Inspection on 02/02/06 for Seton Unit

This inspection was carried out on 2nd February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Seton Unit 28/10/08

Seton Unit 21/11/06

Seton Unit 07/07/05

Seton Unit 13/01/05

Seton Unit 21/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Seton Unit The Marillac Eagle Way Warley Essex CM13 3BL Lead Inspector Helen Laker Unannounced Inspection 10:00 2 February 2006 nd 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 Unit DS0000018091.V273315.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 Unit DS0000018091.V273315.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Seton Unit Address The Marillac Eagle Way Warley Essex CM13 3BL 01277 220276 01277 204060 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) SISTERS OF CHARITY OF ST VINCENT DE PAUL Care Home 8 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (8) of places Seton Unit DS0000018091.V273315.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of service users to whom personal care is to be offered shall not exceed 8 (eight). Personal care to be offered to no more than 8 older people over the age of 65 years (OP). Personal care to be provided to no more than 8 service users with dementia over the age of 65 years (DE(E)). 7th July 2006 Date of last inspection Brief Description of the Service: The Seton Unit is a small Care Home for eight people. It is situated on part of the first floor of the Marillac Nursing Home. All the service users are Sisters of Charity of St Vincent de Paul and the Home provides facilities and an environment which supports their spiritual needs. There is an attractive lounge/diner and a separate well-equipped activities room. Each single room has ensuite facilities. Meals are provided from the main kitchen, however snacks and drinks are produced in the Home’s own kitchen. The Seton Unit has a pleasant rooftop garden, as well as access to the grounds of the Marillac. Seton Unit DS0000018091.V273315.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection which took place over three hours with one inspector in the home. There was a tour of the premises and grounds and an inspection of records and documentation. Time was spent discussing the care of the service users. The manager in charge of the day to day management of the home, two staff and service users were spoken with. Eighteen National Minimum Standards were inspected on this occasion, seventeen overall outcomes were met and there was one requirement and three recommendations detailed in the full report. Discussion of the inspection findings took place with the manager in charge of the day to day management of the home at the end and throughout the inspection, guidance was given. What the service does well: What has improved since the last inspection? What they could do better: Some minor issues were noted with some staff recruitment files and bought to the manager’s attention on the day of inspection but overall it was noted that the home operated a robust procedure and process for the recruitment of staff. All staff including the manager should receive a minimum of six structured supervisions and one appraisal annually. An application for the manager still needs to be made. Health and safety fire requirements such as drills had not been maintained regularly, this was discussed on the day of inspection. Seton Unit DS0000018091.V273315.R01.S.doc Version 5.0 Page 6 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 Unit DS0000018091.V273315.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 Unit DS0000018091.V273315.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): 1,2,4,5 Prospective service users and their supporters have adequate information about the home so that they can make informed choices. The admission procedure does include an adequate assessment which ensures that service users needs can be met. The home provides a caring environment where visitors are made welcome. EVIDENCE: The statement of purpose and service users guide have been reviewed and are up to date and all service users have a copy. Relevant information is available to prospective service users. The Statement of terms and conditions of residence was seen to be comprehensive. The home was expecting their most recent admission on the day of inspection. The home demonstrated that it can meet each service users needs on an individual basis from very independent to high dependence. A sample of care plans seen demonstrated that a full assessment has generally been undertaken prior to admission. Prospective service users are invited to visit the home pre-admission and admissions are planned appropriately. Seton Unit DS0000018091.V273315.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): 7,9,11 Each service user has an individual plan and service users are supported to take risks as part of an independent lifestyle via a process of assessment. Improvements have been made to the care planning process to ensure that service users needs are met. The health needs of service users are well met and better documentation will ensure clarity of needs. Personal support is provided in a way that promotes dignity and propriety. EVIDENCE: Care plans are in place for service users and these overall were comprehensive and detailed the care required. Of those inspected improvements were noted and contained adequate information and instructions for staff to ensure that residents needs were known and met consistently. One service user who had been in the home for more than one month had not yet had a care plan formulated. The managers explanation for this is noted but is reminded that all service users should have a care plan formulated, and in place within 5 days of their admission. Risk assessments were seen and adequately completed. Service users health is adequately promoted. Health care professionals visiting the home were complimentary of the care service at the home. No service users have pressure sores despite some being wheelchair dependant. Seton Unit DS0000018091.V273315.R01.S.doc Version 5.0 Page 10 A medication round was not observed, however the home is fully aware of the need to follow the Royal Pharmaceutical Society of Great Britain’s guidelines with particular regard to administration and recording. Records were previously studied and an organised system was in place. The manager was previously advised to have individual protocols in place for medication prescribed ‘as and when required’ (PRN) and for self medicating service users. This has now been put in place. One service user self medicates. Medication training is being addressed by the manager as a priority. Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. Seton Unit DS0000018091.V273315.