Inspection on 23/09/05 for Sedlescombe Park Residential Home

This inspection was carried out on 23rd September 2005.

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

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

Other inspections for this house

Sedlescombe Park Residential Home 22/05/08

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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sedlescombe Park Residential Home 241 Dunchurch Road Rugby Warwickshire CV22 6HP Lead Inspector Yvette Delaney Unannounced Inspection 23rd September 2005 06:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 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.V253709.R01.S.doc Version 5.0 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 Pinnacle Care Ltd Mr A Dytham Mrs Anna Josephine O Connor 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.V253709.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered manager (Anna O`Connor) muast obtain a suitable management qualification (equivalent to NVQ 4) by December 2006. 26th August 2004 Date of last inspection 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. 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. 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. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine inspection, carried out during a Friday evening between the hours of 6.00 pm and 11.00 pm. A tour of the premises was undertaken. Records were examined, which include care plans, risk assessments, staff rotas and medication administration records for the home. Conversations were held with three members of staff and five residents receiving long term. There were no visitors to the home at the time of inspection. The inspection focused on the progress made on the requirements and recommendations made at the last inspection. The home provides a service for up to 24 residents requiring long-term care. Facilities and services are provided for older people with varying degrees of dementia. The inspection progressed with the support of an experienced senior carer who had worked at the home for sometime and therefore knowledgeable about the residents and the running of the home. Conversations were held with three care staff who were receptive and positive throughout the inspection with a good level of knowledge about residents in their care. Some residents who were able to hold some conversation were happy with the home and the staff. What the service does well: What has improved since the last inspection? It was not evident that marked improvements had been made in the home since the last inspection. There remains a lot of work to be done to address the requirements and recommendations from the last inspection of August 2004. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Copies of the Statement of Purpose and Service User Guide was not available therefore prospective residents do not have the information needed to help them and their families make a choice about where they live. Residents living in the home do not have information available to them, which could support them in making informed choices about their day-to-day life in the home. All residents are assessed prior to moving into the home and given assurances that their needs can be met by the home and the services offered. EVIDENCE: Copies of the Statement of Purpose and Service User Guide were unavailable for examination at the time of inspection. There were no documents available and accessible to prospective and current residents that would provide up to date information about the home and the services offered. The senior care staff on duty said that the documents were somewhere they were not found. The Certificate of Registration is not available in an accessible place and looks hidden away. The placement of the Certificate in this area does not allow potential residents and visitors to the home to easily confirm that the home is registered and for which services. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 9 Three care profiles were examined these contained copies of a detailed preadmission assessments. Copies of care management assessments, which had been completed by the referring Care Management Team, namely Social Services were available. Information was available in resident’s files to confirm that residents and relatives had been informed in writing that the home had the facilities and resources to meet the individual needs. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The health care needs of residents were not consistently assessed to ensure that current needs are identified, which could result in the oversight of care and possible harm to residents. Residents are not protected by the home’s policies, procedures and practices in dealing with medicines. Medication records were not accurate and the management of stock was not efficient. This places residents in a position of risk of harm. It is acknowledged that generally residents are treated with respect through good communication however where this does not occur residents could be caused distress. EVIDENCE: The three care plans examined demonstrate that staff have developed comprehensive individual care plans, which identify the personal care needs of residents currently accommodated in the home. Risk assessments had been carried out and the outcome and prevention measures had been identified with written details available. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 11 Communication with residents living at the home was limited due to the varying levels of confusion. Residents were unable to fully express their views and opinions. Information gathered relied on observation and interactions between residents and residents and staff. Evidence in care plans, care practices observed, the availability of special equipment for residents, which include special mattresses, nursing beds and bedrails confirmed that support was available to meet health care needs. Access has been secured for residents to a range of health care professionals and treatments. Care plans evidenced that a Dentist, Chiropodist, Optician, Community Psychiatric Nurse and GP had seen residents in the home. A residents weight plan indicates lost weight, but no further action documented. The inspector was informed that the weighing scales were not available, as shared with another home. Daily statements show care staff initialling and not signing and timing entries. Care plans were not consistently updated to provide details of resident’s current needs. The care plan of one resident detailed concern about an incident where behavioural patterns were changing and this behaviour was having adverse effects on residents and staff. There had been expressions of aggression towards other residents. There was no information to confirm that positive steps had been taken to address this deterioration in the residents’ condition in the long term. A review of the residents needs had not been carried out with the involvement of and support of specialists and other professionals. There was no evidence that action had been taken to direct staff on how to deal with this situation if it occurred again. There was no confirmation seen that assessments had taken place to ensure that residents continence needs are being appropriately met. Two pads were seen left on top of toilets and radiator, these were ‘sopping’ wet demonstrating that the wrong sides pads are being used and the opportunity to toilet residents not taken. Only size 5 pads were observed being used. Information was not available to confirm that residents have the right sized incontinence pad for night and day use. The medication ordering, storage and administration procedures carried out in the home were examined, these identified that there is a need for improvement in some areas, the following was observed: • Medications are stored in a locked room, the cupboards within the room containing prescribed medication did not have a door on it and therefore drugs were not securely stored. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 12 • Omissions were identified in Medication Administration Records (MAR Charts) where medication had been removed from their container but not signed to confirm that residents had taken the medication. An example of this is Digoxin, which had not been signed for on three occasions. Two different medications had been signed for indicating that the residents had taken the medicine but the tablets were still in the pack. Eye drops were not dated with the date of opening from which to ensure that they were only used for a 28 day period from the date of opening. A container containing insulin was dirty. The medication fridge was not locked. A repeat prescription was not requested for two different medications, one of which was out of stock for 6 days and the other for 4 days. One blister pack showed that 19 tablets had been removed but only signed for on 16 occasions. Five resident MAR charts checked state that medication had not been supplied, which includes drugs such as Thyroxine. There was no information to confirm that the medication was no longer required, whether they were discontinued or any enquiries made with the residents GP. Entries on Mar Charts had been scribbled out. There are no times indicated for when drugs will be administered, medication charts just state ‘morn’ or ‘night’. The drug trolley and medicine bottles containing liquid medication were sticky and not clean, this provides a good medium for bacteria to grow and a potential risk to residents. • • • • • • • • • • One resident had been transferred to a shared room following a fall. The inspector was informed that the family had requested this move. A moveable screen is available to provide an element of privacy. Individual residents toiletries were clearly identified but examination of wardrobes show that clothing was not labelled with the resident’s names and wardrobes contained other residents labelled clothes. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 The absence of a record of visitors to the home has the potential to put residents, staff and visitors at risk of harm. EVIDENCE: There were no visitors to the home during the time of inspection. Staff said that residents are able to receive visitors throughout the day. There was no visitor’s register/book available for the inspector to sign and be able to confirm visitors to the home. The senior carer stated that a record of visitors to the home is not maintained. Staff would have no idea who was in the home at any one time, which is dangerous for residents, staff and visitors. This could be further highlighted if an emergency should occur. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for these Standards were not assessed at this inspection. EVIDENCE: Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 The home is in need of improvements to provide a well-maintained environment with sufficient and suitable equipment and facilities, which ensure safe and comfortable surroundings, are provided for all residents. The lack of consistency in the standards maintained could impact on the health and safety of residents whilst reducing the quality of life and wellbeing experienced by the residents. EVIDENCE: The home is situated away from the road secluded behind a row of tall trees, which is good for security but the sign posting is poor and not visible from the road. A tour of the home was carried out with the senior carer on duty. Some bedrooms were homely and furnished with resident’s own possessions. A number of bedrooms are sparsely decorated, and uninviting. In one bedroom the position of an ornate chest of draws owned by the resident causes staff to abuse its use by using the piece of furniture to prop open doors causing deterioration in its condition. There were unpleasant smells in some bedrooms. