Inspection on 28/12/05 for Sedlescombe Park Residential Home

This inspection was carried out on 28th December 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 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 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 28th December 2005 09:30 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.V278358.R01.S.doc Version 5.1 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.V278358.R01.S.doc Version 5.1 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.V278358.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered manager (Anna O’Connor) must obtain a suitable management qualification (equivalent to NVQ 4) by December 2006. 23rd September 2005 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.V278358.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection for this inspection year to determine the progress made in meeting the requirements made at the last inspection. The inspection was carried out during the hours of 10.00 am and 8.00 pm on a weekday. A tour of the premises was undertaken with the registered manager to view the number of rooms available and the ratio of shared bedrooms to single bedrooms. Records were examined, which include care plans, risk assessments, staff rotas, medication administration records and maintenance and service contract documents in the home. 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 and have medium to high dependency needs. Conversations were held with four members of staff and three residents receiving long term and two visitors to the home at the time of inspection. Staff 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. Visitors expressed that they were happy with the care their relative was receiving and that staff were always welcoming. What the service does well: What has improved since the last inspection? The Statement of Purpose and Service User Guide are available and accessible to prospective residents and those residents living. Work has started to prevent the risk of cross infection in the home. Gloves and aprons are available and easily accessible to staff for use when attending to personal care needs. Bins for the disposal of pads in the communal toilet and bathroom are available and a laundry basket is available for the transport of dirty linen into the laundry. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 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.V278358.R01.S.doc Version 5.1 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.V278358.R01.S.doc Version 5.1 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, 2 and 5 Prospective residents their relatives and residents living in the home have information available to them, which could support them in making informed choices about day-to-day life in the home. Written contracts/statement of terms and conditions are issued to residents or their relatives ensuring that residents are aware of and accept the terms and conditions for living in the home. Potential residents and/or their family are able to visit the home prior to admission offering them the opportunity to make a choice about moving into the home. EVIDENCE: Copies of the Statement of Purpose and Service User Guide were available for examination at the time of inspection. The manager advised that copies of the documents are issued to residents and their relatives at the time of admission. Further copies are available in the office if requested due to previous copies being destroyed when left on display. Both documents provide residents and potential residents with information, which will help them to make an informed Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 9 choice about moving into the home and what can be expected when living in the home. The Certificate of Registration has been moved to ensure that it is displayed in an accessible place. A Statement of Terms and Conditions for moving into the home is available and copies were seen in resident’s files. The document provides residents with the information they need prior to moving in the home. Prospective residents and their families are invited to visit prior to admission giving them the opportunity to assess the facilities and suitability of the home. Three relatives said they had been given the opportunity to view and ask questions about the home before accepting a place for their relative. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 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, 10 and 11 The residents’ health, personal and social care needs were not clearly set out in individual care plans increasing the risk of an oversight in care and inconsistent approaches to challenging behaviour. The residents’ health care needs are not fully met by the home increasing the risk of deteriorating health and poor outcomes for the 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. At times the privacy and dignity of residents is met, this in inconsistent and may result in poor self-esteem and outcomes for the residents. Care plan documentation does not demonstrate that information related to care of residents at the time of their death was used effectively to ensure residents’ and their families are treated with sensitivity and respect which ensured their wishes are respected. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 11 EVIDENCE: Two care profiles were examined both of which showed inconsistencies throughout. One care profile mentioned that the resident had a ‘bad night’ in respect of behavioural problems there was no follow up statements to state how this was managed and no written information to reflect the type of day the resident had. There is evidence that the resident is disturbing other residents at night by entering their room and can become aggressive. There were no corresponding care plans to ensure consistency of approach and care for the resident by care staff. Staffing levels and the needs of the resident had not been reviewed to help manage this situation. There was no evidence of whether one to one care was considered to ensure that suitable support is available to the resident when behaviour causes disruptions. There was also no information to show an increase in staffing levels to ensure other residents in the home have consistent care when these problems occur. It was stated that a resident had fallen out of bed, there was no evidence that a risk assessment was carried out from which to develop a suitable plan of care and ensure preventative measures were put in place. Daily statements were not consistently made for day and night shifts and entries made were not timed to provide an audit trail of care given. One resident who has lost weight over a three month period had not been weighed since September and although there was a care plan indicating poor nutrition it was unclear and it could not be established whether this information was still current. The inspector was informed that the weighing scales were not available, as these are shared with another home. Care plans in all three profiles were evaluated in an ad-hoc manner. There was little indicating that a full evaluation took place and in one profile related to the resident losing weight there was no recognition that the residents weight had not been carried out frequently nor whether there was a change in the nutritional status of this resident. Equipment to support meeting the needs of individual residents is available these include nursing beds, special mattresses, hoists and assisted bathing facilities. The manager advised the inspector that a Continence Nurse Advisor had visited the home to reassess the resident’s continence needs. Information was not available to confirm that these assessments had taken place. There were no written details to indicate the assessed size of incontinence pads for night and day use by individual residents, which would help in future assessments. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 12 Medication procedures carried out in the home were examined and a number of unsafe practices, which could put residents at risk, were evidenced: • • • The cupboard used for the storage of prescribed medication does not have a door on it therefore medication continues to be insecurely stored. The controlled drug cupboard was being used to store other items not related to drugs. Controlled drugs, which should be administered every 3 days was not administered as prescribed. The resident was left for up to 8 days without the medication due to staff allowing the medication to run out and not requesting a repeat prescription. On three occasions’ periods of 5, 6 and 7 days were allowed to elapse before re-administering the medication. Written statements were not made in care plans to inform of these omissions and details of action taken to address these errors were not available. Other medication had also been allowed to run out of stock, which has been a concern on previous inspections. Allowing prescribed medication to run out of stock results in the omission of care and could have adverse effect on the health and well being of resident’s. Scribbling out over initials already made on MAR Charts was evident. It could not be confirmed whether medication was given as tablets not available in the blister pack. The electrical lead on the fridge has to be passed through a cupboard in order to be plugged in. Minimum and maximum fridge temperatures are not recorded. Initials made on MAR Charts were not legible. The drug trolley and medicine bottles containing liquid medication continue to be sticky and not clean, providing a good medium for bacteria to grow and a potential risk to residents. • • • • • • Residents in the home are dependent on care staff to support them in maintaining privacy and dignity. In one shared bedroom there was no curtain or screen provided to ensure the privacy of residents especially when attending to their personal hygiene. Staff were observed to address the residents in a respectful manner and address them by their preferred name. Two relatives stated that the staff were always caring and friendly and were happy with the care given. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 13 A care profile examined related to a resident who had died since the last inspection demonstrates that the records were not updated to reflect the deterioration in the persons condition and care given leading up to their subsequent death. There was no evidence that the family had been involved in making decisions, related to the care required and if they or their relatives’ wishes had been taken into consideration. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 There are no organised activities and the residents are often left with little or nothing to do increasing boredom that may result in depression and an increase of challenging behaviour. Residents maintain contact with family and friends with no restrictions on visiting. Community contact is limited and some residents rarely leave the home. The absence of a record of visitors to the home has the potential to put residents, staff and visitors at risk of harm. The residents receive a wholesome appealing and balanced diet in nice surroundings increasing the experience of a social event. EVIDENCE: A structured activity programme was not evidenced. Residents were seen to be watching television and one resident was playing a board game with their relative and a member of staff. Visitors were observed to visit the home during the time of inspection. Relatives stated that they were able to visit the home freely. It was observed that visitors were not consistently asked to sign the visitor’s book. Visitors felt that they were not expected to sign in and out of the home when they visited, Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 15 as there was not a visitor’s book. Two visitors did express concern about this. Stating that they had signed to confirm their visits at other homes and had been told that this was for their protection if there was an emergency. This is not good practice, as staff would have no idea who was in the home at any one time, which is dangerous for residents, staff and visitors. The residents can receive visitors in the lounge areas, the reception area and the residents’ own rooms if they wish. Two relatives spoken to stated that they are always made welcome and can go to their relatives’ own room if they wish. One resident attends a local day centre there were no further evidence was not available to confirm if the home has links with any community groups. The meal presented to residents at lunchtime looked appetising and well presented. A choice of stew or sausage was the main meal served with Yorkshire pudding, seasonal vegetables and potatoes. Pudding served was steamed toffee pudding, which was home made. Four week rotation menus were examined these evidenced that varied meals are offered to residents and records were maintained of meals actually cooked. Staff were courteous to residents and provided support and assistance to residents where needed. Residents were seen to enjoy their meal. Residents ate their meal in the dining rooms, which helped to encourage this time to be a social occasion and encouraged communication between residents. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Procedures are in place to ensure that complaints are dealt with promptly, in a structured manner, objectively and within stated timescales. The service ensures that resident’s legal rights are protected and have systems in place to protect them from the risk of abuse, increasing their feeling of safety and their quality of life in the home. EVIDENCE: A detailed complaints procedure is available and accessible to residents, staff and visitors in the home. The inspector was advised that there have not been any complaints received since the last inspection. Residents are encouraged and supported to exercise their legal rights. Access is available to advocacy services and leaflets/notices are available informing residents and visitors of the facilities available. A procedure for responding to allegations of abuse is available with clear guidance for staff to follow. Training records showed that some staff had attended recent adult protection training sessions. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 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: A tour of the home with the registered manager demonstrates that there has been minimal work done to address the concerns raised at the last inspection of September 2005. Sign posting for the home remains poor and is not visible from the road. The home was noted to be cold and radiators were either turned down low or not working. A resident sitting in the small lounge expressed that she was cold and asked for some socks. The weather on the day of inspection was extremely cold, the temperature outside registering less than minus 1ºC. The maintenance man visited the home at the time of Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 18 inspection to check the radiators. An electric heater was seen in one bedroom, it was not confirmed whether this heater was in use. Bedrooms were varied in the level of decoration some were homely and furnished with resident’s own possessions and others sparsely decorated, and uninviting. There were unpleasant smells in some bedrooms. Two bedrooms have a dividing door between them, this was not locked and residents who do not know each other use the rooms. One bedroom door was tied back with a piece of elastic to keep the door open. In one shared bedroom there was no curtain or screen provided to ensure the privacy of residents especially when attending to personal hygiene. The headboard had broken off a bed that was still in use. The bed had been in this state for several days and was still being used for the resident to sleep in. The maintenance man visited and mended the bed on the day of inspection. There are five shared bedrooms giving a percentage of 75 single bedrooms to 25 shared bedrooms available, rather than the 80:20 ratio expected. There has been no evidence to confirm that five shared bedrooms were the original number of shared rooms on transfer to the Commission. Ad-hoc decoration has taken place and the manager advised the inspector that plans are to change some carpets in the home in January 2006, which will include the stair carpet. There was no evidence of structured plans for the redecoration and refurbishment of the home to ensure that the décor is suitable for the residents accommodated in the home, which will take into account their mental health needs. The communal toilet situated off the main corridor by reception remains dirty and the piece of wood used to raise the toilet was still dirty stained and splintered. There is no paper towels dispenser and communal towels, flannels and toiletries are still being used. The small medicine cupboard on the wall was used to store toiletries some of which belonged to residents in the home; others had no identification as to whom they belong. This practice presents a potential risk for cross infection and an immediate requirement was issued for the registered provider to address the issue of the communal use of towels for residents and staff. The air vent in this toilet was also dirty. One of the bathroom facilities on the top floor of the home is not an assisted bath and is not suitable for use by residents in the home. The Inspector was advised that the bath is not used. The unsuitability of this bath does decrease the number of bathing facilities available to residents. The windows/frames on the top floor of the home are damaged and need replacing. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 19 A general risk assessment had been carried out to assess the safety of residents when accessing the front entrance of the home. The assessment did not contain sufficient information to support the prevention of possible risk to residents accommodated in the home. Keys to resident’s lockable space in bedrooms were left in the key locks there was no information to evidence appropriate risk assessments for those residents holding their own key. Records related to procedures in the kitchen were examined and demonstrate that they are maintained. Documentation examined includes the recording of food temperatures, fridge and freezer temperatures and cleaning. The laundry is a small room, which offers poor access for staff to carry out the laundry safely. There was no lighting in this room on the day of inspection. The home does not provide suitable facilities for staff to change and leave their outside clothing or to have an appropriate break away from residents. The inspector was advised that staff breaks can be taken in the conservatory, which is the area used for residents meals. The expectation is that staff will take their break with residents. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 20 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, 28, 29 and 30 The deployment and number of staff on duty are maintained at minimum levels and are not based on the identified care needs of residents accommodated in the home, which could lead to the omission of care and leave residents at risk. The absence of qualified care staff means that the skill mix of staff employed in the home is not adequate which could result in inappropriate care being given and deterioration in the quality of life for individual residents. Recruitment policies and procedures in the home ensures the support and protection of the residents. EVIDENCE: Staffing levels in the home have not changed there are three staff on duty during the day 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. Residents in the home have varying degrees of mental health problems. The manager informed the Inspector that night staff no longer carry out the comprehensive list of domestic duties. There remains two staff on duty at night, which is insufficient to meet the needs of twenty-four residents with medium to high dependency needs. Staff would also be unable to take a break as the dependency of residents requires to staff to assist plus only one member of staff would remain to cover three floors. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 21 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 do all the laundry in the home and make or finish tea for the residents and ensure that the kitchen is left tidy. There has not been any progress with increasing the number of staff trained to NVQ level 2. There are currently 2 of 14 (14.3 ) care staff with NVQ level 2 qualifications. The files of two new members of staff were examined all files contained evidence that appropriate checks had been carried out to ensure prospective employees were able to work with vulnerable adults. The outcome of criminal records checks were available in files. Documentation available demonstrates that not all staff are up to date with training. Statutory training is not up to date, which include fire and moving and handling. Records show that one member of staff had last attended fire training in August 2004 and two other members of staff had last attended in September 2004. Moving and Handling information indicate that one member of staff had last attended training in September 2002, another February 2003, two in November 2003 and one member of staff December 2003. Some staff had attended adult protection training and one day dementia care training. The files of the two staff also evidenced that the two members of staff had attended an induction period which covered topics related to Toppss and NTO targets. A list indicating training planned for 2005/06 was examined. The programme showed the availability of varied training for staff, which includes Dementia care, continence, care report writing, fire, first aid and infection control. Training records examined evidenced that the opportunity to attend these sessions had not been fully taken up by staff. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 22 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): 31, 32, 33, 34, 35, 36, 37 and 38 There are concerns that management systems and procedures in the home do not ensure that the health safety and welfare of residents are consistently promoted. EVIDENCE: A number of issues discussed in the previous report of September 2005 have been repeated in this report as limited action was noted to have been taken to address the requirements made. 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. There was no evidence that a structured approach to quality assurance had been implemented by the organisation. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 23 The presentation of the home, level of maintenance work and other resources required in the home did not provide evidence to demonstrate that accounting and financial procedures for the home are managed appropriately. There was no evidence of an ongoing maintenance programme in the home. The registered provider manages the budget for the home. A valid and current insurance liability certificate is displayed in the home. The registered manager informed the inspector that the home does not hold any money for residents, and that residents are supported in managing their finances by relatives or a representative. Secure facilities have been made available for safe keeping of money and valuables on behalf of residents. The site of the safe facility is not suitably placed. Documentation was not available to confirm that supervision of all care staff is carried out at least six times per year. Statutory training requirements were not up to date, which include fire and manual handling. Fire drills had not taken place in the home. Service and contract records are available and up to date. Records examined include maintenance, contracts and servicing documentation for gas, clinical waste and all other services supplied to the home. Resident aids and equipment have current service records, this includes hoists and assisted baths. Maintenance work has been completed and records completed to confirm daily or as required checks of fire prevention systems, which include alarms, fire drills and water. Tests on electrical appliances in the home were last completed in 2003. Legionella testing records were not available and an emergency lighting certificate stated that it was invalid due to faults on the system. The documentation goes on to state that the faults need to be rectified to validate the certificate. Evidence of the work being carried out was not available. 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. Visitors to the home are not monitored and a record is not maintained, which could cause a problem if an emergency should occur. COSHH risk assessments were available and had been updated to include action to be taken if and incident occurs. The laundry is an extremely small room offering very poor access to carry out the laundry safely. Paper towel and soap dispensers are not available in all communal areas where residents and staff wash their hands in the home. Suitable accommodation is not available for staff to take a break away from their working area. Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 2 2 2 2 2 STAFFING Standard No Score 27 2 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 2 2 2 3 2 Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 S.3 15 S.3 15 S.3 Requirement Timescale for action 31/03/06 2 OP7 3 OP7 4 OP7 15 The management must ensure that the resident and/or the family are involved in the care planning process where possible. The management must ensure 31/03/06 that the care plans are evaluated monthly and changes to care needs are clearly indicated. The management must ensure 31/03/06 that the care planned reflects the actual needs of the residents and when changes occur these are clearly indicated and new plans developed. More information must be 31/03/06 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. Outstanding from previous inspection dated September 2005. DS0000004295.V278358.R01.S.doc Version 5.1 Sedlescombe Park Residential Home Page 26 5 OP8 12, 13 6 OP8 17 15 14 17 S.3 S.4 The registered manager must 31/03/06 ensure that care prescribed is carried, which includes frequency of weights. Residents weight be monitored and recorded regularly. The managers must ensure that 31/03/06 all residents have full risk assessments and where a risk is demonstrated an appropriate plan of prevention must be devised. These risk assessments must be assessed monthly and changes in risk factors clearly recorded. 7 OP9 13(2) All medicines must be administered to the right person at the right time and at the right dose and all records must reflect the exact transaction. The MAR chart must be referred to before the administration, signed or the reason for nonadministration recorded immediately afterwards. Staff drug audits must be undertaken for all staff that handle medicines on a regular basis to demonstrate staff competence in medicine management. Appropriate action must be taken when discrepancies are found. 28/12/05 8 OP9 13(2) 28/12/05 9 OP9 13(2) 18(1) 19(1) 31/03/06 10 OP9 13(2) The refrigerator temperatures 31/03/06 (maximum, minimum and current) must be recorded daily and all must lie between 2°C and 8°C to ensure the medicines requiring refrigeration are stored in compliance with their product licences to guarantee their stability. DS0000004295.V278358.R01.S.doc Version 5.1 Page 27 Sedlescombe Park Residential Home 11 OP10 12(4) 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: • The dividing door between the bedrooms identified must be suitably locked to prevent access. • A screen or curtain must be provided in the shared bedroom identified at the inspection to ensure residents are provided with privacy and dignity at all times. Care plans must reflect the actual needs and care to be given to residents who are dying and at the time of their death. Daily reports must contain details of the care given. The manager must ensure that there are suitable activities during the day that meet the interests, hobbies and abilities of the residents, records must be available for inspection. The registered provider must ensure that activities and contact with the community is developed taking into account the interests and needs of the residents. A robust system for monitoring visitors to the home must be implemented. Outstanding from previous inspection dated September 2005 The registered manager must complete a detailed risk assessment