Inspection on 07/07/05 for Seton Unit

This inspection was carried out on 7th July 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 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 02/02/06

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 Thursday 7th July 2005 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 Unit I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Seton Unit Address The Marillac Eagle Way Warley Essex CM13 3BL 01277 220276 01277 204060 enquires@mariac.co.uk Sisters Of Charity Of St. Vincent De Paul 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) Sr Zoe ONeil CRH Care Home 8 Category(ies) of DE(E) Dementia -Over 65 (8) registration, with number OP Old Age (8) of places Seton Unit I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of service users to whom personal care is to be offeres shall not exceed 8. 2. Personal care to be offered to no more than 8 older people over the age of 65 years (OP). 3. Personal care to be offered to no more than 8 sdervice users with dementia over the age of 65 years (DE(E). Date of last inspection 13th Janurary 2005 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 I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 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 six 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. Twenty seven National Minimum Standards were inspected on this occasion, twenty one overall outcomes were met and there were six requirements and one recommendation 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. It is acknowledged that the home being an integral part of the Marillac has had to cope with the sad passing of the previous manager and that the homes present manager has been in post just six months. The inspector was assured that progress had been made since the last inspection and that any shortfalls will be addressed and that these are a temporary lapse in the homes current progression due to an unsettling period. What the service does well: What has improved since the last inspection? As the home is an integral part of the Marillac at the time of this inspection the home was still adapting to an unforeseen circumstance of change in management, and staff were understandably unsettled by this. Although most requirements from the last inspection have been met and others have been highlighted the inspector is positive that concerted efforts will be made by the home and that by the time of the next inspection that these will have been addressed. Seton Unit I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 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 I56 S18091 Seton Unit V233768 070705 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 Unit I56 S18091 Seton Unit V233768 070705 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) 3,6 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 new Manager 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. New service users have clearly assessed needs identified. There have been no new admissions since the last inspection. The Seton Unit does not provide intermediate care. Seton Unit I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 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. While some improvement has been made to the care planning process some further progress is required to ensure that service users needs are met. The health needs of service users are well met although better documentation would ensure clarity of needs. Personal support is provided in a way that promotes dignity. EVIDENCE: Care plans are in place for service users and these overall were comprehensive and detailed the care required. Of those inspected some were very brief in places, using abbreviations and not providing adequate information or instructions for staff to ensure that residents needs were known and met consistently. The lack of adequate assessments limited the homes ability to write adequate care plans especially in the case of two service users proper risk assessments were not adequately completed. This was discussed with the new Manager along with training for staff. Service users health is adequately promoted. Health care professionals visiting the home were complimentary of the care service at the home. It was noted positively by the Inspector at the previous inspection that tissue viability is Seton Unit I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 Page 10 vigilantly addressed and no service users have pressure sores despite being on bed rest or wheelchair dependant. 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 apart from minor shortfalls which were discussed an organised system was in place. The proprietor was advised to have individual protocols in place for medication prescribed ‘as and when required’ (PRN) and for self medicating service users. One service user self medicates. It is of concern to the inspector that on the day of inspection the nurse administering the medication had not undertaken any training It was observed that service users 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 I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 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 standard(s) 12,13,14,15 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 service users who are Sisters of Charity. Mass is carried out every morning and early evening prayer is available on the Seton Unit and service users are supported to attend according to their personal wishes. Service users 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 service users have visitors who will attend mass with them. Service users can have access to their own records at all times. It was clearly evident that service users 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 found to be correct. Service users 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 or cultural choices. Service users can choose to Seton Unit I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 Page 12 take meals at any time but often choose to eat together. Service users were complimentary of the meals provided. Seton Unit I56 S18091 Seton Unit V233768 070705 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 The home has an appropriate complaints policy which informs complainants of their rights and assures them their complaint will be taken seriously. Not all staff have received relevant training relating to the protection of vulnerable adults and this has the potential to put residents and staff at risk if there is a lack of knowledge relating to this. 