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 16 The tour of the home also identified that there are five shared bedrooms, which decreases the number of single bedrooms available to 75 , which is less than the accepted ratio of 80 . The owner of the home has stated that there have always been five shared bedrooms. The current level of bedroom accommodation provided in the home will be reviewed at the next inspection. Some carpets in bedrooms were noted to have an unpleasant smell and stained. There are two lounges the smaller lounge housed two hoists and an unpleasant smell was present The en suite facilities in bedrooms do not offer much space in one bedroom the toilet seat raiser with frame could not be used due to the lack of space. Additional aids and equipment supplied for a resident could not easily be stored in the bedroom. A lot of space was taken up leaving limited useable space for the resident and the commode could not be accommodated in the en suite and the door had to remain open. The communal toilet situated off the main corridor by reception was dirty and had an offensive smell. A piece of wood was used to raise the toilet, this was dirty stained and splintered and the light was not working. There was no paper towels dispenser a communal towel was being used and the soap dispenser was empty. The small cupboard contained numerous toiletries with no identification as to whom they belong. There are no soap dispensers in bathrooms or toilets, and communal towels are used presenting a potential risk for cross infection. Access to the garden is through the conservatory where level access is available for all residents. The conservatory serves as a dining room for the residents. The front entrance to the home does not provide level access and requires residents to step up. The kitchen area was generally clean. Examination of the fridge showed it to contain cheese that had been opened and not dated or re-packaged properly. Uncooked bacon was defrosting at the bottom of the fridge on top of the milk and butter. The deep fat fryer contained dirty oil. Records examined demonstrate that food temperatures are not consistently recorded. Fridge and freezer temperatures indicate that they are maintained within a safe range. Cleaning records were not clear and do not identify the frequency with which cleaning should be carried out. Health and Safety poster was accessible to staff. COSHH risk assessments do not state action to be taken if an incident occurs. The linen room on the ground floor is overstocked with various items making access difficult. Staff lockers are also situated in this area there is not a separate staff room for staff to take a break. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 17 The laundry is an extremely small room, containing an industrial washing machine, dryers and a boiler. There is very poor access to carry out the laundry safely. The laundry room and the machines are dirty. Resident’s slippers were drying on a dirty windowsill. There were two laundry baskets one of which was dirty inside. Care staff undertakes the laundry during the night shift, which includes washing bed linen and residents personal clothing. This includes washing bed linen and residents clothes. The inspector was informed that a cleaner is available between the hours of 9.00 1m and 12 midday. The cleaners role then changes to a kitchen assistant, helping in the kitchen from 2.00 pm and 3.00 pm. The stair carpet is heavily stained and looks in need of cleaning or replacing. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30 The deployment and number of staff are maintained at minimum levels on both floors and are not based on the identified care needs of residents. The number of staff on night duty is not sufficient to meet the care needs of residents accommodated in the home. The time available to meet care needs is further decreased by the numerous housekeeping tasks required to be carried out at night, which could lead to the omission of care and leave residents at risk. EVIDENCE: Staffing levels on the evening of inspection were based on the minimum required. There were three staff on duty a senior carer in charge and two carers, this level was observed to be insufficient to meet the needs of residents accommodated in the home. The need for two carers to attend to residents was evident due to the high dependency levels observed. There are concerns about the number of staff on duty at night, two for twenty-four residents with medium to high dependency needs. It was not apparent that the layout of the home had not been taken into consideration when determining staffing levels. There is also a comprehensive list of domestic duties to be carried out by the night staff, which includes: • • • Preparing vegetables, potatoes must be peeled and breakfast trays set Washing up The kitchen is to be left tidy, cleaning and bleaching the sinks, work surfaces are to be wiped and bins are to be emptied and new liners put in place DS0000004295.V253709.R01.S.doc Version 5.0 Page 19 Sedlescombe Park Residential Home • • • • • • • Sweeping and mopping the floors Cleaning and scrubbing the toilets, downstairs toilets must be cleaned and floors mopped All washing and drying residents clothes and bed linen