Inspection on 13/12/06 for The Seagulls

This inspection was carried out on 13th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Seagulls 24/07/07

The Seagulls 15/11/05

The Seagulls 04/05/05

The Seagulls 14/09/04

The Seagulls 01/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 The Seagulls 6 Crowborough Road Saltdean East Sussex BN2 8EA Lead Inspector Elaine Green Key Unannounced Inspection 13th December 2006 11:00 The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 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 The Seagulls DS0000021406.V322339.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 Adults 18-65. 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. The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Seagulls Address 6 Crowborough Road Saltdean East Sussex BN2 8EA 01273 390610 01273 308672 pedniki@yahoo.co.uk 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) Mr Driss Zemouli Ms Niki Clarke Ms Niki Clarke Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is six (6). Service users should be aged between eighteen (18) and sixty-five (65) years on admission 15th November 2005 Date of last inspection Brief Description of the Service: The Seagulls is a well-appointed detached property situated in a residential area close to the main coast road and cliff tops at Saltdean. The home is registered to provide care for six adults with a learning disability; it does not provide nursing care. The owners have another home nearby and there are often joint activities between the two homes. Local shops and amenities are a short walk away and bus services to Brighton and other areas run close by the home. Parking is freely available in the street outside. Accommodation is provided on two floors, with two bedrooms on the ground floor and five rooms on the first floor. Communal areas include a comfortable lounge and a separate dining room, which is also used as an activity room. There is a smoking conservatory leading out to a pleasant garden situated at the rear of the property. The fees charge range from £600 per week and are based on an individual assessment of care needs. Included in the fees are all usual hotel costs and the cost of staffing a supported holiday. Additional charges are made for Hairdressing from £6.50 per cut, personal toiletries, newspapers and magazines, an annual holiday approximately £200 - £300 a year, chiropody £18 per month, outings £8 - £10 per week and live shows approximately £45 per year. A copy of the last Inspection report is available upon request from the manager of the home. The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The National Minimum Standards refer to individuals who reside in Care Homes as “Service Users”. The people who live at The Seagulls will be referred to as “Resident(s)” throughout this report. As part of this Unannounced Inspection of The Seagulls, a site visit took place to the home on the 13th December 2006 and the Registered Manager completed a Pre Inspection Questionnaire that provided the Inspector with statistical information relating to the home. Residents of The Seagulls and their relatives or representatives were also given the opportunity to complete surveys and return them to the Inspector. Feedback from the 2 surveys returned will be included in this report. On the day of the site visit, issues relating to the day-to-day running of the home were discussed with the Registered Manager and 2 of the staff on duty. The Inspector spoke with 3 of the residents who also showed the Inspector their rooms. A range of documents were examined including two residents care plans, two recruitment files, a selection of the homes’ policies and procedures and some of the homes daily records. What the service does well: The home has a relevant and up to date statement of purpose and service user guide that is available to prospective residents to help them make an informed decision about whether or not to reside in the home. Prospective residents are welcome to visit the home and the first months’ stay is on a trial basis to enable them to ‘test drive’ the home. Each resident has a care plan that is reviewed and updated on a regular basis. These care plans include an activities timetable. Residents lead active lifestyles and enjoy going out into the local community regularly. Activities regularly participated in include going out for a meal once a week, buying the provisions, going for walks, attending local day centres and attending local colleges. All residents have the opportunity to participate in an annual supported holiday that they also enjoy. The Seagulls is decorated and furnished in a homely way and is domestic in character. All the residents have their own rooms and they are decorated and furnished to their own tastes. There is ample space in the home for residents to spend their leisure time including a dining room, lounge and conservatory. Residents stated that they like living at Seagulls and enjoy doing the shopping and helping to keep the home clean and tidy. The atmosphere in the home is relaxed and informal. All residents are registered with a GP and dentist. They also have access to the other relevant health care professionals. Staff are available to support The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 6 residents to attend appointments and if treatment is needed at the home then it is given in the privacy of their own rooms. The majority of the staff at Seagulls have worked there for a number of years and over 50 of the staff have obtained a National Vocational Qualification (NVQ) in Care at Level 2 or above. Staff have received appropriate and relevant training and staff meetings are held on a regular basis. Staff know the residents well and appear to have a good working relationship. The manager, who is also the joint owner of the home, has over 20 years experience of working win care and holds the relevant appropriate qualifications. The deputy manager is also qualified and experienced. The staff and residents spoke highly of the manager and stated that they found her approachable. The manager ensures that residents’ views are listened to