to ensure that residents are able to: • Access the front entrance to the home safely. Outstanding from previous inspection dated September 2005 DS0000004295.V278358.R01.S.doc 31/03/06 12 OP7OP11 12, 15, Sch3 31/03/06 13 OP12 4, 16, Sch1 31/03/06 14 OP13 12, 16 31/03/06 15 OP13 Schedule 4(17) 31/03/06 16 OP19 13, 23 31/03/06 Sedlescombe Park Residential Home Version 5.1 Page 28 17 OP19 23 Plans for the re-decoration and refurbishment of the home must take into account the mental health needs of residents admitted to the home. The registered manager must have systems in place which monitors maintenance work needed in the home to ensure that the work is prioritised and carried out promptly so as not to leave resident’s at risk. The registered provider must ensure that there are sufficient and suitable bathing facilities, which are suitable to meet the needs of residents. 31/03/06 18 OP19OP38 23 31/03/06 19 OP21 23(2) 31/03/06 20 OP21 23 31/03/06 The piece of wood used to raise the toilet must be replaced with a more suitable material or removed and a suitable toilet installed. An action plan with time scales must be forwarded to the Commission. Outstanding from previous inspection dated September 2005 21 OP24 12(4)(a), 13(4) The registered manager must ensure residents’ provided with keys are suitably assessed, before a key is issued. The central heating system in the home must be serviced regularly and records maintained and made available for inspection. The registered manager must ensure that the temperature in the home is comfortable and appropriately heated to meet the needs of residents at all times. DS0000004295.V278358.R01.S.doc 31/03/06 22 OP25 23 31/03/06 23 OP25 23 31/03/06 Sedlescombe Park Residential Home Version 5.1 Page 29 24 OP26OP38 13(3)(4), 16 The registered manager must ensure that effective measures are in place to control the risk of infection. The following must be addressed: Suitable facilities must be available where staff can wash their hands. Paper towel and soap dispensers must be available in identified communal areas where staff and residents would be expected to wash and dry their hands to maintain standards of hygiene. The home must be kept free of offensive odours. Outstanding from previous inspection dated September 2005 The layout of the laundry needs to be reviewed to ensure that it is accessible and safe for use by all staff. Outstanding from previous inspection dated September 2005. Staffing levels must be reviewed to ensure that there is sufficient staff on duty to meet the needs of all residents accommodated in the home. 31/03/06 25 OP26OP38 23 31/03/06 26 OP27 18(1)(a) 31/03/06 27 OP28 18(1) Outstanding from previous inspection dated September 2005 The registered manager must 31/03/06 develop an action plan, which identifies timescales for ensuring that a ratio of fifty per cent of care staff are trained to National Vocational Qualification level two or equivalent. Outstanding from previous inspection dated August 2004 DS0000004295.V278358.R01.S.doc Version 5.1 Page 30 Sedlescombe Park Residential Home 29 OP30 18 The registered manager must ensure that staff attend planned training sessions. The registered manager must complete an audit of training attended by staff. Outstanding from previous inspection dated September 2005 The registered manager must be able to demonstrate what management systems are in place to ensure suitable running and management of the home. Evidence must be available to demonstrate the effectiveness of these systems. The registered provider and manager must ensure that suitable quality assurance and monitoring systems are in place, the outcome of these must be shared with the Commission and reports available for inspection. 31/03/06 28 OP30 12 31/03/06 29 OP31OP32 10 31/03/06 30 OP33 24, 26 31/03/06 31 OP34 25 32 OP35 23(2)(1) The manager must ensure that 31/03/06 the home is carried on in a way, which proves that it is financially viable. The registered manager is 31/03/06 required to take steps to ensure that secure and appropriately located facilities are made available, and used for securing items being held for safekeeping. Outstanding from previous inspection dated August 2004 The registered provider and 31/03/06 manager must ensure that all care staff are formally supervised six times a year, clear and informative records must be maintained and available for inspection. DS0000004295.V278358.R01.S.doc Version 5.1 Page 31 33 OP36 18 Sedlescombe Park Residential Home 34 OP38 23 35 OP38 12, 13 36 OP38 23 Maintenance and servicing work 31/03/06 carried out in the home must be kept up to date and appropriate action taken to address any action requested. The Registered Manager must 31/03/06 have systems in place, which ensures the health, safety and welfare of service users and staff. Action must be taken on issues highlighted in this report, specifically related to the administration of medicines in the home. Suitable accommodation must be 31/03/06 available for staff to take a break away from their working area. Outstanding from previous inspection dated September 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 3. Refer to Standard OP19 Good Practice Recommendations 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 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 4. 8. OP19 OP32 Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 32 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. Extracts may not be used or reproduced without the express permission of CSCI Sedlescombe Park Residential Home DS0000004295.V278358.R01.S.doc Version 5.1 Page 33 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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