Ironing clothes (clothes to be passed up to member of staff on top floor). Ironing to be brought down when completed and placed outside residents bedrooms Both lounges/dining rooms to be vacuumed and dusted Vinyl chairs are to be wiped down with disinfectant and all waste removed Hallway must be vacuumed Within the above there were more domestic tasks on the list also mentioned was that staff should undertake 2 hourly care checks and read residents care plans reporting as and when necessary any situation or problem that should be noted. The extent of the work and time involved in undertaking the above tasks raised concerns about the time available to staff to provide appropriate care for residents in their care. This is further enhanced by the availability of only two care staff to care for 24 residents during a night shift. Information available from staff did not clearly demonstrate the qualifications held, what training had been completed and whether they were up to date with mandatory training requirements. Statutory training was evidenced to need updating for all staff; these include fire awareness training where staff have not attended two fire awareness training per year and infection control. There is one member of staff employed to clean the home between the hours of 2.30 pm and 5.30 pm. The home has a cook available between the hours of 8.00 am and 2.00 pm four days per week and 8.00 am and 1.00 pm on the remaining three days. Care staff are required to make tea or finish tea for the residents and ensure that the kitchen is left tidy. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 38 There are concerns that the health safety and welfare of residents are not consistently promoted. EVIDENCE: As discussed throughout this report there are a number of areas related to the homes management and operation, which need to be improved to ensure the safety of residents at all times. The level of maintenance in the home was observed to be in need of improvement to ensure that a safe environment is accessible to residents at all times. Some of which are as follows: Care plans examined were not consistently updated to provide details of resident’s current needs. Medication procedures carried out in the home were examined, these identified that there is a need for improvement. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 21 Visitors to the home are not monitored and a record is not maintained, which could cause a problem if an emergency should occur. Poor food and hygiene practices were observed examination of the fridge showed it to contain cheese that had been opened and not dated or repackaged properly. Uncooked bacon was defrosting at the bottom of the fridge on top of the milk and butter. COSHH risk assessments were available but do not state action to be taken if an incident occurs. The laundry is an extremely small room offering very poor access to carry out the laundry safely. The laundry room was also very dirty presenting risk of cross infection. A communal toilet was dirty and there were no light in this area. A notice had not been placed to state that the toilet was not to be used. The Certificate of Registration was not available in an accessible place and looks hidden away. Residents and visitors to the home would not be able to confirm that the home is officially registered as a care home. Poor practices were evidenced related to food hygiene procedures uncooked bacon was being defrosted whilst being placed on top of milk and butter in the fridge. This practice could lead to the risk of food poisoning. Procedures had not been implemented to prevent the risk of cross infection, practices observed include staff did not wear appropriate protective clothing and dirty washing was carried next to their clothes. Paper towel and soap dispensers are not available in the home and suitable bins are not provided in toilets and bathrooms for the safe and hygienic disposal of pads. Statutory training requirements were not up to date and the attendance at the minimum of 2 fire awareness training sessions per year had not taken place. Fire drills had not taken place in the home. Information on the chemical products used in the home did not provide staff with the information on action they should take if an incident should occur. Suitable accommodation is not available for staff to take a break away from their working area. Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 22 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 1 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 2 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 2 2 3 2 2 2 2 STAFFING Standard No Score 27 1 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 2 2 Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 23 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 OP1 Regulation 4, Sch 1 Requirement Timescale for action 31/12/05 2 OP1 5 3 OP1OP38 CSA Pt II, Sec.28(1) The registered manager must ensure that there is a suitable Statement of Purpose available in the home. A copy of the completed document must be forwarded to the Commission. The registered manager must 31/12/05 ensure that a suitable Service User Guide is available in the home. All residents must be issued with a copy of the Service User Guide. The information included in the document must reflect current practice in the care home. A copy of the document must be forwarded to the Commission. 