Inspection on 21/11/06 for Seton Unit

This inspection was carried out on 21st November 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 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 Unit 28/10/08

Seton Unit 02/02/06

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 Key Unannounced Inspection 21st November 2006 11:00 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 Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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.V313003.R01.S.doc Version 5.2 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 Sister Bernadette Ryder 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.V313003.R01.S.doc Version 5.2 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)). 2nd February 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 residents 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 Homes own kitchen. The Seton Unit has a pleasant rooftop garden, as well as access to the grounds of the Marillac. The Service User Guide and Statement of Purpose have been reviewed and are updated as required. The residents and their representatives can be provided with this information and the manager stated previously that the home would provide them with Commission for Social Care Inspection reports too. These can be displayed for reference. At the time of this report the manager supplied information regarding the home’s charges via a pre inspection questionnaire. These range from £418.06 to £438.00 per week Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced key inspection which took place over one day 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 residents. The manager in charge of the day to day management of the home was on this occasion rostered on a day off, four staff and residents were spoken with. Further feedback was also received from service users and care staff through discussion. Responses have been included in the relevant sections of the report. A pre-inspection questionnaire and other reports and correspondence provided by the staff on duty were also used as evidence to inform this report. Twenty two National Minimum Standards were inspected on this occasion including all of the key standards, seventeen overall outcomes were met and there was one requirement and four recommendations detailed in the full report. Discussion of the inspection findings took place with the four staff on duty at the end and throughout the inspection, guidance was given. The staff are thanked for their participation and input with this inspection which for some was a new experience. The home has expressed a wish that service users be referred to as residents with which this report complies. What the service does well: What has improved since the last inspection? Many improvement’s were noted to have been made at this inspection. Care planning has improved with better documentation and up to date and reviewed risk assessments were seen to be in place. Planned training is evident. The manager is now registered and has achieved her NVQ level four Documentation of fire drills is now in place. It is acknowledged that since the last inspection a lot of progress has been made and the manager and staff’s hard work is noted. Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 6 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 Unit DS0000018091.V313003.R01.S.doc Version 5.2 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.V313003.R01.S.doc Version 5.2 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): 3 and 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective service users and their supporters have adequate information about the home so that they can make informed choices. The admission procedure on the whole includes 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 Manager previously stated that where practicable for example depending on the location, all prospective service users are visited in their own homes prior to any decisions regarding admission to the Seton Unit. Although differing documentation was seen and was noted to be completed by other professionals, for some admissions it was not clear in all cases that an assessment had been undertaken by Seton Unit itself. More definition of some areas was noted to be required. For example one resident was noted to be allergic to pain killers but these were not identified on the assessment. New Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 9 residents should have clearly assessed needs identified. The Seton Unit does not provide intermediate care. Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 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. The health needs of service users are well met and better documentation ensures clarity of needs. Personal support is provided in a way that promotes dignity. EVIDENCE: Care plans are in place for residents and overall these were comprehensive and detailed the care required. It is noted that good improvements in care plan formation and completion have been made. Of those inspected adequate information was included for staff to ensure that residents needs were known and met consistently. Risk assessments were seen to be in place and adequately completed. Training for staff has also been undertaken. Resident’s health is adequately promoted. Feedback from Health care professionals who visit the home were complimentary of the care service at the home. It was noted positively by the Inspector at previous inspection’s that tissue viability is vigilantly addressed and no resident’s have pressure sores currently. Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 11 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 studied and an organised system was in place. Training for staff is being addressed and individual protocols are in place for self medicating residents. It was observed that residents are treated with great respect and their privacy, religious beliefs and dignity preserved. District Nurses spoken with at previous inspections, were complimentary of the care service they observe to be available at the home. Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Current residents found the current lifestyle did match their expectations and preferences. Links with families and advocates are good and contact is maintained. Choice in the routine of the day is adapted to ensure residents rights and beliefs are maintained. The home provided a wide range of good food in ample quantities. EVIDENCE: The routines of the home centre around the spiritual needs of the resident’s who are Sisters of Charity. Mass is carried out every morning and early evening prayer is available on the Seton Unit and resident’s are supported to attend according to their personal wishes. Resident’s receive visitors on a regular basis and this was confirmed through discussion and by evidential recording in individual daily notes. There are no restrictions on visiting time. A number of resident’s have visitors who will attend mass with them. Resident’s can have access to their own records at all times. It was clearly evident that resident’s are given a great deal of choice throughout their time at the home e.g. Meals, religious services and personal care. All monies are maintained through the office and those checked were Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 13 found to be correct. Resident’s needs can be well represented through advocacy if required. Meals are varied and there is a regular wide choice. Special diets are well catered for such as vegetarian, puréed or cultural choices. Resident’s can choose to take meals at any time but often choose to eat together and were complimentary of the meals provided. Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 14 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 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints policy which informs complainants of their rights and assures them their complaint will be taken seriously. Most staff have now received relevant training relating to the protection of vulnerable adults. EVIDENCE: The home has robust policies and procedures regarding complaints. Complaints are logged appropriately although none have been made for some time and not since the last inspection. Resident’s spoken with were aware of the process to take if necessary. All those spoken with during the inspection were complimentary of the care delivered and services provided at the home. The home maintains robust policies and procedures regarding the Protection of Adults and safeguarding service users from abuse. Training for staff has been undertaken. The new Manager previously stated she would investigate how to access the POVA first system. This could not be confirmed at this inspection but will be followed up at the next. Resident’s spoken with were confident that they are safeguarded from abuse and staff spoken with during this inspection could demonstrate that they understood what actions to take if there was any incident of witnessed or suspected abuse of resident’s living at the home. This was discussed previously Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 15 with the manager and it is acknowledged that an incident of this type has never arisen at the Seton Unit to date. Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 16 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 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 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 resident’s. The home was clean and hygienic on the day of inspection. Appropriate systems were in place to control cross infection. Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 17 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, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. It was not possible to confirm that adequate recruitment policies, supervision and training practices were in place on this occasion due to the inaccessibility of records. The home has an effective and competent staff team who receive training to the required standard. EVIDENCE: A number of staff have worked at the home for some time. The rota is accurate and reflected staff on duty. There are sufficient staff employed to cover care and ancillary tasks. Although there is only one member of staff on duty at night, Seton unit are supported by the Marillac in the event of staff breaks and assistance being required. Disappointingly staff recruitment, training and supervision files could not be inspected at this inspection as the manager who held the only key was on a day off. Files should be available for inspection at all times and it is suggested that when the manager is not on duty a key be left to allow access to these records for inspection and emergency purposes. Staff spoken with confirmed that they did receive regular mandatory training and although training files could not be inspected, there was evidence of the specialist training provided for staff. The inspector was previously informed that Criminal Record Bureau checks have been sought and that POVA checks will be investigated. The manager was previously advised that staff members should not start work at the home until all relevant recruitment checks have been completed including POVA first and CRB checks. Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 18 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, 33, 35, 36 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 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: Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 19 Since the last inspection the Manager has been registered and worked hard to demonstrate competency in her management role shown through the improvements the home has made. She has many years experience in the role of managing a care home – one of which was a care home for 105 people. Sister Bernadette Ryder has also completed her NVQ 4. Policies and procedures are in place and regular regulation 26 reports are received by the CSCI Service users monies are managed on the whole between the home and the individual. These could not be inspected at this inspection as the manager had the only key and was rostered on a day off. 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. Fire drills are now being regularly documented and the last one undertaken on the 6th November 2006. Employers liability insurance was in date and displayed. Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 20 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 X 2 X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 2 X 3 Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 21 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 Standard OP29 Regulation 17 (3) (b) Requirement Recruitment records required by regulation for the protection of service users and for the effective and efficient running of the business must be maintained, up-to-date and accurate and be easily available and accessible for inspection and emergencies at all times. This also with reference to other staff records such as training and supervision files. Timescale for action 05/01/07 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 OP3 OP30 Good Practice Recommendations A documented, dated and signed pre admission assessment should be made, and put in place by the staff of the home prior to all new services being admitted As a result of recruitment records not being inaccessible training records could not be inspected. These must be easily available and accessible for inspection and DS0000018091.V313003.R01.S.doc Version 5.2 Page 22 Seton Unit 3 OP35 4 OP36 emergencies at all times. As a result of the key for resident monetary records not being available these records could not be inspected. These must be easily available and accessible for inspection and emergencies at all times. As a result of recruitment records not being inaccessible supervision records could not be inspected. These must be easily available and accessible for inspection and emergencies at all times. Seton Unit DS0000018091.V313003.R01.S.doc Version 5.2 Page 23 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.V313003.R01.S.doc Version 5.2 Page 24 - 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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