Inspection on 28/12/06 for Seeleys House

This inspection was carried out on 28th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Seeleys House 06/01/09

Seeleys House 16/04/08

Seeleys House 12/04/07

Seeleys House 30/05/06

Seeleys House 22/03/06

Seeleys House 06/09/05

Seeleys House 31/03/05

Seeleys House 30/11/04

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Hillview Farm

Dalewood Respite Care

Orchard,The

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Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Seeleys House Seeleys House Campbell Drive Knotty Green Beaconsfield Bucks HP9 1TF Lead Inspector Gill Gentles Unannounced Inspection 13 and 28th December 2006 09:30 th Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 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 Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seeleys House Address 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) Seeleys House Campbell Drive Knotty Green Beaconsfield Bucks HP9 1TF 01494 670902 Buckinghamshire County Council Mrs Wendy S Rutland Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th May 2006 Brief Description of the Service: Seeleys House is registered to provide respite care at any one time for up to 12 people with learning disabilities. There is a rolling programme for respite care. The home is sited in a residential area of Beaconsfield and is owned by Buckinghamshire County Council. It is an adapted old school and provides single accommodation for service users with shared social space. Half of the building provides Day Care Services and is also owned by the Council. The fees charged are based on a unit cost per bed per night of £197.96 this is paid by Social Services. In addition to this fee the Service Uses each have a contribution to pay which is based on a financial assessment undertaken by the Counties Finance Department, this is based on the level of income support and disability allowance received by an individual (minus the personal allowance of £18.00 per week) this combined figure is then divided by seven giving a nightly contribution. This contribution is usually between £7.00 and £11.00 per night. Information to support potential Service Users and their families to make a decision for admission to the home is provided in the homes Statement of Purpose and the Service Users Guide. Both of these documents are provided to potential Service Users, with additional copies held in the home. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced in section took place during the course of two days. The first day lasted 2.5 hours before the inspector abandoned the visit. This was due to the fact that the staff on duty were unable to locate documentation pertinent to service users welfare. The manager was on leave until after the Christmas period and therefore staffing records were unavailable. The second day visit was arranged after looking at the rota and identifying when the manager would be back from leave. On arrival at the home on the 28th December 2005 it was clear that the manager had only come in because the inspection was taking place and should have been working from home. The manager confirmed that she, due to unforeseen circumstances, has been working off site more frequently and in her absence arrangements had been put in place, which was for the line manager to oversee the service. The day consisted of reading documentation, talking to the manager, staff and a couple of service users who were in the home during the time of the visit. The care of three Service Users each visit were identified to be case tracked. Documentation pertinent to the health and welfare of Service Users and health and safety around the home were checked. A tour of the environment pertinent to the three service users being case tracked (receiving respite on the day of the second visit) was carried out; this included bedrooms, bathing and toileting facilities as well as the communal areas. What the service does well: Effective complaints procedures are in place to ensure that issues raised by service users and their representatives are listened to. Adult protection is appropriately managed to ensure that service users are not placed at risk of harm. In general the environment creates a homely, comfortable and safe home for service users Menus seen indicate that meals provided are a balanced and nutritious diet, taking into account service users cultural and religious needs. Service users are supported to maintain contact with family and friends, to keep important social contacts as and when the need arises. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home/organisation is failing to ensure service users are appropriately assessed prior to commencement of the service therefore not identifying service users current needs. EVIDENCE: Three-service users care was tracked during the course of this inspection and files pertinent to individuals were viewed and discussed with the manager and staff. The home had assessment records for two service users, which had been carried out by care managers. However, both service users had only commenced using the service in December 06 but the assessments were actually dated June 05 and January 06, six to twelve months prior to commencement of the respite service. One service user who has been living in this respite service for approximately 11 months due to a change of need did not have a current assessment of need in place. On the first day of the inspection two other service users files were viewed and again no assessments were evident. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home is failing to ensure, that personal care needs, of the service users are identified through the Care Plans to ensure individual needs, wishes and preferences are met. There are few Risk Assessments in place to ensure service users are safe. EVIDENCE: The three service users whose care was being tracked and the two files viewed during the first days visit did not have care plans in place. The manager and the staff on duty searched for the documents that were evidently unavailable. It was unclear as to how staff were able to meet service users needs appropriately without documentation. As there is vital information missing there was no evidence to support whether service users are given any choices or encouraged to make decisions about their lives. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 10 Due to the complex and diverse needs of the service users it was not possible to confirm whether service users had been asked to be involved in the development of their care. Seeleys House is meant to be a respite service with service users receiving one or two nights care at a time. However, at the time of the inspection three service users were living permanently in the home. The Statement of Purpose clearly identifies that service users will stay for no more than 21 days at a time and the home is therefore working outside of its stated aims and objectives. In these cases there was also no evidence to support service users involvement in identifying individual needs, personal preferences and wishes. Risk Assessments were viewed and it was found that out of the three service users whose care was tracked only one had Risk Assessments in place. The other two service users files viewed during the first day of inspection were also missing current Risk Assessments. The manager explained that as they are a county council home the Risk Assessments are to be the same as the risk assessments completed by the day services, (other county council services) to avoid duplication of work. In areas where they were missing the home had not received copies from other facilities. The manager must remember that risk assessments that may be appropriate in other settings may not be appropriate within the care home as the risks maybe very different. This is therefore being very poorly managed and could potentially place service users at serious risk. It was clear that the manager and staff team are awaiting Risk Assessments being completed by the other services to implement in the home. Risk Assessments must be in place for all service users and although Risk Assessments need to be consistent for the individual the home must implement them when the service users commence using the service not weeks or months later. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are not enabled to access the community and arrange of activities to support their lifestyle choices and promoting independence. Service users are supported to maintain contact with family and friends, to keep important social contacts as and when the need arises. Menus seen indicate that meals provided are a balanced and nutritious diet, taking into account service users cultural and religious needs. EVIDENCE: Due to the nature of the home being predominantly respite and the Statement of Purpose stating a maximum of twenty one nights at a time; generally the home does not get involved in arranging work experience or college placements for the service users using the service. However they do facilitate Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 12 attendance at either of these places if the need arises. All service users have access to a day centre in Buckinghamshire, transport is either arranged directly by the home or via the county council transport service who pick up service users and take them to and from their day centres. Through discussion with the senior staff and manager during the course of the two-day inspection, it was clear that the only way of identifying support given to service users to access the local community, was by reading the daily records. The daily notes were perused of the three service users being cased tracked failed to confirm that service users have been taking part in activities the local community has to offer. The three records seen for the six-weeks leading up to the inspection did not mention any activities having taken place either indoors or in the community. Through discussion it became apparent that one service user had gone home to mum for Christmas, but nothing was written to support this information. Due to the nature of the service being respite, service users generally only stay at Seeley’s for one or two nights at a time. Therefore there isn’t always a need to ensure service users maintain family contact for such a short period of time and that families use the respite service so they can get the break needed. Staff confirmed that they would support and encourage service users to contact family and friends if they so wished. The home does not have a visitors room identified, however there is a large lounge or dining room if not in use. Service users can see people in the bedroom allocated to them for privacy. Where possible service users are supported and encouraged to maintain as independent lifestyle as possible. One-service user whose care was being tracked has an independent lifestyle, unfortunately due to unforeseen circumstances needs the support the home can offer temporarily. Meals are prepared during the week by an agency cook as the home has not been able to recruit somebody permanently for several years now. The care staff are responsible for cooking meals over the weekend and some during the week. The manager supplied menus as part of the Pre-inspection information, which identifies that balanced meals are available with alternatives for cultural, religious and dietary needs being identified. One service user spoken with eating lunch said he was eating a “great” bacon sandwich. Meals can be partaken in any room within reason, however the dining room is encouraged. The kitchen was seen and their seemed to be a variety of fresh and frozen foods available in the kitchen. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 13 Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Records fail to evidence Service users healthcare needs of that service users are offered personal, physical and emotional support as and when required. Shortfalls were identified in the recording and handling of medicines in the home placing staff and service users at risk. EVIDENCE: The health care plans for three service users being case tracked were viewed and found to be none existent. Medication records and the storage and administration were viewed. Staff’s training records were viewed. Health care needs are not identified for the three service users whose care was tracked and currently receiving respite care at this home. This was very Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 15 concerning as one of the service users living in the home has serious healthcare needs and no plan was in place to support the care required. As the home is respite the service users remain registered with their own GP and healthcare professionals through their families or representatives. The manager has an arrangement with a local practice in an emergency, which has been in place for several years now and appears to work. Medication is stored in a locked trolley shackled to the wall in the office, which is locked when not in use. Medicines are brought into the home via transport with the individual service user sent from parents or the carers. All medicines are in their original bottles with the pharmacists labels attached. Medication Administration Records were found to be a little messy with lots of incomplete information such as – only half the full name of the medicine, no record of the amount received, no clear dosage or how many times a day. Staff are hand writing the