31/12/05 The Certificate of Registration must be displayed in an accessible area of the home as stated in the Care Standards Act Part II, Section 28 (1). A Certificate of Registration issued under this part of the Care Standards Act in respect of any establishment or agency shall be kept affixed in a conspicuous place in the establishment or agency. DS0000004295.V253709.R01.S.doc Version 5.0 Sedlescombe Park Residential Home Page 24 4 OP7 15 5 OP7 15 6 OP8 12, 13 7 OP9 13(2) 8 OP9 13(2) 9 OP10 12(4) Care plans must be reviewed and updated monthly or more frequent if necessary to ensure residents individual current needs are identified. Where there is a change in needs a new care plan is written and implemented. More information must be included in care plans with regard to resident’s health and medical needs and interventions. Written information must allow for methodical monitoring and provide evidence that all health care needs are identified, professional and specialist services are accessed and health care needs are continuously reviewed. The services of a continence advisor must be accessed to ensure that the incontinence needs of all resident’s are appropriately assessed. The registered manager must make arrangements for ensuring that the safe administration of medication is adhered to at all times. The issues highlighted in this report. The registered manager is required to ensure that all medication is administered as prescribed. Outstanding from previous inspection dated August 2004 The registered manager must ensure that the care home is conducted in a manner, which respects the privacy and dignity of residents at all times: • Staff must ensure that residents have access to their own clothes at all times 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 25 and clothing belonging to other residents are not placed in the wrong rooms or worn by residents. • The registered manager must ensure that staff treat residents property with respect. The use of residents’ furniture to prop open doors must cease. The registered manager is required, in so far as is practicable, to ascertain and take into account the wishes and feelings of service users’ should they have a life limiting illness. Outstanding from previous inspection dated August 2004 A robust system for monitoring visitors to the home must be implemented. The registered manager must complete a risk assessment to ensure that residents are able to access the front entrance to the home safely. The registered provider must review the assisted bathroom facilities and plan how to achieve the ratio required in the standard. A copy of the action plan must be forwarded to the Commission for Social Care Inspection. This requirement was not assessed at this inspection. The registered provider must ensure that the communal toilet on the first floor is suitable and safe for use by residents. The room must be cleaned, the light bulb replaced and the piece of wood used to raise the toilet replaced with a more suitable DS0000004295.V253709.R01.S.doc 10 OP11 12(3) 31/12/05 11 12 OP13 OP19 Schedule 4(17) 13, 23 30/11/05 30/11/05 13 OP21 23(2) 31/12/05 14 OP21 23 31/12/05 Sedlescombe Park Residential Home Version 5.0 Page 26 15 OP23 23 16 OP24 12(4)(a), 13(4) 17 OP24 23 18 OP24 12(4) 19 OP26 13(3)(4), 16 material or a suitable toilet installed. An action plan with time scales must be forwarded to the Commission. The registered manager must ensure that residents are accommodated in bedrooms suitable to meet their changing needs. If a change of room is not possible a risk assessment must be carried out to ensure the safety of the resident. The registered manager must ensure residents’ are provided with keys unless their risk assessment suggests otherwise. Outstanding from previous inspection dated August 2004 The registered provider must ensure that the carpet on the main stairway is cleaned or replaced. The registered manager must ensure that all rooms accommodated by residents are suitably furnished. The registered manager must ensure that effective measures are in place to control the risk of infection. The following must be addressed: • Appropriate protective clothing must be readily available to and worn by staff when attending to residents personal care needs or involved in practices which involve a risk of cross infection. Suitable facilities must be available where staff can wash their hands. Paper towel and soap dispensers must be available 30/11/05 31/12/05 31/01/06 31/01/06 31/12/05 • • Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 27 in identified communal areas where staff and residents would be expected to wash their hands to maintain standards of hygiene. • Suitable bins must be available in toilets and bathrooms for the safe and hygienic disposal of pads. Laundry bins must be available for the safe and hygienic transport of dirty laundry. The laundry room must be cleaned to provide a safe environment in which to work. • • • 20 OP26 13 21 OP26 23 The home must be kept free of offensive odours. The registered manager must ensure that all staff practice strict food hygiene procedures to prevent food poisoning. Issues to be addressed include, the correct storage of food and ensuring that all stored food are sealed labelled and dated. The layout of the laundry needs to be reviewed to ensure that it is accessible and safe for use by all staff. Staffing levels need to be reviewed to ensure that there is sufficient staff on duty to meet the needs of all residents accommodated in the home. The registered manager must confirm that there is sufficient care staff on night duty to meet the needs of individual residents. Details of the systems put in place to ensure that care staff are available at DS0000004295.V253709.R01.S.doc 30/11/05 31/12/05 22 OP27 18(1)(a) 31/12/05 23 OP27 18(1)(a) 31/12/05 Sedlescombe Park Residential Home Version 5.0 Page 28 24 OP28 18(1) 25 OP29 19, Schedule 2 26 OP29 19, Schedule 2 all times when undertaking housekeeping duties and that the time