CARE HOMES FOR OLDER PEOPLE
Seely Hirst House Care Home 62-68 Mapperley Road Mapperley Park Nottingham NG3 5AS Lead Inspector
Jayne Hilton Unannounced Inspection 9th August 2007 8:00 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 Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Seely Hirst House Care Home Address 62-68 Mapperley Road Mapperley Park Nottingham NG3 5AS 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) 0115 960 6610 0115 9856283 careatseely@aol.com /lynda.dyer25@btinternet.com The Trustees of Seely Hirst House Miss Lynda Dyer Care Home 38 Category(ies) of Dementia (12), Old age, not falling within any registration, with number other category (38) of places Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st August 2006 Brief Description of the Service: Seely Hirst House is registered to accommodate up to 38 older people some of whom may be suffering from dementia. The accommodation is provided over two floors with a passenger lift providing independent access. Seely Hirst House is maintained to a very good standard with well-maintained enclosed gardens. Seely Hirst House is situated in a residential area with good public transport links to the city centre. At the inspection on 9th August 2007 the registered manager stated that Seely Hirst House’s current weekly fee range is £323 to £353. She also stated that there are additional charges for hairdressing, personal newspapers and a minimal contribution towards social outings. Information about Seely Hirst is available through a brochure and the service user guide. A copy of the inspection report was on display. Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 6 daytime hours and was conducted unannounced. The main method of inspection used was called ‘case tracking.’ This involves selecting three residents and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Many of the people who live at this home have a very limited ability to understand and communicate. Therefore many judgements in this report are from observation and reading residents’ records and documents, however four residents were spoken with during the inspection. Five members of staff and the manager were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history including complaints and adult protection referrals, and an annual quality assurance assessment questionnaire completed by the registered manager. Sixteen completed residents satisfaction questionnaires were also received prior to this inspection and eleven relatives/representatives and two visiting professionals returned their views and comments about the service to the Commission for Social Care Inspection. A review of the registration certificate was undertaken. What the service does well: Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 6 The personal and healthcare needs of individuals are fully evaluated and met. Excellent systems in place ensure residents receive positive individualised support which ensures their well being andy safety. The home is run in the best interests of residents and their health and safety is promoted and protected. Residents are able to enjoy a full stimulating lifetstyle with a variety of options to choose from. Meals are well balanced and highly nutritional and cater for varying cultural and dietray needs of the people who use the service. Residents are fully informed and supported through the admission and assessment process of the home and their needs fully identified and addressed. Residents are supported by well trained and supervised staff. An excellent number of staffing provision provides person focused care. Residents live in a comfortable, clean, safe and well maintained environment. Residents and their representatives know how to make a complaint and feel that they would be taken seriously. Residents safety and well being is protected. Comments from residents/relatives and other visitors included the following: “They provide an individual care plan with diligence and compassion and they have an in depth knowledge of all their residents likes and dislikes and can always give an accurate and honest account of situations when needed. The staff have a lovely caring and friendly outlook and create a lovely homely environment so that residents and carers can feel at ease.” “They give their residents a reel sense of belonging. The care service supports people to live the life they choose always-this reflects the residents attitude to being in the home.” “The residents are always clean and well presented and are treated with dignity and respect. Staff are always trying to perfect their care in the home.” “Focused on individual needs of the residents, very resident focused indeed. A wonderful team of staff”. “This home where my relative lives seems to be the best in the area. We have looked at quite a few homes and thought this was the best, the staff seem keen to look after the residents very well and there is always at least one staff member looking after the residents when they are in the lounge.” “Staff are well trained and treat each resident with great care and dignity, I really find it hard to find anything the home does not do well”.
Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 7 “I am delighted that my relative is in such a wonderful home. The manager is excellent and all staff reflect this excellence”. “I am very impressed with the care my relative receives, all the staff are lovely to both me and my relative” What has improved since the last inspection?