and has a good relationship with he residents’ families with whom the home has regular conact. What has improved since the last inspection? What they could do better: Whilst the outcomes for residents of this home are generally adequate or good there are shortfalls particularly in relation to the records that are required to be kept by the Care Standards Act 2000. Due to a change in regulation all existing residents must be provided with a costed statement of their terms and conditions of residency and any prospective residents must be provided with this prior to them moving into the home. The manager must ensure that all the information and assessment details obtained through the assessment and reviewing processes are transferred onto care plans and that staff have the guidance they require to support residents appropriately. Care plans should be based on robust assessments and be reflective of residents preferences and lifestyle. The decisions made by residents in relation to how they spend their time must be documented within the care plan and the records relating to ‘in house’ reviews and assessments. Residents’ preferences in relation to the way they receive personal care should be documented as should the specific guidelines staff need to support residents to manage their health care needs, particularly in relation to diabetes and epilepsy. Residents should be consulted with in respect of their food preferences and a menu should be introduced that is reflective of the food they like. This menu should be available in a format accessible to residents. A variety of sweets of puddings suitable for a diabetic should be available. The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 7 The two residents bedrooms that had an offensive odours must be kept clean and hygienic and the home must be kept warm at all times. Door wedges must not be used on fire doors and advice should be sought as to safe and appropriate alternatives. A staff rota should be implemented and the number of staff on duty at one time should be based on an assessment of residents needs’. The rota must specify in what capacity staff are working and, the shift leader and the on call person. 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. The summary of this inspection report can be made available in other formats on request. The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can test-drive the home and are supplied with the information required in order to make an informed decision about whether to reside in there. EVIDENCE: The Inspector discussed the pre admission procedures with the registered manager and examined the relevant documentation. The manager stated that residents have the opportunity to come and have a look around the home prior to moving in and that they are given copy of the homes Statement of Purpose and Service User Guide to help them make an informed decision about whether or not to reside there. It was discussed with the manager that in addition to this information in future all prospective residents should also be provide with a costed statement of their terms and conditions of residency/contract prior to moving into the home. All existing residents should also be provided with this information. It is recommended that the manager keep a record of the visits made to the home by prospective residents to show that they have had the opportunity to assess the homes ability to meet their needs. The pre admission documentation was examined for two of the residents and satisfactory. The manager had contacted the placing authority for both residents and obtained a copy of their social care assessment, which was detailed, and comprehensive. The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,&9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Albeit residents’ care plans are reviewed and amended as required they do not provide all the information required for staff to support service users in their daily living. Residents are supported to make choices and take risks. EVIDENCE: Two residents’ care plans were examined. Both of the care plans had been reviewed on a regular basis and so were up to date. However, neither of the care plans included assessments and guidance for all the areas specified within the National Minimum Standards for Adults and so did not adequately reflect their current lifestyles. In addition to this not all the information that had been gathered through the review and assessment processes had been transferred onto the care plans. Therefore the staff did not have all the information they require about the residents needs in order for them to support them appropriately. The manager must ensure that all the information obtained through the preadmission processes and assessments are transferred appropriately. Discussions with staff and residents confirm that residents are supported to make decisions about their lives. The Inspector observed residents being given The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 11 choices throughout the site visit for example what they wanted to do for the afternoon, whether they wanted to go out for a drive and something to eat. Residents stated that they can get up when they want to and are able to go to bed at a time to suit them. Residents are supported to take risks and relevant risk assessments are in place. One of the residents that the Inspector spoke to said that they helped around the home by participating in doing their laundry and cleaning their own room. Staff stated that some of the other residents also help around the home and Two of the residents were able to tell the Inspector that they enjoyed living at Seagulls and that the staff support them to do the things they enjoy. The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16&17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with the opportunity to access the community and participate in meaningful and appropriate activities. The menu provided at the home is not reflective of residents’ preferences. EVIDENCE: During the site visit the residents were engaged in a range of different activities. One resident was attending a one-day