staff members started working in the home with a before a satisfactory CRB was obtained. Both staff had a satisfactory PoVA First check before they started to work in the home and, although there was evidence of an induction programme, there was no evidence of supervision. This practice does not protect people living in the home from the risk of abuse. Care staff who have received a clear POVAFirst check can only be employed subject to the induction and supervisory arrangements stipulated in the Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. The employee can only work with vulnerable Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 23 adults in accordance with these prescribed supervisory arrangements until a full satisfactory CRB and POVA check is received. A training matrix is maintained and used to record staff training and to identify any gaps in learning. Records demonstrate that all staff complete an induction programme and receive mandatory training in moving and handling, infection control, first aid, abuse awareness, fire safety and food hygiene. This should mean that staff are updated in safe working practice. Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 24 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, 33 and 38 were assessed. Quality in this outcome area is adequate. The manager is qualified to run the service but some working practices and poor safeguarding procedures fails to ensure the safety of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post since January 2008 and is experienced in the care of older people. He is suitably qualified to run the home. He has a BA in Health Studies and has achieved the registered manager’s award (NVQ level 4). Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 25 The manager completed the Annual Quality Assurance Audit (AQAA) comprehensively and sent it to us within the timescale we requested. The service undertook surveys of the opinion of relatives and other stakeholders (such as GPs) in February 2008. The results were collated and analysed and action plans were developed to address issues raised. This was available on display on the office notice board. Action plans have not yet been reviewed against the objectives set. There was no evidence of any other review of working practices against outcomes for people living in the home. There was no formal action plans developed to address shortfalls made during the last inspection although evidence is available throughout this report demonstrating that the service has met the requirements issued at the last inspection. However, the manager told us that medication is audited every three months, care plans are audited by the operations manager for the home, regulation 26 visits are made regularly and unannounced visits have been made by the manager at night to review their practice. The service does not hold service users’ personal monies or valuables for safe keeping so standard 35 is not applicable and was not assessed. Service users are invoiced for additional costs such as hairdressing or chiropody. A sample of service and maintenance records were examined and found to be up to date; hoists were serviced in May 2008, Fire alarm systems are checked weekly, hot water outlet temperatures are recorded weekly and were noted to be within recommended limits and Electrical Portable Appliance Testing was completed in February 2008. The Fixed Electrical Installation Certificate (‘5 year electrical check’) was not available during this inspection visit or previous inspection visits. The health and safety of people living in the home is supported by the programme of mandatory training for staff. Medication management, recruitment procedures and the manager’s awareness of his responsibilities in responding to allegations of abuse must be improved to maintain the safety of people using the service. Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X N/A X X 2 Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement The needs assessment of prospective residents must identify and record all their needs. Timescale for action 31/07/08 2. OP7 15 This is to make sure the home can meet the needs of prospective residents before they are offered accommodation in the home. Arrangements must be made for 31/07/08 care plans to be reviewed at least monthly. This is so the service can be sure residents’ needs have not changed and the care they give remains appropriate. 3. OP8 12 Arrangements must be made for residents with an identified risk of poor nutrition or weight loss to have their weight monitored at appropriate intervals. This is to promote the health and well being of people using the service. 15/07/08 Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 28 4. OP9 13(2) Systems must be in place to maintain accurate records of changes to the prescribed medication for people using the service. This is to protect residents from medication errors and comply with legislation. 31/07/08 5. OP9 13(2) Arrangements must be made to account for all medicine received into the home and removed from the home. This is to make sure an accurate audit trail of medicines can be made to protect people from medication error or misuse. 31/07/08 6. OP9 13(2) Arrangements must be made to make sure timely requests are made to the community nursing service when they are required to administer medication, including vitamin injections. This is to make sure people have their prescribed medicine at the correct intervals. 31/07/08 7. OP18 13 Arrangements must be made to make sure the manager is aware of his role and responsibilities in responding to allegations of abuse in line with joint agency guidelines. This is to ensure that people living in the home are safeguarded from abuse. 31/07/08 8. OP26 13 Arrangements must be made to make sure the ground floor bathroom is clean. Broken or cracked tiles around the bath must be repaired. 31/07/08 Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 29 This is to protect residents from the risk of infection. 9. OP29 19 Systems must be in place to 15/07/08 ensure that staff who have received a clear POVAFirst check are employed subject to the induction and supervisory arrangements until a full satisfactory CRB and POVA check is received. This is to ensure that people living in the home are protected from the risk of abuse. 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. Refer to Standard OP19 OP27 Good Practice Recommendations A programme of redecoration and refurbishment should be developed. This should improve the quality of the environment for people using the service. A system should be implemented to make sure that the numbers of staff required to meet the needs of residents are available on duty at all times. The service should be able to demonstrate that the needs of residents are considered when deciding the number of staff required. This should make sure that the needs of people living in the home are consistently met in a way that is acceptable to them. 3. OP28 The service should be able to demonstrate that 50 of care staff have a National Vocational Qualification in Care at level 2 or equivalent. This should make sure that people living in the home are cared for by competent staff. Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 30 4. OP33 The service should be able to demonstrate the review of working practices and quality of care delivered to people living in the home. This should ensure that the home is run in the best interests of people living in the home. 5. OP38 Systems should be in place to ensure the effective maintenance of equipment and services in the home and records should be available for inspection. This should promote the safety of people in the home. Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Sedlescombe Park Residential Home DS0000004295.V365217.R01.S.doc Version 5.2 Page 32 - 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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