The manager has addressed the requirement ste at the previous inspection in respect of medication management. In addition, the home has produced a toolkit for nutrition and implemented a hydration toolkit with policies and information for staff and residents to ensure they are drinking enough water. This has led to increased fluid intake and records being kept of fluid intake of residents who are at risk of dehydration. A tool for dealing with a virus in the home has been developed which centres around infection control procedures. Heatwave information and action has been developed and circulated to residents and staff. An in depth flu plan has been formulated in line with NHS guidelines and staff are aware of its whereabouts and familiar with its contents. There is a two monthly newsletter which informs residents and visitors of any forthcoming activities in the home so that they can access them. There is an annual activities survey which enables residents to highlight any current activities they enjoy/do not enjoy and also any activities they would like to see be introduced in the home. A full security inspection by the local police has been undertaken in July. A list of possible security improvements were made and are being addressed Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 8 The carpets on the 1st and 2nd floor corridors have been replaced. The bungalow area has been decorated. A new toilet floor has been layed in the communal toilet. Room 101 has had a new toilet and toilet floor to meet the needs of the current occupier, Rooms 105, 108,212 and 204 have been decorated and given new carpets. Room 205 has had a new carpet and room 106a has been decorated. The home has had a new laundering system (otex) and washing machine installed to assist with infection control measures. The first stage of the kitchen upgrade has been completed with a new suspended ceiling installed. The home has recognised that due to the increasing demands of a more dependant client base, an increased staffing level during the night would be benificial. Two further care staff have been recruited and inducted so that four night care workers are awake during the night as well as a designated emergency on call person. The home has completed the new fire risk assessment which raised areas where improvements might be made to safeguard the residents and staff. This is well documented along with any action taken as a result of the new assessment. The Manager has completed a 2006/2007 workforce plan in line with guidance from Skills for Care. The manager was having difficulties with time management due to the location of her office. This was addressed and now she has a separate office away from the main reception and a plan was put in place where she works in the separate office until 11am, completing any administration tasks and then she can be found in the main body of the building spending time with residents, staff and visitors. This ensures residents and staff know that the manager is available at certain times of the day. Although all staff are encouraged to see the manager with any suggestions, enquiries or concerns, the manager has introduced an open time for staff to see her on a specified day. This takes place once a month in the privacy of the upstairs office and is spread over two shifts so that it is available to both the morning and afternoon shift. Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 9 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. Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 10 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 Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 11 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are fully informed and supported through the admission and assessment process of the home and their needs fully identified and addressed. The home does not provide an intermediate care service EVIDENCE: The manager stated that it is their aim to enable potential residents to make an informed choice of where to live and to have as much information as possible on the quality of service they provide. Potential resident and their relatives/friends are encouraged to visit the home as often as they like before they make any decisions. The home also offer the chance for potential residents to visit the home for a few hours to see if they like the home and the services we provide and if have a vacancy at that time
Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 12 then potential residents are able to book a short stay visit to try out our services for anthing from a night to a month or any other specified time. The management team are very flexiable in the way they deal with each applicant and this ensures individual needs are met. Support and reassurance is offered to the potential new resident and their families with sensitivity to what will be a huge decision for them all to make. Prior to admission they carry out their own assessment either in the potential residents current environment or preferrably within the home setting an along with any other assessments available and after discussions with the care staff to decide if the care needs of that individual can be met in the home. Privately funded residents have a more in depth assessment record due to the absence of an assessment by a qualified social worker. Residents are not admitted on an emergency basis unless a full assessment is available and the home is able to complete their own assessment and are sure the individual needs of that resident can be met. Information from these assessments is used to commence the individuals plan of care and on the day of admission. Staff sit with the new resident and their family (If that is the individuals wishes) and complete the plan of care.The home has a written admission procedure and admissions are well organised and planned and are handled by the management team. The home is looking at developing other formats for the statement of purpose /service user guide. Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 13 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,8,10 and 11 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of individuals are fully evaluated and met. Excellent systems in place ensure residents receive positive individualised support which ensures their well being and safety. EVIDENCE: Privacy, dignity, rights to privacy and individual choice is at the forefront of the way the home is run. Residents are encouraged to exercise these rights and are kept as free from rules and restrictions as much as possible. Residents are encouraged to have a say in the way the home is run via residents meetings and suggestion boxes and an open door policy by the manager. Staff have an extensive training schedule to ensure they understand what person centered care is about and how best to deliver it. Residents health and personal care is treated with respect and the staff strive to provide that personal touch that makes the residents feel valued, have good
Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 14 self worth and very much a part of a well respected group. A keyworking system ensures that residents have their own member of staff who will liase with them about what level of assistance they require. A senior member of staff is responsible for the residents Hearing aids, visual aids and hospital appointments and files and records are kept in a well run manner of these aids and appointments. Each resident has a plan of care that is user friendly for the care team to use and that includes a wide range of information to ensure that individual needs are identified and met. The care plan is developed during a meeting with the resident and their family and takes into account assessments made by social workers and other external professionals. The information contained in the plans include details of health, social, religious and cultural needs, life history information including medical and family history, individual preferences around social activities and nutrition as well as a range of other information collated from the resident and their family. A range of risk assessments are in place, which have individual action plans for each risk and each need of the individual. The home has set policies on dealing with terminal illness and death and the staff are trained on induction and given regular refresher training on this sensitive area. The home recognises the importance of this time and responds well, ensuring residents, relatives and staff are treated with sensitivity and respect. In the event of a resident having to go to the hospital for any reason and at any time of the day or night, a member of staff always accompanies them (unless a relative has offered) The medication policies are robust and user friendly for all staff to understand and follow. The home has a good medication system with all staff being trained in the handling and administration of medication although only the more experienced and senior members of staff have the authority to actually administer the medication. Some handwritten entries of prescriptions were not signed and dated by the person making the entry, neither had the person obtained a witness signature to minimse the risk of error. The trolley used for the medication is old and does not meet with the new systems now used and a it is recommended that a new medicines trolley be obtained, which would house the blister packs.
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The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to enjoy a full stimulating lifetstyle with a variety of options to choose from. Meals are well balanced and highly nutritional and cater for varying cultural and dietray needs of the people who use the service. EVIDENCE: The social side of the residents life plays a large role in the way the home is run. The maanger reported that they believe that providing the residents with external links as well as activities within the home is an important aspect of their sense of worth and well being. Structures are in place which gives support to residents wishing to pursue religious and social activities. A member of staff in the lounge at all times and staff are encouraged to use this time to provide stimulating activites to residents, from talking about the residents life experiences, painting nails to playing dominoes and completing jigsaws.
Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 16 The home has access to a minibus and uses this to go on outings every month. All residents are asked if they would like to participate and ideas for new outings are sought at resident meetings. Volunteers from the local Christian church collect any residents wishing to attend church on a Sunday and twice a week volunteers from the local Catholic church collect one resident who wishes to attend meetings there. The local church also visits the home on a pre-arranged day each month to deliver Holy Communion to any residents wishing to attendand also delivers special services at times such as Easter, Harvest Festival and Christmas. The home has a list of entertainers and a minimum of two entertainers visit the home each month to do singing, dancing, organ playing or clothes shows. The activities co-ordinator arranges a summer programme of events and also a winter/Christmas programme of events, which is always full of things for the residents and visitors to attend and enjoy. Visitors regularly eat with their relative or friend and a drink making facilities are available in the quiet room. A fair number of residents go out for Christmas day with their families and they are supported to do this with staff making sure they have everything they need for the day and relatives feeling confident they have adequate facilities and resouces. Residents have the options of being with their visitors in the lounge, the quiet lounge, their bedroom or the garden areas. Some residents are taken out regularly by their relatives and the staff support them to do this. The homes dining area provides a pleasant and comfortable environment for residents to sit and eat their meals. Residents are encouraged to have their meals in the dining area as this in its self provides a social aspect to the individuals daily life. However if residents prefer to eat in their bedroom then this is documented in their care plan and arrangements are made. Drinks and snacks are offered to the residents regularly and there is a drink making facility in the quiet lounge which some residents use. The home has a varied menu and there is a choice of menu for every meal. Meals have a variety of fresh fruit and vegetables with the use of frozen food kept to a minimum. Menus are also reviewed by residents at their meetings and changes made when specified by them. Residents said that the meals are wonderful, one resident made a comment that they woukd like a snack at around 7pm. Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives know how to make a complaint and feel that they would be taken seriously. Residents safety and well being is protected. EVIDENCE: A comprehensive complaints procedure which is easy to understand is displayed in different areas within the home, as well as given in the residential enquiry pack. The complaints procedure gives information of how and where to make a complaint as well as timescales for the complaint to be investigated and resolved. Residents said that they knew how to make a complaint should they have one and that they felt safe. There were no complaints recorded in the home since the previous inspection The home has a display in the main foyer where residents can get information on obtaining advice from an external advocate. Residents are encouraged and supported to vote in elections with postal votes being applied for if the resident does not want to or is unable to go out to the local polling station.
Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 18 The manager requested a full security inspection by the local police and this was carried out in July. The home also has policies and set procedures on dealing with adult abuse and also. Staff are trained on dealing with complaints, Safeguarding Adults and whistleblowing on induction. Through discussion with the manager it was established that the manager needed to update the safeguarding adults procedures in the home and that senior staff would benefit from training in the referal of safeguarding issues. Comprehensive policies are in place for the use of restraint and where bedrails are used a detailed informative risk assesment and consent form is in use. Where service users present challenging behaviour this is fully documented within care plans. Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, clean, safe and well maintained environment. EVIDENCE: The home environment is a comfortable, attractive and well maintained one. The home prides inself on the lack of odours which is maintained with good practice, staff training, high standards of cleanliness and hygiene. There are infection control policies and procedures and staff are fully trained in using these. The home has extensive audit systems in place including:The inspection of the entire home once every two weeks to check for any maintenance problems that have not been picked up on daily checks, health
Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 20 and safety issues and to ensure odours are wiped out at the source. Records are kept of these audits. An extensive legionella auditing system which includes weekly, monthly, quarterly, six-monthly and yearly inspections and treatment of the water systems and staff are trained in this area. Residents are encouraged to provide their own furniture and to make their rooms as personalised as they wish, with personal possessions around them. Hoists and other lifting equipment such as bath chairs and stand aids are available throughout the home. Staff are fully trained in the use of lifting aids and other equipmentLarge signs and pictures show where different areas are so that residents with visual impairments or with dementia can recognise where the homes facilities are and there are two very large clocks with the time and date prominantly displayed in large format. All three floors of the home are subtely colour coded so that residents can recognise their own floor and all bedroom doors have large numbers on with the residents name displayed. All of the homes external doors are alarmed so that anyone cannot enter the building without staff knowing. This also means that any residents with dementia are protected if they open any external door to leave the building. This does not restrict the residents who are able to leave the home without any supervision as the door is easy to open and does not require any specialist key or code. The home has a variety of lounge areas for the residents to sit in and use and they are also given a key to their own bedroom and encouraged to use their room as often as they would like without any restrictions whatsoever. The home has a walk in shower which is used by a couple of residents who prefer that to having a bath. Toilets are placed around the home at various intervals so that the location is not too far away from residents areas where there is not an en-suite in place or from communal areas.70 of bedrooms are en-suite and where possible residents are given a choice of room. Radiators in bedrooms have adjustable controls and all are fitted with protective decorative radiator covers. All baths and sinks have thermastatic valves fitted to ensure the water temperature does not exceed the recommended temperature. The home has had a full and comprehensive Fire risk assessment completed with an actionplan to further minimise risks drawn up.