a week college course, another was attending a local day care centre, a member of staff had taken a resident out for a walk and the other two residents were in the dining room completing a jigsaw puzzle. Other activities planned on the day of the site visit included some of the residents joining the manager when she went to Newhaven and it was planned that they would stop on the way back for something to eat. The manager explained that some of the residents enjoy going out for drives, going to the local pub, eating out, reading the newspaper and going on holiday. The care plans examined contain a weekly timetable of activities that residents participate in and an examination of the activities book The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 13 confirms that activities are also provided ‘in house’. One regular activity is that the residents go out for a meal together to the local pub. Three residents told the Inspector they enjoyed this and two of the residents said they liked going on holiday. All residents have the opportunity to participate in an annual supported holiday and some of the residents choose to go on holiday with their friends who live at the owners other home. Residents often receive visitors in the home and also go to visit their families on a regular basis. The home arranges activities, such as a summer barbecue, where relatives are invited to join in with the residents the manager stated that there are often group activities with their other home. The manager stated that for a variety of reasons the majority of the residents no longer attend day care centres or local colleges. Although some of the reasons for this were beyond the residents control due to closures of services etc and their social services review documentation recorded this fact, these decisions had not been recorded on the individuals’ care plans or on any ‘in house’ review documentation. It is important that the manager documents fully the assessments undertaken in relation to residents’ preferred activities and social care needs and demonstrates how the home are supporting residents to achieve their goals in these areas particularly where services have closed or residents needs and or preferences have changed. Care plans should contain information in respect of the guidance that staff needed in order to support residents in their chosen activities. The Inspector examined the menu that was on display in the kitchen. It was noted that there was no choice on offer and when the Inspector asked the staff what was for evening meal it was not the meal specified on the menu. It was pointed out to the Inspector that the reason that the meal was different was because the residents do not like the meal specified. It is important that the residents of the home are consulted with in respect of their preferences for the food offered at meal times and that this consultation is documented and made available for Inspection. The residents must be involved in the setting of the menu and offered a choice of food at mealtimes. The daily food choices should be based on the outcome of the consultation with residents and be presented in a format accessible to all. For example to illustrate the choices on offer photographs or pictures could be used alongside words. The manager and staff explained that the residents are offered an alternative if they do not like the food offered. One resident who is diabetic stated that they would like to eat sweets and puddings. Staff confirmed that this resident is usually offered fruit or yogurt for instead of sweets and puddings. Appropriate and varied alternatives should be provided for this individual. Residents are encouraged to lay the table, prepare the food, and to clear up afterwards; they also enjoy shopping for provisions. The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of guidance for staff to follow to ensure residents receive personal care in the way they prefer and are supported appropriately with their health has the potential to compromise residents’ dignity and health and safety. The homes’ medication policies and procedures are safe. EVIDENCE: Residents preferences in relation to how the receive their personal support is not documented as is required therefore it is impossible to establish whether or not residents have been consulted with in respect of this or if their preferences are being taken into consideration. In addition to this the specific guidance required for staff to appropriately support residents with their health care needs is missing. One resident is diabetic and although the manager is a qualified nurse and was able to discuss with the Inspector how the staff support this resident manage their diabetes there is no written guidance for staff to follow in relation to an appropriate diet for this individual or of how to support this resident to regulate their blood sugars. There is also a lack of guidance in relation to how to support another resident who suffers from epilepsy. There is no information on what is a normal seizure for this individual or of what to do in the event of them having a more serious seizure that would require the GP or emergency services to be called. It is required that care The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 15 plans fully document the health care needs of residents and that they include robust guidance for staff to follow. The manager explained to the Inspector that home works closely with health care professionals and an examination of records confirmed this. All residents are registered with a GP and dentist and the manager was supporting one of the residents to attend a health care appointment on the day of the site visit. Records are maintained in respect of all visits to health care professionals. Personal care takes place in private, as do medical examinations in the home. Medication administration records were examined and were complete. Staff had signed for all the medication that had been administered. The manager had also signed to show she had checked the medication and the records and that they were complete. All residents are supported with their