Inspection on 21/07/05 for Sefton Hall

This inspection was carried out on 21st July 2005.

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 20/09/06

Sefton Hall 07/12/05

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 HOMES FOR OLDER PEOPLE Sefton Hall Plantation Terrace Dawlish Devon EX7 9DS Lead Inspector Douglas Endean Announced 21st July 2005 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 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. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sefton Hall Address Plantation Terrace, Dawlish, Devon, EX7 9DS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01626 863125 01626 864952 karen.friskey@southernhealthcare.co.uk Southern Healthcare (Wessex) Ltd Karen Friskey Care Home with Nursing 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 D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 01/12/04 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 three 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 hotel style kitchen, a hair dressing saloon 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 ensuite 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 and the rear of the home. This home is under new management. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 21st July 2005 and was announced. The inspector was at the home for approximately 4 hours and in that time he reviewed the care records of 4 clients, drug administration records, maintenance records and other information displayed on notice boards throughout the home for the clients and their visitors. The inspector toured the home speaking to 6 clients and three staff during this portion of the inspection. Comment cards were received from 4 clients and 2 relatives. The registered manager had also prepared the Commission for Social Care Inspection preinspection questionnaire as requested. The inspector chose only to inspect the core standards on this occasion. What the service does well: 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. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3. Standard 6 is not applicable to this home. The manager, or her representative, gather sufficient information on clients prior to admission to enable them to make a decision about the appropriateness of placements. EVIDENCE: The manager told the inspector that all prospective clients are seen at their place of abode, either their home or hospital, and assessed prior to any decision being made about admission. All assessments are carried out by a registered nurse. The sample of clients files seen held copies of the homes comprehensive preadmission assessment tool. This provided information on 27 areas of interest that result in a score. These cover physical need i.e. mobility, continence and diet as well as information about emotional needs and cognition. This tool also is used to produce a fee to be charged for the individual client based on the care that is assessed as needing to be delivered. The sample of clients files read also held other information that helps in the assessment process and the drawings up of care plans, such as the hospital discharge referral forms and care management information. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 8 Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10. The home does plan care for each individual client based upon his or her comprehensive assessment, which is reviewed regularly. It then provides appropriate resources to meet the care needs that may include the services of the National Health Service. EVIDENCE: The home has a care plan for each Service User developed from the comprehensive assessment information, which is then made available for all care staff to use. The care plans are well constructed and cover basics such as moving and handling and nutrition to the more complex wound dressings where this is needed. The care plan’s are reviewed at least and their was evidence of seen in the sample of care plans reviewed during the inspection. The manager said that there are plans to further improve upon the recording system’s presently in use. There was evidence on each floor that staffs are allocated duties on a daily basis. The protection of clients from acquired infection is enhanced by alcohol hand gel being provided all around the home. The homes management of medication related activity remains satisfactory. There was photographic identification of clients and evidence of procurement Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 10 records on the administration sheets. Registered nurses carry out the entire handling process of medication from receipt to disposal. The staff were seen to respond in a respectful way to the clients when managing personal care, including nutrition, so as to preserve their dignity. The home has an induction pack for newly appointed Social Care staff that covers issues of privacy, dignity and respect that was seen during the inspection. Should a client need to see the General Practitioner or a specialist nurse these visits are carried out in the privacy of the clients own room. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15. The home provides an environment that enables the client’s to make choice’s in how their day is to unfold such as who will deliver their care (nursing and personal), what activities they will be involved in, what they will eat and what company they will keep. EVIDENCE: The home does display a range of activities that take place at the home, for individual or groups of clients, on the notice boards that are to be found in central locations on each floor of the home. These include aromatherapy, musical events and quizzes, etc. The grounds at the front of the home can be safely accessed by the clients via steps and a ramp from the front of the home. There is a large sun house in this garden area that is made private by a large wall between it and the residential road at the front of the home. The contracts, statement of purpose and Service Users Guide inform Service Users and those they are in contact with of the homes visiting policy. Clients do receive visitors in their own rooms if that is there wish. The home does not manage the financial affairs of clients but will hold small amounts of pocket money for safekeeping. During the tour of the home the inspector saw that many clients have personalised their room’s and some clients commented on how this made them feel more comfortable and secure. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 12 The inspector saw copies of completed daily menu request that clients have used to make their choice of food, from the menu, known to the chef. The main meal was taken in the dining room during the inspection. The meals provided did look to be of adequate portions and were well presented. The clients that were spoken to at this time were complimentary about the event that meal times provide and the standard of food they receive. The clients do have a choice as to whither they eat in the dining room or their own rooms. Those clients that are in the dining room and need assistance with eating helped in a way that maintains their dignity. Where the nutritional assessment has indicated the need for a special diet the chef does provide this, presenting it in the most attractive way possible. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18. The policies that provide protection to the homes vulnerable adults are robust, and the homes practices comply with these policies. EVIDENCE: The complaint procedure has is displayed on each notice board throughout the home and gives clear instructions as to the way to complain and the time scales for a response. The procedure also gives the reader information as to how they may contact the local Commission for Social Care Inspection office if they wish to do so. The home records complaints that they receive and how they have investigated and addressed them. There are suitable arrangements in place for “Vulnerable Adults Training” that has included using the Adult protection Team of Devon County Council who provides formal training sessions to all care home staff. The inspector also saw the in house training literature that is supported by the Adult protection Team of Devon County Council training video. Staff files were looked at and found to include those documents that are required and that provide evidence of the identity and character of the person they are about. This information include the results of the POVA first check, Criminal Records Bureau check, references and proof of identity such as passport details and a copy of birth certificates. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26. The home is suitably situated near all the amenities that clients may wish, or need to use. The staff keep the home in a clean and presentable condition providing a suitable environment for the clients to live in. EVIDENCE: The home is located near to the town centre of Dawlish, which has many facilities to meet the social and medical needs of the clients such as a park, beaches, a range of shops and also a hospital. There was evidence that general maintenance has taken place at the home to keep it in a safe condition. The inspector also saw the maintenance reports left by outside contractors who had services equipment such as Parker baths, shaft lift’s and the hoists. Both the carpet in the dining area and the lounge have been cleaned since the last inspection and are now satisfactory. The grounds at the front of the home provide a safe place for the clients to enjoy the outside of the home during good weather. The grounds at the rear of the home are presently less accessible due to building work. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 15 The home provides a laundry service for personal clothing only. They have arrangements for foul and infected laundry to be cleaned by a private laundry service. The home employs domestics in sufficient numbers who keep the home clean and odour free as seen by the inspector during his tour of the home. Policies on management of clinical waste, use of protective clothing and the Control of Substances Hazardous to Health (COSHH) regulations are followed. The home has sluicing disinfectors that are in sufficient numbers to meet the present need. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30. The home has sufficient numbers of staff who are appropriately vetted and trained individuals. EVIDENCE: There were 47 clients residing at the home during the inspection. The staffing levels provided are adequate in both numbers and skill mix. No client commented about staffing levels verbally during the inspection, nor in the comment cards. One anonymous visitors comment card was ticked to say that there was not always sufficient staff on duty and one visitors comment card was ticket that they did not know if the staffing levels were sufficient or not. The registered manager is a registered nurse and she is generally on duty Monday to Friday and is not included in the care staff numbers. There is evidence in the rotas that there is always a registered nurse on duty at the home. Staff files were looked at and found to include those documents that are required and that provide evidence of the identity and character of the person they are about. This information include the results of the POVA first check, Criminal Records Bureau check, references and proof of identity such as passport details and a copy of birth certificates. There are suitable arrangements in place for “Vulnerable Adults Training” that has included using the Adult protection Team of Devon County Council who provides formal training sessions to all care home staff. The inspector also saw the in house training literature that is supported by the Adult protection Team of Devon County Council training video. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 17 The registered manager provided evidence that the staff, registered nurses and care staff, have had sufficient induction and ongoing training such as manual handling, continence and wound care. Staff training records support the information provided in the pre-inspection questionnaire. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 38 The home provides a safe environment for the clients to live in, and the staff to work in as a result of good maintenance practices. EVIDENCE: The registered manager is an experienced registered nurse and experienced manager who provided evidence of her Registered Manager Award at National Vocational Qualification level 4. The registered manager provides the staff with training, supervision and the resources to enable them to meet the needs of the clients as identified in their care plans. The home employ’s registered general nurses who provide a 24 hour a day service and are considered by the Health & Safety Executive as competent at first aid. There was evidence that the home has been maintained by the in house maintenance man and outside contractors to a satisfactory standard. Proof of maintenance on such things as the shaft lifts, hoists, water storage and Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 19 delivery systems and fire systems were seen by the inspector during the inspection. Staff of all grades have received training that, when put into practice, should protect them and the service users from injury such as moving and handling training and fire training. Evidence of these samples was seen by the inspector during the review of staff records and also has been supplied by the manager in the pre-inspector form. There has been training in infection control and gloves, protective clothing and alcohol hand wash gel is provided through out the home. There is a satisfactory system in place for the recording and reporting of accidents in the home that was reviewed by the inspector. The records of accidents are seen by the registered manager at the beginning of each day so that she may take steps to pursue any issues to prevent recurrences if possible. All the clients have risk assessments in their records based upon their individual needs such as falls, the need for forms of restraints i.e. bed guards or the need to be accompanied when leaving the home, and tissue viability that may result in the provision of some sort of pressure relief equipment. The home has the resources to provide specialist equipment should an assessment, by a person qualified to do so, require it such as hoists, stand aids, pressure relief mattresses and disabled bathing facilities. These items were seen during the inspector’s tour of the home. Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x x x x x x 3 Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 21 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. 1. 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. Refer to Standard Good Practice Recommendations Sefton Hall D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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 D54-D07 S64054 Sefton Hall V233926 210705 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!