Inspection on 25/08/07 for Sefton Hall

This inspection was carried out on 25th August 2007.

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 20/09/06

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 15th August 2007 10:30 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.V343704.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.V343704.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 Mrs Karen Anne Bull 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.V343704.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2006 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 people living at the home, 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 person 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. The manager confirmed that the fee level is dependent on the care needs, if they need nursing care and the age of the person. Additional charges are made for hairdressing, chiropody, physiotherapy (if private), personal toiletries, newspapers and books. Sefton Hall DS0000064054.V343704.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, which took place on 15th August 2007 between 10:30 am and 5 pm. During the visit a tour of the home was completed 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. Eight people living at Sefton Hall, members of staff on duty, the manager and visiting professionals were spoken to during the inspection. Some of the comments made have been incorporated into this inspection report. 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 Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 6 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sefton Hall DS0000064054.V343704.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.V343704.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6, (Older People) and 2, (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Sefton Hall can have confidence that they will be given the information they need to make informed decisions about the home and the services it provides. They can also have confidence that knowledgeable staff, who have their best interests at heart, will assess their care needs. EVIDENCE: At the time of this inspection Sefton Hall did not provide intermediate care. However they do provide short stay respite care on a regular basis for Older and Younger adults with disabilities. Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 9 Revised copies of the statement of purpose and service users guide were provided for the Commission at this inspection. These reflected the changes since the last inspection. The service users guide continues to be provided in each person’s individual room and copies were kept in the office. Four people had their care followed as part of the inspection. Each person had a plan of care, which included comprehensive risk assessments. These assessments covered the individual health and personal care needs of the person, manual handling, nutrition, pressure sore risk, risk of falls and individual risk assessments for the person’s chosen activity i.e. smoking. Personal preferences and choices people had about the care they received and how they like to be addressed were also included. Since the last inspection the manager has introduced an activity folder which shows the activities each person has participated in and the type of activities they enjoy. These provide a social care assessment for individuals, which should enable them to take part in activities that interest them. The people living at Sefton Hall spoken to said staff regularly discussed their care with them and encouraged them to do the things they could do for themselves. The manager has continued to improved the way people’s care is recorded. The initial assesment documentation includes a template to record the things that are important to the person as an individual. This included the time they liked to get up and go to bed, their meal prefernces and activities they enjoy. Sefton Hall DS0000064054.V343704.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, (Older People) and 6,9,16,18,19,20, (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Sefton Hall have their care needs assessed and planned in a way that promotes independence and dignity. EVIDENCE: The four people whose care was followed had a plan of care in place, which set out the care needs of the individual and how staff should assist them to meet Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 11 their needs. Each person’s plan of care had been developed from a comprehensive assessment of their care needs, which covered personal care, health care and the social support they needed. The people whose care was followed had signed their plans of care. Those asked said that staff had spoken to them about their care needs and how they could be assisted. Two people said the staff encourage them to do the things they can do for themselves and help them with those that they cant. People whose care was followed had had their care reviewed monthly or sooner if they care needs has changed. A record of the review had been signed and dated by staff. The manager confirmed that people are involved in the review of their care. She also commented that external health care professionals and family where this had been agreed with the person were also involved. The home has two communal lounges and a dining room on the ground floor. During the inspection people were choosing which room they occupied. One person spoken to who spent the day sitting in the dining room looking at the garden said they like to be able to sit there quietly and watch what was going on. Other people were chatting to each other and with visitors in the large lounge. People asked during the inspection said they were able to choose whether they spent time in their own rooms, in the garden or in one of the communal areas. They commented that staff enabled them to choose how they spend their day. The manager has introduced a robust system for assessing people prior to their admission. This includes risk assessments for their chosen activities. Risk assessments had been completed for those people whose care was followed. These showed the actions staff and the individual should take to minimise the identified risks and hazards. Observation during the day of the inspection showed that people living at Sefton Hall are given the opportunity to make choices about their daily lives. People asked said they chose what time they got up and went to bed and whether they had their breakfast