medication and staff only administer medication after they have completed training and have been assessed as competent to do so. The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are listened to. The homes’ adult protection policies and procedures protect residents from abuse and harm. EVIDENCE: The manager explained that there had only been one complaint recently and this had been resolved amicably. This had been a relatively minor incident and was in relation to one resident complaining about another shouting. Unfortunately this had not been documented. It is recommended that a record is kept of all complaints that are made however minor they may appear. This will evidence the fact that residents’ views are taken into consideration and that they are listened to. The three residents that the Inspector asked all said that they would go to the manager or a member of staff if there was something wrong. Both the resident surveys stated that they knew who to go to make a complaint. All staff have received training in adult protection. On the day of the site visit the home did not have a have a copy of the local adult protection guidance the Brighton, Hove and East Sussex, Multi Agency Policies, Procedures and Guidance for the Protection of Vulnerable Adults however, the manager has since confirmed that the home has obtained a copy. The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,28,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all areas of the home are free from odours. Residents own rooms promote their independence and the home is suitable for its’ purpose. EVIDENCE: The Inspector had a tour of the home on the day of the site visit and 3 residents showed her their rooms. The home was clean and tidy however, there was an offensive odour in two of the residents bedrooms. This was discussed with the manager and staff on the day of the site visit and they stated that they were aware of this and were taking steps to ensure this was resolved and as far as possible prevented. It is required that these rooms are monitored regularly and that the appropriate cleaning tasks undertaken without delay. The Inspector also noted that the home was cold. Although staff stated that they weren’t cold one resident was in bed and another was in their room with their coat on and both stated that they were cold. This was also discussed with the manager and staff and they stated that the heating came on at 3 o’clock daily. While it is accepted that the day of the site visit was a old day and the heating may not always be needed, it is required that the The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 18 temperature in all areas of the home accessible to residents is maintained at a reasonable temperature at all times. On the ground floor of the home there is a large lounge, a dining room, kitchen, laundry, two bedrooms one of which is en-suite and a small conservatory where it has been assessed as safe for residents to smoke. There is level access to the home from both the front and rear of the building and there is a lawned garden to the rear of the property. On the first floor there is a staff sleeping in room/office and 5 other bedrooms. The home is decorated and furnished in a homely and is domestic in character. The three residents whose rooms the Inspector was invited to see were all decorated and furnished to reflect the residents own taste. All the residents showed pride in their rooms and two of them confirmed that they had been involved in making choices about how they were decorated. All the rooms examined met the residents’ needs. The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34&35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment procedures not consistently followed. All staff are trained appropriately. Staffing levels are low. EVIDENCE: The owner and the deputy manager manage the home. In addition to this there are 3 other members of staff 2 of which are full time. On the day of the site visit there was no staff rota in place and the manager stated that this is because staff work the same hours each week. In order to establish that there is a sufficient number of staff on duty at all times with relevant experience and qualifications, a weekly staff rota must be introduced. Following the site visit the manager provided the Commission for Social Care Inspection with a staff rota however it did not contain the information needed. The rota must specify the capacity in which staff are working e.g. whether as manager or as care staff and who is leading the shift. This is to make it clear how many staff on duty are actually working with residents. It should also specify who is on call in case of emergency. The rota supplied states that there are only 2 members of staff on duty from 8 am until 8pm and this includes the management. It is required that in order to protect and promote residents health and safety the staff rota must be based on an assessment of residents needs and that staffing The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 20 levels are such that these can be met by the number of staff on duty who are working directly with the residents. Staff induction, recruitment and training files were examined. The recruitment procedures followed are generally safe and the all the required security and identity checks re completed prior to staff being deployed to work in the home. However, a requirement made at the last Inspection for the manager to obtain all the required documents before new workers can start at the home has not been met for one of the employees. The manager explained that this was because this member of staff had not worked before. It is required that the manager obtains the relevant information and documentation for this individual. Most of the staff employed have completed the mandatory training. In addition the manager two members of staff hold a National Vocational Qualification (NVQ) in Care, one at Level 2, one at Level 3 and the newest member of staff has enrolled on the Skills for Care award. The manager showed the Inspector a staff members’ certificate of attendance in respect of an induction/foundation