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): Not Inspected EVIDENCE: Not Inspected Seton Unit DS0000018091.V273315.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): 17 The home has effective procedures in place to ensure that service users legal rights are protected. EVIDENCE: Service users are supported to vote, in person or by post. Service users are supported by 2 Sisters of Charity who can act as advocates for them and one independent who works for the League of Friends. The manager was advised regarding information on independent advocacy for the service users. Seton Unit DS0000018091.V273315.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 The Seton Unit is bright and airy and provides the service users with homely and comfortable surroundings. EVIDENCE: The home is presented in an attractive and comfortable way and adequately meets the current needs of the service users. Since the last inspection the garden has been re-landscaped and double glazing to the whole of the front of the building has been put in. In addition new water tanks have been fitted and the laundry has had a new roof and extractor. The manager also stated that a computer has been purchased for the service users on Seton Unit and would be placed in the activities area. Seton Unit DS0000018091.V273315.R01.S.doc Version 5.0 Page 14 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): 28,29,30 Adequate recruitment policies and practices were in place overall. The home has an effective and competent staff team who receive training to the required standard and this is to be maintained. EVIDENCE: Staff rotas on the day of inspection verified staff on duty and were up to date. Staff recruitment files for two members of staff were assessed. Improvements were noted and some issues such as permissions to work and permits were discussed with the manager. Overall it was noted that the home operated a robust procedure and process for the recruitment of staff. There was evidence that staff complete a probationary period before a decision is made to offer a permanent position. Staff spoken with previously confirmed that they received regular mandatory training and there was evidence of the specialist training provided for staff. POVA and medication training required prioritising and this is being addressed. The homes staff training plan was on display on the day of inspection. There was evidence of inductions and the Manager was aware of the TOPSS guidance and training targets. Both induction packs were viewed by the Inspector previously and this covered the 6 week and 6 month induction. The inclusion of abuse issues being given more prominence on induction was discussed with the manager who stated she was going to address that. Training opportunities for staff are good. Staff spoken with previously confirmed they are supported to attend all relevant training offered. Seton Unit DS0000018091.V273315.R01.S.doc Version 5.0 Page 15 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): 31,32,34,36,37,38 There is guidance and direction to staff and the home has in place practices that will promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The Manager has been in post for just over one year now. She demonstrates competency in her management role and has many years experience in the role of managing a care home – one of which previously was a care home for 105 people. She is currently doing her NVQ level 4 and when she has completed this she states she will apply to the Commission to be registered as the homes manager. At the present time she feels it will be too much all at once to do both. Regulatory requirements were discussed with the manager and clarified. The home appears to be led in an inclusive way. Service users confirmed the atmosphere is positive and were complimentary of the management of the home. Seton Unit DS0000018091.V273315.R01.S.doc Version 5.0 Page 16 The finances for the Seton Unit are managed by the Marillac organisation. There is a group of financial staff within the organisation and there appeared to be efficient management of the business. Supervision has taken place once for all staff in the last year. This was discussed. It is recommended that all staff receive a minimum of six structured supervisions and one appraisal annually. Supervision of all staff including the manager needs to be implemented on a more regular basis. Induction for new staff was effective and met training standards. Records inspected were well maintained. Service user records are stored safely in the Manager’s office in lockable metal cabinets. The Manager is fully aware of her responsibilities for health and safety and staff can receive regular training on health and safety. COSHH assessments are in place and up to date. Emergency call systems are checked regularly by the unit and the homes maintenance personnel. Certificates in respect of service and maintenance of gas, electric (including portable appliance testing), lifting and fire safety equipment at the home were noted to be satisfactory previously. Fire drills had not been regularly documented and undertaken at the homes previous inspection, this had limited progress made at this inspection but it was later clarified that both homes had combined documentation which was causing confusion and copies are to be kept on the Seton unit also to ensure all staff are participating in fire procedural drills or training. Seton Unit DS0000018091.V273315.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 3 3 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 x 11 3 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 3 18 X 3 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X 3 X 3 3 3 Seton Unit DS0000018091.V273315.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES 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 OP31 Regulation 8(1) &(2) 9(1)& (2) Requirement The registered person must ensure that the home has a registered Manager. An application must be submitted Timescale for action 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP36 OP38 Good Practice Recommendations All new service users should have a care plan formulated within 5 days of their admission It is recommended that all staff including the manager receive a minimum of six structured supervisions and one appraisal annually. A record of all fire drills and or training undertaken should be kept on Seton Unit documenting the names of all staff attending and the date and time. Seton Unit DS0000018091.V273315.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Unit DS0000018091.V273315.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. 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