in the dining room or in their own room. One person said they preferred to have their breakfast in their own room and staff provided this for them, they also said that they enjoyed having their lunchtime meal and evening meal in the dining room with the other people in the home. The plans of care included personal preferences and choices for individuals relating to the food they liked and the time they like to get up and go to bed. The persons preferred form of address was also recorded in the individual plans of care seen during the inspection. Staff were observed to use the individuals chosen name when addressing them. Three comment cards received from people living at Sefton Hall all indicated that they receive the care and medical treatment they need and staff always act on what they say. The health care needs of the people whose care was followed had this clearly recorded in their plan of care. This gave staff the Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 12 information they need to ensure the individuals health care needs are met in a way that they need and prefer. Those people who required wound care had a separate plan of care, which identified the treatments used and demonstrated wound healing. The manager confirmed that pressure relief equipment had been provided for those people who needed this. These were seen in use during the inspection. During this inspection a member of staff was escorting one person to a hospital appointment. Records in the care plans for the people whose care was followed showed that people have access to the health care professionals they need. Multi-disciplinary records with in care plans showed the treatment/advise professionals had recommended. Where this had been recorded; the person’s plan of care had been adjusted to reflect the professionals advise. One visiting health professional advised that “staff at the home are always receptive to advise and they carry out their instruction.” They also commented that, “staff had become skilful in caring for people who sometimes challenged the service.” The controlled drug record was checked against the stock held for one person as correct. The home has a lockable drug trolley to transport medication to individual people. 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. The medication had been stored in a way that gave good stock control. The nurse in charge advised how individual peoples medication is managed to ensure they always have the medication they need. A system for assessing people who manage their own medication is in place. Staff have access to a policy folder, which provides guidance for medication practices in the home. Referenced material relating to the medication being used was available in the nurse’s office on the first floor. The staff observed speaking to people and providing care were doing so in a friendly professional way. When staff were working in pairs with a person they were involving them in their topic of conversation, which evidenced staff valued them as an individual. Sefton Hall DS0000064054.V343704.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, (Older People) and 12,13,14,17, (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Sefton Hall are encouraged to maintain links with the community and participate were possible in events. This means that people are enabled to choose and have control over their lives. The meals times at Sefton hall are a pleasant experience for the people who live there. Meals are prepared to ensure they are nutritionally balanced and attractively presented, this should ensure people received a balanced nutritious diet that meet their expectations. Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 14 EVIDENCE: People at Sefton Hall are encouraged to continue to take part in activities in the local community. The manager had arranged extra support staff to enable people to attend the carnival in Dawlish. Two people said they regularly went into town and if they needed help staff provided this. The manager provided information about the type of activities arranged on behalf of the people living at Sefton Hall. She advised that people had the opportunity to voice their opinions about the different activities provided either personally or as part of a group meetings. In addition to the external activities organised the manager advised that she was increasing the amount of one-one time provided individually for people living at Sefton Hall. This included giving them the opportunity to go out side the home with a member of staff or have “pampering sessions” for the ladies. One person said they looked forward to these sessions, as they liked having their hair done and nails manicured. One person spoken to during the inspection said that they enjoyed being able to go outside the home using their electric wheelchair. They commented that staff at the home had been supportive in helping them to do this. This persons plan of care had a risk assessment in place for use of the electric wheelchair. Discussion with the managers revealed how one person’s risk of smoking when they were on their own was being managed. She further advised that the restrictions had been put in place with the agreement of the person. Staff were seen assisting this person to smoke in a designated safe place. The records of expenditure and money held for one person was viewed. Clear records were being kept with receipts of expenditure and money held. The home provides the people who live at Sefton Hall, their relatives and friends, with information on how to contact external agencies. Each of the peoples rooms entered during the inspection had been personalised with items of the person’s choice. The meals times at Sefton Hall are a pleasant experience for people who live there. Menu’s are provided each day and a weekly rotational menu is available for those who wish to see this. People asked said they were able to choose what they wanted the next day from the menu and if there was nothing on the set menu they liked then alternatives would be offered. One person added that the “food is always excellent and they liked everything offered.” The menus offered showed that each day there is a choice of meals, which includes a vegetarian option. The meals seen at lunchtime were attractively presented and nutritionally balanced. Those who needed a soft or pureed diet had this prepared in a way that enabled them to experience the different tastes of the foods. Staff observed assisting people to eat their meals were doing so in a non-intrusive supportive way, they were speaking to the person about the Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 15 meal while they were assisting them. The lunch time meal time was unhurried with people eating their meals at their own pace. Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18, (Older People) and 22,23, (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Sefton Hall can have confidence that any concerns they have will be dealt with sensitively by staff that have their best interests at heart. EVIDENCE: The manager has introduced a robust complaints policy and procedure. This enables people to raise concerns knowing that these will be dealt with in a sensitive professional way by the staff. The eight people spoken to during the inspection also said they knew who to complain to had any concerns and felt confident staff listen to their concerns. A computer record of complaints was available. This showed the concerns that had been raised, the date and what actions had been taken to address the concerns raised. The manager advised that by recording all the concerns in this way it enabled her to look at ways the service could improve. Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 17 The complaints received by the Commission had been investigated fully by the manager and where these were substantiated actions had been carried out to address the concerns raised. The manager provided training records for staff this showed that all staff have access to protection of vulnerable adult training and training for managing behaviour that challenges the service. One health professional visiting the home at the time of the inspection said they had been impressed with the way staff had managed some of the challenges their clients presented. They went on to say that they were able to provide training and support for the staff for managing challenging behaviours. The recruitment process in place ensures that people are protected from unsuitable staff. The manager confirmed that all staff have police checks and references taken up prior to their employment in the home. Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26, (Older People) and 24,30, (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Sefton Hall have a pleasant, homely environment to live in, which meets their needs. However care should be taken that the separate toilets and bathrooms people use are easily accessible to them, to ensure these are able to meet their assessed needs and promote enablement. Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 19 EVIDENCE: Since the last inspection the dining room and small lounge have been redecorated and a new carpets provided. The people asked said they liked the way the dining room had been redecorated. The manager and owner advised that they were in the process of redecorating and renewing carets through out the home. The interior decoration and colour schemes planed for the home were seen. One person who had recently had their room redecorated said they had been able to choose new curtains and bedspread for their room. The said they really liked this and were pleased with how quickly it had been done after they had chosen the curtains. The manager provided a planed programme of repairs and renewals and decoration of the premises this showed that the redecoration of individuals rooms would be completed over the period of the plan. The people who live at Sefton Hall have access to a front garden, where a small patio area with planted borders and a summerhouse is provided. People were using this area with their visitors during the inspection. The tour of the home revealed that all areas that people who live there have access to were clean and fresh and reasonably decorated. Some of the toilets and bathrooms on the upper floors would not easy for independent wheelchair users or people 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 owner advised that these would be up graded as part of the longer term plans to up grade the home. He further commented that he intended to make these bathrooms and toilets easily accessible for wheel chair users. The manager confirmed that people admitted to rooms on these floors are usually more able, and accessing the toilets and bathrooms isnt usually a problem for them. Lifts are provided to all floors, which people are able to use independently or with the support of staff. Ramps are provided from the main entrance of the home into the garden. The manager advised that if people wish to spend time in the rear garden they could get to this from the front of the home. The main entrance to the home has a key coded lock and doorbell. The manager advised that those people who are able to use it are given access to the code. Infection control policies and procedures are available for staff. Staff observed providing care for individuals were using gloves and aprons. The manager advised that one of the staff would be the link person for the home with the health protection agency who offered training and advise relating to infection control practices. A yellow bag system for disposal of clinical waste is in place. The laundry is sited away from people’s rooms and communal areas in the basement of the home. The laundry, which was satisfactory at the last inspection, was not seen at this visit. Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30, (Older People) and 32,34,35, (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A committed caring staff team who have the training and support they need, care for the people at Sefton Hall. The recruitment processes at Sefton Hall are robust and should ensure people are protected from unsuitable staff. EVIDENCE: A duty rota was provided for staff in the home. This shows the shift times they cover and in what capacity they are employed. The rota confirmed that registered nurses are available for the people who live at home over a 24-hour period seven days a week. The home employs a manager and deputy manager who are both first level registered nurses. Four registered nurses, four senior care assistants and twenty health care assistants provide the health Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 21 and personal care support for the people living at Sefton Hall. Ancillary staff including a business administrator, chef, kitchen staff, domestic staff and maintenance staff are also part of the staff team. The number of staff on duty appears to be meeting the needs of the people