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The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by well trained and supervised staff. An excellent number of staffing provision provides person focused care. EVIDENCE: The home only employs staff after rigorous interviewing procedures have been followed and potential employees have gone through the necessary checks for background and history. During this time they are invited to spend a few hours supervised in the home staff and residents can give some input on if they think the applicant is suitable. All new employees go through the regulatory common induction training and then go on to complete all mandatory and other desired training. All employees have a personal development plan which highlights areas where individuals need to have more training. Staff are monitored regularly with records being kept of regualr supervision sessions and annual appraisals. Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 22 Staff rotas are on display for staff to use and they show the home has a sufficient mix and number of staff on duty and have staff allocated to certain responsibilities during that time. The manager stated that staff are the most important asset and therefore it is the intention that all staff are valued and have recognition for their contribution in the home. The manager has a back up team comprising of a deputy manager, an assistant manager and a trainee assistant manager. They also have certificates is various aspects of management skills. They each have a different area of responsibility within the home, which is identified in the homes organisational chart. Between the three of them they have a combined number of 40 years experience working within Seely Hirst House. The home also has a team of senior care staff who cover the home 24 hours a day 7 days a week. They have certificates in many aspects of care work as well as years of experience within the homeThe care staff are led by a team of three care supervisors who all hold the NVQ level 2 in care qualification and have a minimum of five years experience in the home The home has a team of 18 care staff who hold many certificates in all aspects of care and 50 (or more) have completed or are working towards their NVQ level 2 in care. The home has a team of 8 dedicated catering and domestic staff who are all qualified in their chosen field of expertise. Not all staff however, have had training in the management of diabetes or dealing with mental health issues and this is recommended All staff have an individual file that holds all relevant information, including: Application and interview forms, references receives, CRB disclosures (unless the disclosure is over 6 months old and then a record of the reference number is placed on the file and the disclosure destroyed) certificates of training, two monthly supervision records and annual appraisal records, however not all files contained photographic evidence as required by schedule 2 and 4 of the regulations. Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33, 34, 35, 37, 37 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Thes home is run in the best interests of residents and their health and safety is promoted and protected. EVIDENCE: The home manager has been employed at the home since 1984 and holds a certificate for the D32/D33 NVQ assessor’s award and certificates for various aspects of management skills. She also completed the RMA (registered managers award) in 2007. There is an Annual quality assurrance survey and residents meetings are held where the residents views and suggestions are sought, reported and acted on
Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 24 The manager embraces the diversity of residents and staff and leads from the front for staff to mirror this essential part of the serviceTraining on equality and diversity given to staff on induction. In the last few months the home have forged a link with the dementia outreach team who are providing tailor made sessions which are set to include sexuality and also diversity for people with dementia. The manager is developing new residential history profiles in care plans that show a wider area of diversity and looking at more training in diversity for all staff and plans to further enhance the care plans to involve details of the residents sexuality. Sexuality training is going to be undertaken for all staff . The home has in place a business plan which determines what the aims are and how they will meet them and at what cost. Residents, visitors, staff and healthcare professionals are consulted. Regular audits are undertaken to ensure all services and standards are being maintained at a high level. The manager is committed to delivering a high quality service for older people and leads by example so that this approach is recognised an mirrored by other staff. She has a reputation for being a good listener to both staff and residents and of acting upon the information she is given in order to futher improve the home and make staff and residents feel respected and valued. The manager produces a development plan each year with targets for the home to meet during the following 12 months. Each of the mangement team has responsibilties with regard to health and safety and this is highlighted in the homes health and safety policy. The manager has put in place an extensive audit system in order that regular inspections of all areas of the home are made and records kept of these. There were no health and safety issues identified from the inspection. The residents financial interests are protected with the home employing an accountant with accounts being audited annually by an independent accountant company. A sample of service users personal finance records were viewed and found to be satisfcatory. It is recommended that the policies for shopping on behalf of residents be further developed to cover the use of bonus cards and other benefits. Seely Hirst House Care Home DS0000002218.V342050.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 Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 4 4 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 3 3 3 3 4 4 4 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 3 3 3 3 4 Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 5 6 7 Refer to Standard OP8 OP9 OP9 OP18 OP29 OP30 OP35 Good Practice Recommendations Provide risk assessments for the use of denture soak products. Ensure handwritten prescriptions are signed by two staff to minimise risk of error. Replace the drug trolley as discussed. Ensure the home has the up to date safeguarding adults protocols in place and senior staff are trained in referral processes. Ensure the missing photograph is located and replaced on the staff file, discussed at the inspection. Ensure staff are trained in Diabetes and mental health. Further develop the financial procedures to include shopping ‘Dos and Don’ts, when staff make purchases on behalf of residents. Seely Hirst House Care Home DS0000002218.V342050.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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
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