Inspection on 20/09/06 for Sefton Hall

This inspection was carried out on 20th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sefton Hall 25/08/07

Sefton Hall 07/12/05

Sefton Hall 21/07/05

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Sefton Hall Plantation Terrace Dawlish Devon EX7 9DS Lead Inspector Rachel Proctor Unannounced Inspection 20th September 2006 10:00 X10029.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 Sefton Hall DS0000064054.V311395.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 and 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. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sefton Hall Address Plantation Terrace Dawlish Devon EX7 9DS 01626 863125 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) Southern Healthcare (Wessex) Ltd Vacancy Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (26), Physical disability (28), Physical disability of places over 65 years of age (28) Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Sefton Hall Nursing & Residential Care Home is in the seaside holiday town of Dawlish in Devon. The town centre is just a short walk from the home. The home is registered as a 52 bedded Care Home with Nursing as it provides both personal and nursing care to meet the needs of adults and older people who can no longer live independently. For those who have a physical disability the home has been designed and adapted so they may gain access to all areas by way of shaft lifts and ramping. This is necessary as the home is laid out over three floors. The ground floor offers two large multipurpose lounges and a large dining room that has two distinct areas to its layout. There are seven single rooms, all with en-suite facilities, on the ground floor. The Registered Managers office and the Administration Office are also found on the ground floor near the main entrance. There is a fully equipped kitchen, a hair dressing salon and various storage spaces. The first floor has 23 bedrooms (most with en-suite), three of which are doubles. A tea kitchen, for use by Service Users, plus two nurse stations and further storage space can be found on this level. The second floor has 20 single bedrooms most with en-suite facilities. Each floor is adapted to meet the needs of the Service Users, with toilets and bathrooms that have disabled persons facilities, wide floor areas with handrails, specialist Parker baths and suitable hoisting facilities. There are two acres of walled grounds that have ramped access to facilities at the front of the home. Access to the rear garden is restricted at present due to some building work that is in progress. Each resident has a service users guide and a copy of the statement of purpose is available from the office. Fee levels were not provided with the pre inspection information. Although the manager confirmed that the fee level is dependent on the care needs and the age of the residents. Additional charges are made for hairdressing, chiropody, physiotherapy (if private), personal toiletries, newspapers and books. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection. One unannounced site visit was undertaken as part of the inspection. During the visit a tour of the home was completed. Residents and staff were spoken to and some records were inspected. Information received from the home since the last inspection was reviewed, some of which has been incorporated into this inspection report. Six service users, members of staff on duty and the manager were spoken to during the inspection. Four comment cards were received from health and social care professionals, four GP comment cards and two relatives comment cards were received. Comments made in these have been incorporated into this inspection report. What the service does well: What has improved since the last inspection? What they could do better: The manager should ensure that the foreign staff employed have sufficient understanding of spoken and written English - to ensure they are able to understand and care for the residents and communicate clearly with visiting professionals. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 6 Although the continued redecoration and renewal of furniture and fittings continues, not all the areas the residents have access to have been upgraded. 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. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP, 3 and YA2 This judgement has been made using available evidence including a visit to the service. The quality in this outcome area is good. The residents can have confidence that they will be given the information they need to make informed decisions about the home and the services it provides, and that their care needs will be assessed by staff who have their best interests at heart. EVIDENCE: Revised copies of the statement of purpose and service users guide were provided to the Commission prior to this inspection. These reflected the changes since the last inspection. The service users guide is provided in each of the residents rooms and copies were kept in the office. The private contract seen for one resident identified the applicable amount for Funded Nursing Care”. However, the sample contracts contained in a Statement of Purpose Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 9 dated June 2006 did not have the weekly fee split to show the amounts payable by whom. The length of the trial period (Standard 5) when a resident is first admitted to the home was also not stated in the contract. This could mean that the residents do not have all the information they need in the contract provided by the home. Four residents had their care followed as part of the inspection. These residents’ plans of care included comprehensive risk assessments. These assessments covered the individual health and personal care needs of the resident, manual handling, nutrition, pressure sore risk, risk of falls and individual risk assessments for the residents chosen activity. Personal preferences and choices the residents had about the care they received and how they like to be addressed were also included. A new recording tool had been developed since the last inspection, which enabled a record of the new residents personal preferences and choices to be kept. The manager advised that this had enabled them to, more recently, provide care in a way that the residents expected. The residents spoken to said staff regularly discussed their care with them and encouraged them to do the things they could do for themselves. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10, YA 6,9,16,18,20 This judgement has been made using available evidence including a visit to the service. The quality in this outcome area is good. The resident’s care is assessed and planned in a way that promotes independence and dignity. However the manager needs to ensure that all staff have the ability to clearly commuicate with the residents and visiting professionals to enable the residents and the professionals to have confidence in the way care is delivered. EVIDENCE: Each of the four residents who had their care followed had a comprehensive assessment of their care needs documented. A plan of care had been Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 11 developed from this assessment. Risk assessments were an integral part of the care planning process; these included manual handling, falls risk, nutrition and pressure sore risk assessments. Where risk had been identified the plan of care gave instructions for staff on how to minimise the risks. Each of the care plans for the resident’s case tracked had been reviewed monthly or sooner if their care needs had changed. The wound care plans in place for one resident showed the treatments used and how the healing process of the wound was progressing. Those residents who were identified as having high risk of pressure sore development had pressure-relieving equipment provided. High dependency airflow mattresses were seen in use. One resident told the inspector that the staff at the home had helped them to increase their ability by encouraging self-care. They also said that they had a “sore bottom” when they were admitted to the home and staff had helped this to heal, so it was no longer sore. Polices and procedures were easily available for staff in the home’s office; the manager advised that staff were using these to assist them completing an NVQ in care as well as for guidance on care issues for the residents care. The residents asked said the home staff had discussed their care needs with them and asked them about their personal preferences and choices. One resident had moved rooms to enable the en-suite to be easier for them to access independently. Two residents spoken to during lunch told the inspector that they had been given keys to their rooms and felt more confident leaving their rooms now a lock had been fitted to the front door entrance to the home. The manager confirmed that she or a senior nurse visits and assesses prospective residents prior to their admission to the home. Two residents asked said they had met some one from the home prior to their admission. The pre-inspection questionnaire gave information about the health and social care specialists who visit the home. During the inspection a GP came to see one of the residents, they were seen by the GP in the privacy of their own room. Four comment cards received from GPs indicated that they had some concerns about the ability of some of the staff to understand the care needs of the residents, and work with them. Three residents told the inspector that all the staff are friendly and helpful, however they did say they “had difficulty understanding some of the foreign staff” and “weren’t always sure the foreign staff understood what they had asked”. The manager advised that she contacted specialist nurses for advice on specific care needs of the residents, these included the Multiple Sclerosis specialist nurse, tissue viability specialist nurse and continence advisor. Reference material relating to specific health care needs of the residents was available in the office. This should ensure that the residents receive care they need. A key worker and named nurse system is used at the home. A key worker communication book used at the last inspection was still in use at this inspection. This enabled the resident’s family and friends to have feedback about the residents with the resident’s agreement. This included the activities they had taken part in during the day. One member of staff told the inspector that they enjoyed finding out what was important to the residents she cared Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 12 for as they felt this enabled them to feel at home, especially when they were able to provide something in a way the resident said they preferred. The manager provided a copy of the resident’s self-medication procedure. This included an assessment form for staff to complete; an example of this was seen in one of the residents care plans. The controlled drug record was checked against the stock held for one resident as correct. The home has a lockable drug trolley to transport medication to the individual residents. A locked treatment room and drug cupboard is also provided for storage of medication. A record of medication orders and disposal of unwanted medication were provided for the medication used by the residents. The medication had been stored in a way that gave good stock control. The staff observed speaking to residents and providing care were doing so in a friendly professional way. When staff were working in pairs with a resident they were involving the resident in their topic of conversation, which appeared to be valuing the resident as an individual Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP12,13,14,15, YA 12,13,15,17 This judgement has been made using available evidence including a visit to the service. The quality in this outcome area is good. The staff team endeavour to provide and encourage activities that the