allocated to carry out these duties are identified separate to that of care duties, must be forwarded to the Commission. The registered manager is required to devise an action plan for ensuring that a ratio of fifty per cent of care staff are trained to National Vocational Qualification level two or equivalent by 2005. Outstanding from previous inspection dated August 2004 The registered manager is required to ensure that, only following completion of a satisfactory police check (and satisfactory check of the protection of Children and Vulnerable Adults register), do individuals commence working at the care home. Outstanding from previous inspection dated August 2004 The registered manager is required to undertake a health and safety risk assessment, to include rigorous checks as to the fitness of the person(s) working at the care home, clearly demonstrating what measures are in place to safeguard service users’. A copy of which must be sent to the Commission. Outstanding from previous inspection dated August 2004 The registered manager is required to make sure that all the required information and documentation in respect of DS0000004295.V253709.R01.S.doc 31/12/05 30/11/05 30/11/05 27 OP29 19, Schedule 2(1) 30/11/05 Sedlescombe Park Residential Home Version 5.0 Page 29 persons working at the care home are held, (including a recent photograph). Outstanding from previous inspection dated August 2004 The registered manager is 31/12/05 required to ensure staff receive foundation training to National Training Organisation (NTO) specification within the first six months of appointment, which equips them to meet the assessed needs of service users, as defined in their individual plan of care. Outstanding from previous inspection dated August 2004 29 OP30 18 The registered manager must provide a written staff training and development programme for 2005/6. A completed staff training matrix must be forwarded to the Commission. This must include details of induction, statutory and NVQ training. The registered manager must complete an audit of training attended by staff. The registered manager is required to take steps to ensure that secure facilities are made available, and used for securing items being held for safekeeping. Outstanding from previous inspection dated August 2004 The registered manager shall take steps to ensure all staff receive regular training on fire DS0000004295.V253709.R01.S.doc 28 OP30 18(1)(c), 12(1)(a) 31/12/05 30 OP30 12 31/12/05 31 OP35 23(2)(1) 31/12/05 32 OP38 13(4)(c) 30/11/05 Sedlescombe Park Residential Home Version 5.0 Page 30 33 OP38 13(3), 13(4)(c) 34 OP38 13(3), 13(4)(c) 35 OP38 37 36 OP38 13 37 OP38 23 prevention/evacuation procedures within the care home. And ensure that the fire risk assessment is kept under review. Outstanding from previous inspection dated August 2004 The registered manager is required to take steps to ensure care staff use only appropriate, and designated hand washing facilities, after assisting service users with personal care tasks. Outstanding from previous inspection dated August 2004 The registered manager shall take steps to ensure protective clothing is made available and used by staff entering the kitchen. Outstanding from previous inspection dated August 2004 The registered manager must ensure that staff attend the minimum of 2 fire awareness training per year and fire drills are carried out. The registered manager must ensure that COSHH regulations are adhered to and a review of the risk assessment providing information on the chemical products used in the home must include the action to be taken by staff if an incident should occur. Suitable accommodation must be available for staff to take a break away from their working area. 30/11/05 30/11/05 31/12/05 30/11/05 31/01/06 Sedlescombe Park Residential Home DS0000004295.V253709.R01.S.doc Version 5.0 Page 31 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 OP8 Good Practice Recommendations The practice of using a bath book is considered to be institutional and should be discouraged. Outstanding from previous inspection dated August 2004 It is recommended that, residents weight be monitored and recorded regularly. Outstanding from previous inspection dated August 2004 The registered manager should produce a programme of routine maintenance and evidence of renewal of the fabric and decoration of the premises. The programme should include costing and dates for implementation. Outstanding from previous inspection dated August 2004 The registered manager must provide suitable signposting, which identifies the location of the home. The registered provider must review the assisted bathroom facilities and plan how to achieve the ratio required in the Standard. A copy of the action plan must be forwarded to the Commission. Outstanding from previous inspection dated August 2004 It is recommended that, the use of friends to provide employment references should where possible be discouraged. Outstanding from previous inspection dated August 2004 It is recommended that the registered manager actively participate in all aspects of the staff recruitment process. Outstanding from previous inspection dated August 2004 The registered manager should consider her office arrangements and identify a more suitable office space, which would afford her the time to fulfil her management and administrative duties. Outstanding from previous inspection dated August 2004 DS0000004295.V253709.R01.S.doc Version 5.0 Page 32 2 OP8 3 OP19 4 5 OP19 OP21 6 OP29 7 OP29 8 OP32 Sedlescombe Park Residential Home Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 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. 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