course. A certificate such as this is not evidence that the course has been completed. It is required that the manager obtains a copy of the certificate of completion. Staff meeting minutes were examined. This confirms that they are regular and relevant. On the day of the site visit the staff on duty demonstrated that they had a good understanding of the residents needs. Most of the staff have worked at Seagulls for a number of years and so know the residents well. There appeared to be a good working relationship between the residents and staff and management. The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39&42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is appropriately qualified and experienced. Residents’ views are listened to. Residents’ health and safety in respect of the risk of fire is not fully promoted and protected. EVIDENCE: Both the manager and the deputy manager are relevantly experienced and qualified. The manager who is also joint owner of the home has worked in care for over 20 years. She demonstrated a good level of understanding of the residents needs and was able to discuss in depth residents current and anticipated care needs. The home has adopted a system for monitoring the homes performance and this includes a survey for both residents and their families. The Inspector examined the results of these surveys and they were all very positive. One relative commented that ‘The home always looks very smart’ they go on to say The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 22 I would like to say thank you to a member of staff who I know works very hard in her support of my relative and this is very much appreciated.’ Another wrote ‘I am very satisfied that my relative is very happy.’ The Pre Inspection Questionnaire specifies that all the homes policies and procedures have been reviewed and updated recently. In relation to residents’ health and safety, several doors were wedged open on the day of the site visit including residents’ rooms. The manager explained that these are removed at night however, in order that residents’ health and safety are protected and promoted in respect of the risk of fire, door wedges must not be used at any time on fire doors. If doors are to be left open they must be fitted with a device that automatically closes them when the fire alarms are activated. Fire drills are completed at the required intervals and water from hot water outlets accessible to residents is regulated at a temperature at or around 43C to minimise the risk of scalding. The insurance certificate was examined and is up to date and relevant. The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 3 29 x 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 x LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 x 3 X 3 X X 2 x The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation 4 Sch 1 14 15(1,2) Sch3 Timescale for action All existing residents must 30/03/07 also be provided with a costed copy of their terms and conditions. The manager must ensure 30/03/07 that all the information gathered through the assessment and reviewing processes is transferred onto care plans. Care plans must be based on robust assessments and provided staff with the relevant guidance to support residents in all aspects of their daily lives. Decisions made by residents 30/03/07 or others on their behalf in relation to the way they spend their time must be fully documented within ‘in house’ review and care planning documentation. That residents are consulted 28/02/07 with in relation to their preferences in relation to food. That a menu is produced that is reflective of residents’ likes and dislikes and is produced in an accessible DS0000021406.V322339.R01.S.doc Version 5.2 Page 25 Requirement 2. YA6 3. YA12 16(2mn) 4. YA18 n 13(5) 16(2ih) Sch3 Sch4 The Seagulls 5. YA17 6. YA18 7. YA19 8. YA23 9. YA24 10. YA33 11. YA34 12. YA35 format. Records of this consultation should be available for Inspection. 13(5) That the home provides a 16(2ih) varied choice of sweets and Sch3 puddings suitable for a Sch4 diabetic. 12(4a) That residents preferences in relation to the way they receive their personal care is documented and the relevant guidelines for staff to follow introduced. 12(1a) That management guidelines 13(1ab) are in place for staff to follow 15 when supporting residents manage their health care needs. With particular reference to epilepsy diabetes. 13(6) That the home obtain a copy of the local guidance in respect of the protection of vulnerable adults. 16(2k) That the home is kept free of 23(2p) offensive odours and that the home is kept warm at all times. 18(1a) That a staff rota is implemented and that the number of staff on duty at one time this is based on an assessment of residents needs. The rota must specify in what capacity staff are working and, the shift leader and the on call person. 19(1b)(4)(5d) The manager must obtain all Sch 2 the required documents as detailed in Schedule 2 before new workers can start at the home. Timescale 30/11/05 not met. 18(1c) That all staff complete who do not hold an NVQ in Care complete the skills for care foundation and that the manager obtains the relevant DS0000021406.V322339.R01.S.doc 30/01/07 30/03/07 30/01/07 30/01/07 30/01/07 30/01/07 28/02/07 30/06/07 The Seagulls Version 5.2 Page 26 13. YA42 23(4,5) certificates and or work books to show that they have been completed. That residents’ health and 30/01/07 safety is protected and promoted in relation to the risk of fire and that door wedges are removed from all fire doors. Advice should be sought from the fire safety officer in relation to suitable safe alternative to door wedges. 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 YA4 YA22 Good Practice Recommendations That a record is kept of any visits made to the home by prospective residents. That a record is kept of all complaints made by residents The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 The Seagulls DS0000021406.V322339.R01.S.doc Version 5.2 Page 28 - 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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