residents are able to participate in. The residents can have confidence that when activities are planned their personal preferences and choices will be taken into account by the staff wherever possible. EVIDENCE: A four weekly rotational activity plan was provided with the pre inspection information. This showed the type of activities provided. One senior carer who had taken the lead for planning activities advised the inspector that the activities plan is put together with the help of the residents. Residents spoken Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 14 to said they had been asked about the type of activities that interested them. The activities provided included a local history group, arts and crafts, a word quiz, gardening club and pottery club. One resident told the inspector that they enjoyed going out into the garden, although they werent able to do very much gardening. The residents were receiving visitors throughout the inspection visit. Some were seeing their visitors in the privacy of their own rooms, others in the large communal lounge. One relative asked said that the staff always make them feel welcome and they enjoy visiting. The relatives comment cards received indicated that they were satisfied with the care their relative was receiving. One resident advised the inspector that the business manager had helped them with their finances. The inspector checked the records of expenditure and money held for this resident. Records were kept with receipts of expenditure and money held. The home provides the residents, their relatives and friends, information on how to contact external agencies. Each of the residents rooms entered during the inspection had been personalised with items of the resident’s choice. The inspector shared a lunchtime meal with two residents. There were two choices for the main course, one of these was vegetarian. The food was nutritional, provided a balanced diet and was attractively presented. Both residents told the inspector that they enjoyed the meals. They also said if they didnt like what was on the menu they could ask for an alternative. They advised that salads and sandwiches are always available on request for mealtimes. Hot and cold drinks were being provided for the residents throughout the day of the inspection. The residents asked said they were able to get drinks when they wanted them. A rotational menu is available for the residents. A copy of the days menu was provided on the day. The lunchtime meal observed was unhurried with the residents eating their meals at their own pace. Those residents who required assistance to eat their meals were being given this in a discreet friendly manner by a member of staff. The staff member was talking to the resident as they helped them to eat their food. Very little wastage was seen at the lunchtime meal. The chef spoken to during the inspection says he regularly reviewed the menu choices with the residents and the manager to ensure they were continuing to meet the residents needs. He also advised that, where possible, fresh vegetables in season were used. The inspector saw the preparation for the lunchtime meal - fresh vegetables were being prepared. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18 YA 22,23 This judgement has been made using available evidence including a visit to the service. The quality in this outcome area is good. The residents can have confidence that any concerns they have will be dealt with sensitively by staff who have their best interests at heart. EVIDENCE: Four complaints relating to the way the residents health care is provided have been received since the last inspection. The manager has investigated the complaints and where concerns have been upheld action has been taken by the manager to reduce the risk of these reoccurring. The Commission has been kept informed of all the complaints received and the action taken to address them. One of the concerns raised by two complainants was that it was difficult to find a member of staff when they entered the home. The manager has provided a lock for the front door and all staff have been given a bleep to alert them if some one arrives at the front door. Also during office hours (9-5) the business administrator answers the door and contacts a member of staff to receive the visitor if required. Another concern raised by more than one complainant was that the call bell system was not being responded to by staff in a timely manner. On the day of the inspection residents spoken to said the call system seemed to be working better than if did, and that staff were responding when they were called. The manager confirmed that the system had been checked and the Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 16 problems identified with some call bells had been rectified. The residents asked said they knew who to speak to if they had any concerns and had confidence in the manager to address the concerns they raised. An adult protection training programme is in place and staff records viewed showed which staff had completed this. Information was also available for staff in policies and procedures provided in the office of the home. The appointment of staff follows best practice guidelines, which should ensure only suitable staff are employed to care for the residents. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP19, 26 YA 24, 30 This judgement has been made using available evidence including a visit to the service. The quality in this outcome area is good. The residents at Sefton Hall have a homely environment. However care should be taken that the separate toilets and bathrooms the residents use are easily accessible to them, to ensure these are able to meet their assessed needs and promote enablement. EVIDENCE: Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 18 Since the last inspection the first floor corridor and three residents rooms have been redecorated. The dining room carpet, which was badly stained at the last inspection, had been professionally cleaned and the majority of the staining removed. The manager advised that it was intended to replace the carpets at a later stage, when other refurbishment work had finished. Several of the resident’s rooms have en suite facilities. One resident told the inspector that staff had enabled them to move rooms to enable them to have an en suite facility that was easier for them to access. The manager advised that the programme of repairs and renewals and decoration of the premises was continuing. The residents have access to a front garden, where a small patio area with planted borders and a summerhouse is provided. Because the building work is still being completed the rear garden of the home was not accessible to the residents. The manager advised that the building work was almost complete and that she hoped the rear garden area would be opened up for the residents use fairly soon. The home received a satisfactory fire officer’s report in August 2006. The tour of the home revealed that all areas the residents have access to were clean and fresh and reasonably decorated. Some of the toilets and bathrooms on the upper floors would not be easy for independent wheelchair users or service users who require hoisting to access because of the width of the corridors, the width of the doorways and size of the toilet or shower room. The manager advised that the residents admitted to rooms on these floors are usually more able, and accessing the toilets and bathrooms isnt a problem for them. The laundry is situated in the basement of the home. There is a large area with washing machines and dryers provided. A separate ironing room is available for staff use. The laundry appeared to have stone flooring; some of the areas close to the wall could harbour dust because they are not easy to access. The manager advised that the flooring had been sealed to make it easily cleanable. Infection control policies and procedures are available for staff use. The inspector saw a yellow bag system for disposal of clinical waste in use. Aprons and gloves were provided for staff use. Staff were seen using gloves and aprons when attending to the residents personal care. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP27, 28, 29, 30 YA 32, 34, 35 This judgement has been made using available evidence including a visit to the service. The quality in this outcome area good Communication could be improved and the manager should ensure that all staff employed have sufficient understanding of spoken and written English to be able to understand and care for the residents - this should enable the residents to continue to be cared for by staff team who can understand and listen to their needs. EVIDENCE: The home manager provided a copy of the duty rota, which shows how many staff are on duty during a 24 hour period. Comment cards from health care professionals indicated that they had some concerns about the understanding of some of the staff whose first language was not English. They also commented that they felt not enough staff were available to care for the complex needs of some of the residents. Two complaints indicated that it was difficult to find a member of staff when entering the home. The home manager has advised that a lock had been put on the enterance to the home and staff Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 20 given a bleeper to alert them when some one was at the door. The record of staff training provided with the pre inspection information indicated that staff had the recruitment checks required and had mandatory training for fire safety, manual handling and health and safety. Three health and social care professionals comment cards received indicated that they were satisfied with the overall care and said the home staff communicated clearly and worked in partnership with them. One was not satisfied that the home staff communicated clearly and worked in partnership with them and they were not satisfied with the overall care. They stated that they felt there were insufficient trained staff to meet the needs of some of the residents who required complex health care. Since her appointment in May the new manger has introduced new ways of working. The duty rota provided showed that there was a registered nurse on duty each shift who was supported by a team of health care assistants. At the time of the inspection the home was caring for 23 residents who required personal care and 18 residents who required personal and nursing care. The manager advised that senior carers are taking more responsibility for the residents leaving the registered nurses more time to care for the residents who require nursing care. The staff have been divided in to two teams lead by a senior carer/team leader, supported by an allocated qualified member of staff. The GP comment cards received indicated that not all the home staff communicate clearly and work in partnership with them. Concerns about the number of staff employed whose first language is not English, who had difficulty communicating with the residents and the GPs appeared to be the reason these comments were expressed. The manager advised that English language training is offered to staff who need this and the way foreign staff interact with the residents was being monitored and training provided if this was required. The inspector observed two foreign staff speaking to the residents - they did not appear to have any problems understanding each other. Two residents told the inspector that all the staff are friendly and helpful. However they did comment that they had diffculty understanding some of the staff with foreign accents and weren’t always sure that these staff understood what they had said. Four staff files were reviewed during the inspection. These provided information that the homes manager follows a robust recruitment policy that protects the residents from unsuitable staff. All staff files had an application form, references had been obtained and CRB checks completed. The staff spoken to during the inspection said they felt supported to do their work. One commented that they felt the standards of care had improved since the new manager had started at the home and they felt clearer about their own role and responsibilities. They went on to say that any concerns or requests for advice were discussed promtly with senior staff or the manager and they felt supported to do their work. The manager advised that she had encouraged the staff team to take ownership for their area of work, which had promoted the staff strengths. The pre inspection questionnaire indicated that 61 of the health care assistants employed have achieved an NVQ level 2 or above and 19 staff hold a current first aid certificate. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 21 The induction training programme for the homes staff was discussed with the manager of the home and the human resources manager for the Southern Heathcare (Wessex) Ltd. At present a ten day induction programme is provided which broadly follows the skills for care recommendations and is relevant to the care needs of the residents at Sefton Hall. The training staff had received was discussed. Copies of training certificates received by staff were avable in their staf file. A list of training undertaken by the staff team was provided with the pre inspection information. The manager confirmed that staff receive madatory training for fire, manual handling and health and safety. She also advised that the registered nurses are given the opportunity to complete training relevant to the health care needs of the residents. These included infection control and tissue viability. The manager also advised that she and other registered nurses in the team regularly contacted specialist nurses for advice regarding the health care needs of individual residents. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31, 33, 35, 38 YA 37, 39, 42 This judgement has been made using available evidence including a visit to the service. The quality in this outcome area is good. The new systems and practices introduced by the manager should enable the residents to live in a well managed home supported by a staff team who understand their care needs. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 23 EVIDENCE: The previous registered manager had been dismissed since the last inspection. A new interim manager has been appointed by the company to lead the home. The new manager is a first level registered nurse with several years experience managing and delivering care. She is also deputy director of nursing for the group (Southern Healthcare (Wessex) Ltd). Since her appointment she has made changes to improve the working practices of the home. Four complaints had been received since the registered manager left regarding the staffing provided and the level of care respite clients were receiving. The new manager has kept the Commission informed of the action she has taken to address the concerns raised by the complainants. How she and other registered nurses on the staff team are kept up to date with current health care practices was discussed. The manager advised that the home had links with the district nursing team, who provided for the health care needs of the residential residents. During the inspection there was an open positive atmoshere in the home. Staff were interacting in a positive way with the residents and each other. Where staff were having converstions between each other, the resident they were providing care for was being involved in the discussion/conversation. All the residents spoken to during the inspection said they knew who to speak to if they had any concerns and had confidence that any concerns they raised would be listened to. A quality assurance/ annual development plan was provided for inspection. This showed commitment to improving the service through a monitoring and review system; areas included staffing, delivery of care, client care packages and contracts for packages of care. There was a commitment to staff training both mandatory and practice specfic included with in this quality asurance plan. A plan to improve the environment for the residents though a maintainance and refurbishmnet programme is being prepared. Some redecoration of the areas accessible by residents had taken place since the last inspection. The activity programme has been drawn up taking into account the residents preferences. This was supported by the comments received from six residents who said they had been consulted about the activities provided. The home has clear policies and procedures, which are easily available for staff. The manager advised of new policies she had introduced, this included a risk assessment for residents who are able to self medicate. The manager has improved the way residents care is recorded. The initial assesment documentation now includes a template to record the things that are important to the resident as an individual. This included the time they liked to get up and go to bed, their meal prefernces and activities they enjoyed. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 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 X 2 X 3 3 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 25 No 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. 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. Refer to Standard OP2 OP19 Good Practice Recommendations The self-funding contract should be reviewed alongside the standard 2 and regulation 5A. The re-decoration and renewal of fixtures and fitting should continue to ensure all residents have access to pleasantly decorated and furnished environment to live in. The manager should ensure that all staff have sufficient understanding of spoken and written English to provide care for the residents and communicate clearly with visiting professionals. 3. OP30 Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. Sefton Hall DS0000064054.V311395.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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