Inspection on 07/12/05 for Sefton Hall

This inspection was carried out on 7th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 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 HOMES FOR OLDER PEOPLE Sefton Hall Plantation Terrace Dawlish Devon EX7 9DS Lead Inspector Doug Endean Unannounced Inspection 7th December 2005 11:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sefton Hall Address Plantation Terrace Dawlish Devon EX7 9DS 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) 01626 863125 Southern Healthcare (Wessex) Ltd Ms Karen Margarette Friskey 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.V256994.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 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 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 of the home. Access to the rear garden is restricted at present due to some building work that is in progress. Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report should be read along side of the previous report in order to establish the homes performance against the National Minimum Standards during this inspection year. The inspection was unannounced and began at 11.40 am and lasted for 3 hours and 50 minutes. In this time the inspector spent time with the Registered Manager looking at the recording methods now used in the home. A sample of four clients files was read and their structure and content discussed. There was a tour of the home that included time spent with five clients who gave their views about the home and the services offered. A number of clients rooms were looked at and the communal areas were entered. 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 DS0000064054.V256994.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 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 the following standard(s): 1&2 The home makes valuable information available to anyone considering moving into this home. The private/self funding contract does not fully meet with the requirements of the Regulations or the Standards. EVIDENCE: The Registered Manager showed the inspector a copy of the revised Statement of Purpose that is on computer and is presently at the printers being bound for distribution. The Service Users Guide was also seen in its completed form, both in the office and also in each of the clients bedrooms that were entered during the inspection. Each document was well written and presented. They hold the level of information required of them that should enable prospective clients to make an informed decision about coming to the home. This information is further enhanced by the Registered Manager making available information from external organisations about services such as the “Advocacy Service” and information about “Funded Nursing Care” that can be made available to clients in care. The homes private contract was looked at, albeit a blank copy. This did not include all the information provided in the National Minimum Standards “ Care Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 8 Homes for Older People”, Standard 2.2 and that which is required by Standard 5A where nursing care is being provided. Some other elements of this contract also needed further thought and advice was passed onto the Registered Manager such as the issue of a trial period as in Standard 5. Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 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 the following standard(s): 7 The new documentation used for each client is very well constructed, has been filled in, and does provide a good level of appropriate information for care to be guided from. EVIDENCE: The home has introduced a new format for recording information about each of the clients who are resident in the home. This is a well structured format that has been purchased from a well recognised provider in the field of care documentation. The inspector looked at a sample number of files, 4 in all, and had the Registered Manager explain how the records are completed and who by. The records included a photograph of each client, physical assessment information, well designed care plans that are reviewed in line with the standards, and a monthly dependency level assessment on about 20 main factors. The home has also begun using a new wound assessment and recording format and the inspector was told that the Area Tissue Viability Nurse from Torbay was included in the process. This was also impressive record keeping. The home have adopted a communications book for each client that is in there room and holds notes from the key worker that can be safely passed onto Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 10 visitors to the room, relatives and friends, to keep them informed about day to day issues particularly when the key worker is not on duty to pass this information onto them. The key worker initially introduces his or her self to the reader by writing about themselves in the book and what their responsibilities are. Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 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 the following standard(s): 12 The home provides an environment that meets the physical and social care needs of the clients that are resident in it. EVIDENCE: These standards were fully reported upon during the last inspection when they met the required standard. The inspector did not fully inspect all these standards again on this occasion. However, the inspector did note that there was a full program of entertainment and events for the month of December 2005 posted on each of the notice boards in the home and that the home was being prepared for a clients party that was scheduled to begin at 19.00 hours on the day of this inspection. During the tour of the home clients were making their wishes known about attending the party to the Registered Manager and other staff, most were looking forward to attending. The clients that were spoken to did feel that the home does in the main meet their expectations both in social and physical care that they receive. Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 16 The homes process for dealing with complaints is satisfactory. EVIDENCE: The manager has a record that was seen of all complaints and how they are addressed. There is a complaints procedure in the Statement of Purpose and Service Users Guide that is also seen on each of the notice boards (on each floor of the home) for the clients and anyone entering the home to see. It has information about how to make a complaint, time frames and how to contact the Commission for Social Care Inspection if this is felt appropriate. Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 19, 20, 21, 22 & 24. The accommodation provided by the home is well designed, equipped and presented so as to meet the needs of the clients. The dining room carpet is the area that lets the rest of the environment down due to heavy staining. EVIDENCE: The décor is satisfactory and the inspector noted that many areas have been upgraded and new carpets have been laid in several of the clients bedrooms. The bedrooms are each furnished satisfactorily and a number do have their own en-suite facilities. The beds that are provided are based upon a risk assessment and where necessary fully adjustable nursing beds with integral bed guards are available and were seen to be in use by the inspector during the tour of the home. The clients have personalised their own rooms in tasteful ways that meet with their own approval. The television lounge carpet remains satisfactory but the dining room carpet, despite obvious attempts to keep it clean, is showing heavy use stains. The area that was communal space for the clients has been reduced with the “Luscombe Lounge” being turned into a “board room” and not for general use. Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 14 The inspector will need to measure the remaining communal space to see if this change has impacted upon the over all communal space required and the score for this standard will not be effected until the evidence has been checked. The clients can access the upper floors by way of three different stair cases, one at each end of the home and one in the middle, or two shaft lifts, one at each end of the home. Toilet and bathing facilities are accessible to the clients either in their own rooms or in the bathrooms and toilet blocks around the home. The bathrooms are large and equipped to meet the needs of disabled clients who are also resident in the home. There is a nurse call system located throughout the home and clients can carry a call unit so they can alert someone that they need attention when not in there own room. There are storage areas for equipment to avoid clutter. Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 15 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were fully reported upon during the last inspection when they met the required standard. The inspector did not fully inspect all these standards again on this occasion. Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 The Registered Manager is qualified and experienced in both management and nursing, and leads her staff to provide good standards of care to the clients resident at the home. EVIDENCE: The Registered Manager is an experienced nurse and home manager, with more than two years experience in her post in this home, and she has achieved a National Vocational Qualification at level 4 in Management in July 2004. She provides support and direction to the care staff assisted by her deputy who is also a Registered Nurse. There are clear lines of accountability in the home and also with external management. Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 3 3 X 3 X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X X Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? N/A 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 floor covering in the dining area should be considered for replacement as it is heavily stained despite attempts to keep it clean. Sefton Hall DS0000064054.V256994.R01.S.doc Version 5.0 Page 19 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.V256994.R01.S.doc Version 5.0 Page 20 - 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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