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. Service users spoken with were aware of the process to take if necessary. All service users 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. The new Manager stated she would investigate how to access the POVA first system. Service users spoken with were confident that they are safeguarded from abuse but staff spoken with during this inspection could not readily demonstrate that they understood what actions to take if there was any incident of witnessed or suspected abuse of service users living at the home. This was discussed with the manager and it is acknowledged that an incident of this type has never arisen at the Seton Unit. Seton Unit I56 S18091 Seton Unit V233768 070705 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) 19,20,21,22,23,24,25,26 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. A large assisted bathroom is available for service users. There was adequate toilet and washing facilities. Each bedroom has an ensuite toilet. Adequate specialist equipment is available to meet the current needs of the service users. Each bedroom is individually decorated and ‘dressed’ according to service user choice. Radiators identified at the last inspection have been encased to provide protection from burns. All other radiators have cool wall surfaces. The activities room has been fully refurbished and recarpeted throughout and new furniture purchased Seton Unit I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 Page 15 The home was presented as clean and hygienic. Appropriate systems were in place to control cross infection. Seton Unit I56 S18091 Seton Unit V233768 070705 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 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 but this needs updating and maintaining. 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. Staff recruitment files for two members of staff were assessed. Some minor shortfalls were noted 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. There was evidence that staff complete a probationary period before a decision is made to offer a permanent position. Photographic ID was not available for one member of staff. Staff spoken with confirmed that they received regular mandatory training and there was evidence of the specialist training provided for staff. POVA and medication training required prioritising. The homes staff training plan was not assessed during this inspection however this was noted to be satisfactory at the previous inspection. The inspector was informed that Criminal Record Bureau checks have been sought and that POVA checks will be investigated. There was evidence of inductions but some job descriptions were missing. The process regarding volunteer and agency recruitment and CRB checks was discussed. The manager was 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. 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. Seton Unit I56 S18091 Seton Unit V233768 070705 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) 31,33,35,38 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. Health and safety fire requirements such as drills had not been maintained regularly. EVIDENCE: The new Manager has been in post for 6 months. She demonstrated competency in her management role and 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 needs to ascertain from the qualifications board, whether her qualification is equivalent to NVQ 4 and to apply to the Commission to be registered as the homes manager The home has an effective QA questionnaire. This has been implemented and a copy of the findings sent to CSCI. 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. It has previously been advised to ensure there are two signatures Seton Unit I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 Page 18 for each transaction – one of which should be the service user. This was noted to now be in place. 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 had not been regularly documented and undertaken and at the homes previous inspection a fire safety inspection had identified some minor issues. Seton Unit I56 S18091 Seton Unit V233768 070705 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 3 x 3 x x 2 Seton Unit I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 Page 20 YES 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 7 Regulation 15(1) & (2)17(1)( a) & (b) Requirement A detailed service user Plan of Care must be drawn up including consultation with service user, families and significant multidisciplinary personnel and to be reviewed regularly. This with particular reference to the maintenance of such plans review dates and use of abbreviations and with a veiw to staff training. The registered person must ensure that comprehensive risk assessments are carried out for the use of bed rails for all service users where bedrails are used, including details of potential implications of their use for the service users within individualised plans of care. This also with regard to all other risk assessments formulated especially those at risk of falls, pressure sores and smoking and those for COSHH and environmental health and safety issues The registered person must ensure that there is a policy and staff adhere to the procedures for the receipt of recording, Timescale for action 15th September 2005 2. 7 & 38 13(4) & 13(8) 15th September 2005 3. 9 & 30 13 (2) 17 (1) 12 (1)–(4) 15th September 2005 Page 21 Seton Unit I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 13 (4) 14 (2) 4. 29 7, 9, 19 (1) to (7) Schedule 2 5. 6. 31 38 8 (1) & (2)9 (1) & (2) 23 (4) storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. This with particular reference to the formation of self medicating protocols and staff training being bought up to date The registered person must operate a robust and thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. This with particular reference to the obtaining of POVAfirst checks and photographic identification. The registered person must ensure that the home has a registered Manager. The Registered Person shall, after consultation, with the Fire Authority, take adequate precautions against the risk of fires, including the provision of suitable fire equipment, detecting of fires and evacuation procedures. This is as well as ensuring staff are suitably trained and with specific reference to regular fire drills. 15th September 2005 15th September 2005 15th September 2005 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 Unit I56 S18091 Seton Unit V233768 070705 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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. 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