living at Sefton Hall. Staff said they were usually sufficient staff on duty to ensure people had their personal and health care needs met. The manager advised that she was exploring ways of enabling people to have more one-to-one time the staff to do the things they wanted to do. The manager advised the home continues to employ foreign staff and four new staff had started recently. Prior to this inspection the Commission had received comments from a relative that indicated they were concerns that some of the new staff were unable to understand and speak English clearly. The manager confirmed that staff would have access to English second language training courses. She also said that these staff as with any new staff employed were on a probationary period. She also said that this relative had spoken to her about her concerns and she was endeavouring to address these with her. People who live at the home who were asked said all the staff who care for them are very friendly and helpful. Although they said they did not always understand some of what the foreign staff said they were usually able work this out; there friendly caring attitude more than helped this process. The manager advised that staff are encouraged to complete a National Vocational Qualification (NVQ) in care. The preinspection information indicated that four staff were working towards this. Two senior carers who had achieved an NVQ level 3 in care had been appointed head carer and deputy head carer since the last inspection. The manager advised that they had taken on some of the responsibility for training new staff ensuring they understood the work ethos and standards expected of them. The deputy head carer was introduced during the inspection. The way staff are deployed shows that the manager is experienced at recognising skills and qualities in the staff and encourages their development. Three staff files were seen during this inspection. These contained all the necessary pre employment checks including references and a police check. Two people living at Sefton Hall said they had been involved in the interviews of the new staff recently appointed. The manager advised that she was encouraging the people who live there to become more involved in this process. The manager has provided the homes staff with the company policies and procedures, which include a code of conduct expected for the staff they employ. These are easily available for staff in the office. How staff are supported to progress and access training and development opportunities was discussed with the manager. The business plan provided showed a commitment to staff training and development. Examples of staff training and development plans were seen completed for two staff. The manager advised that these would be completed for all staff. Four staff spoken to during the Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 22 inspection said they felt well supported to do their work and the manager was approachable and helpful. All said they had access to training that helped them do their work and confirmed they had received manual handling and fire training. Staff training records supported this. The manager was keeping records of staff supervision these covered monitoring individuals work, professional guidance and training and development needs. These supervision records were in addition to the annual appraisals completed for staff, which identified clearly their training and development plan. Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38, (Older People) and 37,39,42, (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems and practices introduced by the manager should enable the people to live in a well managed home supported by a staff team who understand their care needs. Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 24 EVIDENCE: The 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. The Commission has registered the manager following a fit person process since the last inspection. The manager has kept the Commission informed of the action she has taken to address the concerns raised by the complainants. During the inspection there was an open positive atmoshere in the home. Staff were interacting in a positive way with the people they were caring for and each other. Where staff were having converstions between each other, the person they were providing care for was being involved in the discussion/conversation. All the thoes 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, 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 though a maintainance and refurbishmnet programme had been prepared. The manager advised that the activity programme continues to be drawn up taking into account the indivudual preferences of people living at Sefton Hall. The manager advised that the recently appointed head carer had taken responsibility for co-ordinating this. She further commented that although there was an activity programme in place this was changed if the people wanted something different on the day. This was supported by the comments received from eight people who said they had been consulted about the activities provided. Records relating to the management of health and safety for the environment and equipment used in the home were seen. These showed that equipment is regularly serviced and environmental health and safety monitoring takes place. A record of accidents was available and clear information regarding RIDDOR reporting systems for accidents and injuries was available for staff. Fire safety checks and fire training for staff had been completed. The manager advised that they had changed the provider for fire safety since the last inspection. Sefton Hall DS0000064054.V343704.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 X 2 X 3 X 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X ENVIRONMENT Standard No Score 19 X 20 X 21 X 22 X 23 X 24 X 25 X 26 X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X 37 X 38 X Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 26 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. Refer to Standard OP19 Good Practice Recommendations The re-decoration and renewal of fixtures and fitting should continue to ensure all the people living at Sefton Hall have access to pleasantly decorated and furnished environment that meets their care needs and preferences where possible. Sefton Hall DS0000064054.V343704.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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