Medication Administration Records without them being double signed to ensure everything is correct to avoid errors. On the day of the visit, medication had been received into the home and placed in the trolley in a carrier bag for the afternoon shift leader to write up, as the procedure in the home states. The manager explained that often the senior on shift in the morning is the person who has just slept in and therefore is tired and may make mistakes. The staff are placing themselves at risk by receiving medication into the home unchecked for hours, as they are responsible for any medication that may be missing. A member of staff and the manager were asked to show where excess medication is stored for the service users who have been living in the home sometime. This was found to be stored in a locked filing cabinet. Upon perusal it became apparent that the home is hugely overstocking and not disposing of any medicines. For one service user there were approximately 500 pain relief tablets, twelve bottles of anti-convulsant liquid and an excess amount of Stesolid that is not used by the home’s staff. During the tour of the building and service users bedrooms, a small pot was found by a service users sink that contained used needles from an Insulin pen. When staff were questioned they said that the home did not have a sharps bin. The pot was removed as storing these used needles inappropriately was putting other service users at risk, as all bedroom doors are open during the day. The manager was handed these needles and was unaware that this practice was going on. Within minutes the manager located a sharps bin that had been prescribed for the individual service user, which begs the question why wasn’t it being used as this service user had been living in the home since before Christmas. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 16 Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Effective complaints procedures are in place to ensure that issues raised by service users and their representatives are listened to. Adult protection is appropriately managed to ensure that service users are not placed at risk of harm. EVIDENCE: The home/council has appropriate policies and procedures in place to ensure service users views are listened too, called “hearing customers views”. The home has received six complaints since the last inspection that have been handled appropriately. Detailed records of the complaints and the outcomes were being maintained. The Commission for Social Care Inspection has received no information concerning complaints made to the service-by-service users or their representatives. Service users are protected from abuse by the homes/county council’s policies and procedures. 23 out of 23 members of staff received Protection of Vulnerable Adults training in April 06. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In general the environment creates a homely, comfortable and safe home for service users. EVIDENCE: Seeleys House is located in a residential area of Beaconsfield. It is a single storey building attached to Seeley’s day centre which is separate from Seeleys House registration. All bedrooms are single accommodation and of a nice size, Service Users are able to personalise these during their stay. There are sufficient toilets and bathrooms in close proximity to bedrooms with adaptations and equipment in place to support the specific needs of Service Users. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 19 There is a large communal lounge and a large separate dining room, both rooms lead to the patio area. Additional equipment such as a computer is stored in the dining room in pleasant cupboard units, which are in keeping with the rooms’ décor. The bedrooms of the three service users who were cased tracked were viewed. In general they were found to be homely personalised of a domestic nature with natural and electric lighting and heating. One of the rooms had an ensuite shower room. Bathroom/shower rooms were found to be in need of some work. The one at the “Paddock” end flooring is badly stained and looks as though the water may not be draining away appropriately from the shower. The toilet room next to this bathroom has burnt/singed flooring, there is obviously a hot water pipe located immediately underneath the flooring too close to the surface and must be rectified. The bathroom / shower room at “Park” end needs some maintenance also there are tiles off the wall behind the bath which could put service users at risk. The flooring once again is badly stained. The Home was found to be clean and free from offensive odour on the day of inspection with all items of C.O.S.H.H. locked away. The Home has systems in place to ensure the control of infection. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home’s recruitment policy and practices support and protect service users from potential harm. Staff records identify that staff have the some competencies, qualities and training required to meet service users needs however, there is a shortfall in staff being unable to apply basic first aid in an emergency. The manager is failing to ensure that service users receive care from wellsupported and supervised staff. EVIDENCE: The staff who have worked in the home for some time appear to have the knowledge and competences to meet service users needs. However, the manager and members of the staff team are still concerned that they are managing with “seven” whole time equivalent staff short. Three new staff are awaiting Criminal Record Bureau Checks before commencing. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 21 Staff spoken with are concerned that they do not have enough staff to meet service users needs and that each permanent employee is doing overtime/extra shifts a week. The manager confirmed that all staff are doing approximately one extra seven-hour shift per week. The manager has recently employed two young staff members, one who is under 18 years old and is therefore unable to act as a full member of staff without additional training and support. Due to this staff spoken with feel that by including this person in the numbers of staff required per shift to service users an sometimes at more stress when dealing with all personal care needs. An example of excess pressure for staff is that on some nights, four service users could be receiving respite who all have peg feeds in situ. This was discussed with the manager who insisted she would ensure an extra member of staff would be on duty to cope with the additional needs. Due to the complex needs of the service users it was not possible to confirm whether this is actually happening. The Commission for Social Care Inspection has not received any comment cards from carers, relatives, service users or professionals. Four personnel records were viewed of new staff who have commenced employment since March 06. All records were found to contain the appropriate information required to ensure service users are protected from harm. All new staff have commenced the L’DAF induction foundation course and one new staff member spoken with confirmed the training that has taken place. The manager has declared on the pre-inspection documentation that 61 of staff are now qualified at NVQ level 2 and above. The mandatory training of the permanent staff has improved. Although you will note there are still a couple of major shortfalls in this area. Out of 23 staff; • Food Hygiene - 11 • Fire Awareness - 17 • First Aid - none • Manual Handling - 22 • Infection Control – none Due to the complex and diverse needs of the service users and personal care input required by staff, it is essential that they attend Infection Control training. It is required that the home has a designated first aid person qualified to do so on every shift. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 22 Through discussion with the staff and manager in the home it was clear that the senior team are failing to maintain support to new and existing staff by not having any regular formal supervisions. The new staff spoken with had not received any formal supervision since commencing in October 06 and therefore the induction portfolio and competency levels had not been viewed, assessed and signed off. Of the four personnel records viewed only two had received one supervision since starting work at Seeley’s house as far back as march 06. The manager confirmed that she is meeting regularly with her line manager but no records were seen to support this statement. The senior staff on duty were asked for copies of the minutes of team meetings that had taken place. Records produced showed the last recorded team meeting took place on 27th April 06 that was for the senior team only not the support workers. The manager when asked if she attended and led team meetings said that “time permitting” she will attend. She doesn’t like to lead them as she felt the staff team wanted answers there and then that she couldn’t always give. There is no evidence that anybody is overseeing the records to ensure support mechanisms are in place to reduce stress on staff and identify difficulties people may be having. The sickness level appears to be high at the time of the inspection. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home is being poorly managed and circumstances indicate that that the manager and local authority, at the time of the inspection, were not giving clear leadership to the team and promoting continuity of care to service users and improving standards for the benefit of service users. In general EVIDENCE: Wendy Rutland has been the manager of Seeley’s House for a number of years. She has the appropriate qualifications, knowledge and skills to manage adequately. However, it was a little concerning to note that the manager has been working off site more frequently than on site. This is due to a number of contributing Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 24 factors. The first one is down to personal circumstances, which the county council have accommodated, and secondly according to the manager is that the council are increasingly expecting the manager to attend more and more meetings off site leaving the home unmanaged for large periods of time. The staffing structure in this home is such that the manager has sole responsibility for the day-to-day running and the overseeing of achieving the homes Statement of Purpose. In her absence there are three team leaders who take responsibility when on shift, however it is not their responsibility in the long term to manage the home in the managers absence, therefore failures and cracks in the system are appearing and regular support is falling by the way side. The manager confirmed that she believed her line manager was visiting the home and overseeing it in her absence. The home does not have one person in a deputy’s role to assume charge when the manager is unavailable and therefore it is strongly recommended that the need for a deputy be reviewed and assessed. Regular unannounced proprietors visits are carried out monthly and reports were available for viewing. Seeleys House or the county council have not carried out any annual quality audits on the home during the past 12 months. A selection of health and safety certificates was perused, such as fire, gas, hoists and portable appliances and found to be adequately maintained. Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 X 1 X LIFESTYLES Standard No Score 11 X 12 1 13 1 14 X 15 3 16 1 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 2 x 2 X 2 X X 3 X Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15 Requirement A requirement is made for the home to work in the next 12 months towards providing Service Users with Care plans, which are reflective of a more person centred approach and are formulated with the Service User. (Issued at previous inspection, timescale not yet up) That all new service users have a current pre-admission assessment of need in place before commencing the use of the respite service. The manager is required to ensure all service users have a current Care Plan in place that identifies current needs. The manager is required to ensure that Risk Assessments are in place for all service users. That the manager and staff support service users to be part of the local community That the manager ensures service users health care needs are recorded adequately in the support plans. DS0000032334.V320627.R01.S.doc Timescale for action 06/06/07 2 YA2 14 31/01/07 3 YA6 15 28/02/07 4 5 6 YA9 YA13 YA19 13(4) 16(2) (m-n) 15 28/02/07 31/01/07 28/02/07 Seeleys House Version 5.2 Page 27 7 YA20 13(2) 8 9 YA20 YA20 13(2) 13(2) 10 YA35 18(1) 11 12 YA36 YA37 18(2) 10(1) That the manager ensures that the correct information is written on the Medication Administration Records. That the medication is signed into the home immediately and not left for hours. That the manager ensures all excess medicines are returned to the pharmacy appropriately and only orders stock actually required. That there is at least one member of staff on each shift with a current first aid certificate. It is required that all staff receives regular formal supervisions and team meetings. That the management structure of the home is reviewed to ensure there is clear leadership in the absence of the registered manager. 31/01/07 31/01/07 31/01/07 15/02/07 31/01/07 15/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Seeleys House DS0000032334.V320627.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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