Inspection on 27/10/05 for Seton Hall

This inspection was carried out on 27th October 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

Seton Hall 04/04/07

Seton Hall 31/05/05

Seton Hall 20/01/05

Seton Hall 14/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Seton Hall Ord Road Tweedmouth Berwick upon Tweed TD15 2UT Lead Inspector Anne Urwin Brown Announced Inspection 27th October 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Seton Hall DS0000051545.V249758.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. Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Seton Hall Address Ord Road Tweedmouth Berwick upon Tweed TD15 2UT 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) 01289 306391 shirley.mcdougal@setoncare.org.uk Seton Care Ltd Mrs Shirley Isabella McDougall Care Home 47 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (35) Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two identified persons under 65 years with dementia can be admitted for periods of respite. The total number of residents should not exceed the total registered. 31st May 2005 Date of last inspection Brief Description of the Service: Seton Hall provides residential care for up to forty-eight elderly people about a mile from the centre of Berwick upon Tweed. Bus and train links are available in Berwick town centre. The home is operated by Seton Care Ltd, a subsidiary of Berwickshire Housing Association. The accommodation is provided on two floors and there are very pleasant views of the surrounding area. The home is situated within its own grounds and has a short drive from the main road. Ample parking is now available. Day care is provided by separate staff from Mondays to Fridays. Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over one day. It involved talking to the manager, ten residents and four staff. Records were inspected and a tour of the building was carried out. What the service does well: What has improved since the last inspection? What they could do better: One risk assessment needed updating to reflect some changes for one resident. Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 6 The information collected from residents’ questionnaires needs to be used to prepare a development plan for the home. The provision of regular staff supervision needs to be given priority when the new senior care officer has taken up post. 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. Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 7 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 Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 8 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): 2, 6 Each resident has a written contract with Seton Care that outlines the terms and conditions of residence. Intermediate care is not provided at Seton Hall. EVIDENCE: Residents confirmed that they received a contract when they came to live at Seton Hall. The contract contains information about what care and services are provided, the fees paid, the conditions of living at the home and any additional services not covered by the fees. The Manager stated that intermediate care is not provided at Seton Hall and records confirmed this. Seton Hall DS0000051545.V249758.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, 9 Each resident’s health, personal and social care needs are set out in an individual plan of care. Residents are protected by the home’s policies and procedures for dealing with medicines. Residents are able to retain control of their own medicines if appropriate. EVIDENCE: Five residents’ records were seen during the inspection. These showed that each person has a care plan showing their health, personal and social care needs based on an appropriate assessment. The plans are regularly updated and evidence was available of formal reviews of each person’s care. Risk assessments are prepared for each resident. One resident’s plan required updating to show changes that have happened for this person. Moving and Handling and Pressure Area risk assessments are regularly updated. Residents confirmed that care plans are discussed with them regularly. They said that they felt satisfied that their care needs are met and that staff know what their needs are. Written guidance is available about handling medicines. Records of the administration of medicines are kept in an appropriate form and are up to date. Arrangements for storage of medicines are satisfactory. Staff training Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 10 has been provided for all staff involved in administering medicines. The local pharmacist provides information and advice about residents’ medicines. Risk assessments are carried out before residents take responsibility for administering their own medicines and these are regularly updated. Residents are provided with lockable storage for keeping medicines safe. Seton Hall DS0000051545.V249758.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, 13, 14, 15 Residents find the lifestyle of the home matches their expectations and preferences. Residents’ social, cultural, religious and recreational interests and needs are met. Residents are encouraged to maintain contact with family, friends, representatives and the local community. The routines of daily living and activities made available are flexible and varied to suit residents’ expectations, preferences and capacities. A wholesome, appealing and balanced diet is provided for residents. There has been a complete review of the menus to provide a hotel style menu that gives residents much greater choice. Staff are to be commended for giving residents more choice about the food they eat. EVIDENCE: Interests and routines are identified as part of the assessment process and records confirm this. Residents said that they could make choices about their daily routine, activities and relationships. Records confirm this and evidence was available that there is a range of activities available. Residents confirmed that they could have visitors at any time and that they are encouraged to maintain links with the local community. Residents said that their visitors could have a meal with them if they wished. The manager and records confirmed that there are no restrictions on visiting. Information is available for relatives about maintaining links with residents. Relatives’ Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 12 questionnaires showed that they are satisfied with the arrangements for visiting. Residents are encouraged to retain control of their money for as long as they are able. Residents said that they were able to bring in items of furniture and other possessions when they moved into the home. Residents’ rooms show evidence of this. The manager confirmed that residents are informed about an advocate who will act on their behalf. Written guidance is in place to confirm that residents are able to see their personal records. Residents said they had not asked to see their records, but they knew that they could see them if they wanted to. The menus show a very good choice is available and residents expressed their satisfaction with the choice and quality of food available. The food served was well cooked and presented. The catering manager has introduced new hotel style menus since the last inspection. Residents said that they could request favourite foods. They said that they could speak to the catering manager who was happy to discuss their wishes or needs. There is a high commitment to providing a good balance diet that takes account of individual taste and this is to be commended. Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 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 the following standard(s): 16 Residents are confident that their complaints and concerns will listened to, be taken seriously and acted upon. EVIDENCE: Written guidance is in place for dealing with complaints. One complaint has been made since the last inspection and records confirmed that an appropriate investigation had been made. Records of complaints are kept that show appropriate information about the complaint, its investigation and outcome. Residents said that they felt able to raise any concerns or complaints with staff or the manager. They confirmed that they were satisfied that any concerns or complaints would be dealt with appropriately. Staff were aware of the complaints guidance and could describe how they would assist a resident to make a complaint. Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 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 the following standard(s): 20, 21, 22, 24, 25 The home is comfortable and well decorated with sufficient sitting and dining room space for the number of residents living at Seton Hall. Residents have appropriate toilet, washing and bathing facilities. Specialist equipment is available to meet residents’ identified needs. Residents’ bedrooms are safe and comfortable. Most residents have brought in valued personal possessions. The heating, lighting and water supply meet environmental health and safety requirements. EVIDENCE: There are comfortable sitting areas that are spacious, homely and furnished appropriately. Dining areas are well equipped. Two dining areas have been refurbished and new furniture has been purchased. Residents said that they were satisfied with the accommodation available and that they were comfortable. Toilets and bathrooms are accessible and equipped with appropriate aids and equipment to meet the needs of residents. There are sufficient toilets and Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 15 bathrooms. There are no en-suite facilities. There is a sluice on each floor and these have been upgraded within the past year. Evidence was available from residents’ records that showed appropriate assessments are carried out as necessary for aids and equipment. A passenger lift is fitted and grab rails and other aids are available in corridors, residents’ rooms, bathrooms and toilets as necessary. A call system is fitted and points are available throughout the home. Residents’ rooms are appropriately furnished and highly personalised. Lockable storage is available in each room and a door key is available. Residents have a key supplied unless a risk assessment suggests this is not appropriate. Residents said that they were satisfied with their rooms and that they had been encouraged to bring in items from their previous homes. All rooms are naturally ventilated. Central heating is fitted and the temperature can be adjusted. Radiator guards are fitted. Lighting levels are appropriate. Thermostatic controls are fitted to all hot water outlets. Emergency lighting is fitted. Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 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 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): 27, 28 Residents’ needs are met by the numbers and skill mix of staff. Residents are cared for by appropriately qualified and experienced staff. EVIDENCE: The rota confirmed that adequate numbers of staff are on duty during the day and night. The manager said that more staff are on duty on the first floor as residents are more dependent. There is a senior member of staff on duty on each shift. The residents said that they feel satisfied that enough staff are available. They said that staff respond quickly when they ask for help. The manager said that additional cover is provided at peak times or to meet specific individual needs. Evidence of this was available from the rota. Sickness cover is provided by staff working extra hours or by relief staff. One extra post has been created to provide additional staff cover in the kitchen and an additional domestic post has been created since the last inspection. The manager reported that this has allowed improvements to be made in the service provided. A programme of staff training in care is in place. More than half the staff have either completed or are working towards recognised qualifications in care. Twenty staff have completed a recognised qualification in care. Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 17 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, 32, 33, 36, 38 The manager is undertaking training for the manager’s award. She is experienced and competent to care for older people. Residents benefit from the open, positive and inclusive atmosphere created by the management of the home. The home is run in the best interests of residents, however the quality assurance system is not yet fully in place. Staff are not all receiving supervision at appropriate intervals, although they confirmed that a good level of informal support is provided by the management team. The health, welfare and safety of the residents is promoted and protected. EVIDENCE: The manager is currently undertaking a course that leads to the Registered Manager Award. She is almost half way through the course. She is experienced in caring for older people and regularly undertakes training to improve her skills. There is a written job description for the manager. The manager has regular supervision from the Director of Seton Care. Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 18 Staff confirmed that the manager provides a clear sense of direction and leadership that relates to the aims and objectives of the home. Residents and staff are encouraged to communicate their views about the operation of the service at regular staff and resident meetings. Minutes were available for inspection and these showed that the management is open to suggestions for improving the service. Copies of the General Social Care Council’s Code of Practice are provided for staff. The supervision programme has been affected by a senior care staff vacancy. A new appointment has been made. Staff said they feel well supported by the senior staff group who provide a good level of informal supervision. Annual appraisals are carried out yearly. Records of equipment tests and servicing of the fire alarm are kept in an appropriate form. Staff have regular fire training as required and records confirmed this. Records showed that training in safe working practices including moving and handling, first aid, food hygiene and infection control is provided regularly. Written guidance is in place for Health and Safety, Control of Substances Hazardous to Health and Infection Control. Records show the lift is serviced regularly. Accident records are available in an appropriate format. All new staff receive appropriate Induction training. Staff said that support is provided for new staff. Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 19 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 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X 3 3 3 X 3 3 X STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X X 2 X 3 Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP33` Regulation 13 24 Requirement Risk assessments need to be updated to reflect changes identified in any resident’s care. Information collected as part of the quality assurance system must be used to prepare an annual development plan. Arrangements must be in place for the provision of regular staff supervision. Timescale for action 31/12/05 31/03/06 3 OP36 18 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Seton Hall DS0000051545.V249758.R01.S.doc Version 5.0 Page 22 - 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!