CARE HOMES FOR OLDER PEOPLE
Seton Hall Ord Road Tweedmouth Berwick upon Tweed TD15 2UT Lead Inspector
Anne Urwin Brown Unannounced 31 May 2005 12:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Seton Hall Address Ord Road Tweedmouth Berwick upon Tweed TD15 2UT 01289 306 391 n/a shirley.mcdougal@setoncare.org.uk Seton Care Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Shirley McDougall CRH 47 Category(ies) of DE(E) Dementia - over 65 (10) registration, with number MD(E) Mental Disorder - over 65 (2) of places OP Old Age (35) Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: There are no conditions of registration. Date of last inspection 20.01.05 Brief Description of the Service: Seton Hall provides residential care for up to forty-seven elderly people on the outskirts of Berwick upon Tweed. There are bus and train transport links in Berwick and a local bus service is available from the bottom of the drive. The Home is operated by Seton Care Ltd a subsidiary of Berwickshire Housing Association. Accommodation is provided on two floors and there are pleasant views of the surrounding area. The Home is situated in its own grounds with a parking area to the side and rear of the building. Within the Home, a separately staffed day centre operates Monday to Fridays. Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was an unannounced visit, which took place over half a day. It included talking with the Manager, six residents and three staff, inspection of records and a tour of the building was undertaken. What the service does well:
The service provides individual support to suit the needs of the residents. Staff know what the residents’ needs are and residents confirmed this. Residents said that their individual likes and dislikes are well known to staff. Records contain information about residents’ needs and their likes and dislikes. Care plans seen during the inspection contained appropriate information about each person’s care needs and the support required. Residents spoke highly of the staff and the quality of care offered. Residents said that they were very happy with the food served and that they were able to choose whether or not they had meals in the dining room or their own rooms. They also said there was a wide choice of food provided at each meal time and that it was of good quality and well cooked. There was a relaxed atmosphere and it was evident that residents had a good relationship with staff. The Home is well maintained and most of the decoration is of good quality. Residents are not required to share a room unless they have chosen to do this. There is a homely atmosphere in the Home. There is clear direction and leadership from the management of the Home. Staff feel able to raise issues with the Manager. Staff have appropriate training provided to ensure that they are able to meet residents’ needs. Staff feel able to contribute their views about the running of the Home to the Registered Manager or to the Director of Seton Care. Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 6 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. Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 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 standard(s) 1, 3, 4, 5 Information is available for prospective residents about the Home and the service provided. Residents have their needs assessed before moving into the Home. Arrangements are in place to ensure that residents’ needs are met. Pre visits are arranged to the Home so that prospective residents and their family are aware of the facilities and service provided. EVIDENCE: A Statement of Purpose is available in written and audio form. Information is clearly presented about the Home and the service provided. Residents stated that they received information about the Home prior to coming to the Home to live. All residents have an assessment prior to moving into the Home. Every resident has a full assessment of their needs before they are admitted. Records were available to confirm this. The Manager and staff described how the person and their family are involved in this process. Pre-visits to the Home and a trial period are arranged to suit individual needs. Relatives are also encouraged to visit the Home. Residents were able to
Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 9 confirm that they visited the Home before coming to live there. Information was available in one resident’s file to confirm this practice. Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 10 Care plans providing details of each resident’s needs are in place. Staff promote and maintain residents’ health and ensure access to health care services to meet assessed needs. Policies and procedures are in place for dealing with medicines. Residents are treated with care, sensitivity and respect. EVIDENCE: Four files were inspected and these showed that each resident has a care plan in place. Care plans contained information about the health, personal and social care needs of the residents. The plans are regularly updated. Records confirmed that regular reviews of each person’s care and support needs are carried out. Mobility assessments, weight charts, risk assessments, pressure area risk assessments were in place. Residents confirmed that they were satisfied that staff knew what their needs were and that they received appropriate support. They said that staff knew their jobs and were caring. Written guidance is in place for administering medication. An appropriate recording system is in place for recording administration of drugs. Records were available to confirm that staff training has been provided. Individual medication records seen at the inspection were well maintained. Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 11 Staff were able to confirm that they are aware of issues related to privacy and dignity for residents. Staff were observed knocking on residents’ doors before entering. Residents said that the staff are sensitive and respectful. Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 The food provided is wholesome, well prepared and varied. The management of the Home are to be commended for the range of choice of food and the attention given to providing a high quality service. EVIDENCE: New menus have been introduced since the last inspection and the cook stated that more work is going on to provide a multiple choice at meal times. There is a choice of four items at lunch times. Residents stated that they are satisfied with the quality and quantity of food. They said that there is a wide choice of food available and that meals can be served in their rooms if they wish. Special diets are catered for. The cook described how residents are asked for their views about the meals by kitchen staff. Work is going on to improve the dining areas with new furniture ordered. Updating training on Food Hygiene is arranged for twenty-one staff. Kitchen staff have an appropriate qualification in Food Hygiene. Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Residents are confident that their complaints or concerns will be taken seriously and acted upon. Residents feel safe and staff are aware of guidance on abuse. EVIDENCE: There is written guidance in place on dealing with complaints. Staff were able to confirm that they knew the guidance and could appropriately assist a resident to make a complaint. Three complaints have been recorded since the last inspection. Records showed that these have been fully investigated and resolved. Residents confirmed that they felt satisfied that any concerns or complaints raised with the Manager or staff would be dealt with appropriately. They said they felt comfortable about speaking of any concerns to staff and the Manager. Written guidance is in place regarding the protection of vulnerable adults. Staff confirmed that they knew about the guidance and could appropriately assist a resident if they wished to make an allegation of abuse. Eleven staff have had training in dealing with allegations of abuse. Residents said that they are satisfied that they could speak to staff about any concerns. A system for recording allegations of abuse and the outcome of investigations is in place. Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 26 Residents live in a comfortable, safe and well-maintained Home. The Home is clean, tidy and hygienic. EVIDENCE: A tour of the Home during the inspection confirmed the public areas are clean and well maintained. A planned programme of maintenance and upgrading is in place. Flooring in two bathrooms has been replaced. The Home is well furnished to suit the residents’ needs. The Manager confirmed that some new dining furniture has been ordered. One dining area has been redecorated and plans are in place for another area to be done as well as the smoking area on the first floor. New chairs have been ordered for the smoking room. Residents stated that they were satisfied with their accommodation. They said that they felt the Home is comfortable and well maintained. Policies and Procedures are in place for Health and Safety and Infection Control. Records and discussion with staff confirmed that appropriate training has been provided and that they were aware of written guidance. The laundry is fitted with appropriate equipment. A sluice is available on each floor. Water services have been checked and records confirm this. Radiators are to be
Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 15 fitted with individual thermostatic controls. The central heating system is regularly serviced. Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Staffing is sufficient to meet the needs of the residents. Residents are protected by the recruitment policies and practice. Recruitment policies are followed consistently. Staff are trained and competent to do their jobs. EVIDENCE: Rotas showed that sufficient staff are on duty each shift to meet the needs of the residents during the day. Three waking night staff are on duty during the night. There is always a senior member of staff on duty. The Manager stated that there is some flexibility in the level of staffing to provide individual support for particular residents. Residents stated that there are enough staff on duty and they respond quickly when they ask for some help. They also confirmed that staff knew what they needed help with. The staff team are provided with appropriate training and are competent to care for older people. Written guidance for staffing the Home is in place and takes account of experience and age of staff, layout of the building and the dependency of the residents. Written procedures are in place for recruitment of staff. Records showed that appropriate checks are carried out before a new member of staff is employed. The Manager described the procedure for new appointments and this follows the guidance issued by Seton Care. Staff confirmed that regular training opportunities are provided. Staff have received training in care. A staff training plan is in place. The Manager confirmed that new staff have induction and foundation training provided.
Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 37 Residents’ views are regularly sought by staff, but there is not yet an effective quality monitoring system in place. Residents are encouraged to take responsibility for managing their money. Appropriate systems are in place to assist residents who are not able to manage their own money. The health, safety and welfare of residents is protected. EVIDENCE: Staff were able to describe how they seek residents’ views about the service. Questionnaires have been used to find out what residents think of the food. Residents’ meetings are held regularly and the Manager said that they are encouraged to put forward their views. Written guidance is available for staff about handling residents’ money. Records are kept of any money held on behalf of a resident. Samples of the records checked showed that the money held balanced with the records.
Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 18 Records show that the fire alarm and fire equipment is regularly tested and serviced. Seven fire drills have been carried out in the past year. Staff said that they have regular fire training and records show that this is provided at appropriate intervals. Written guidance is available for Health and Safety. Staff confirmed that they were aware of this. First aid, fire, food hygiene, moving and handling training is regularly updated and records confirm this. Accident records are kept and evidence was available that these are monitored by the management. Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 3 Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 33 Regulation 24 Requirement A system must be introduced for reviewing and improving the quality of care provided. The system should include consultation with residents and their representatives. Timescale for action 31.10.05 2. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Seton Hall B53-B03 S51545 Seton Hall V225006 310505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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
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