Care Home: Seacliff Care Home

What the care home does well Pre-admission assessment is recorded in advance of any prospective resident being accommodated in the home. Seacliff meets residents’ expectations, provides access to health care professionals and staff treat residents with kindness. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.2 The home is clean and comfortable, and provides residents with nutritious and appetising food. Residents are encouraged to maintain contact with the local community and visits by their friends and relatives are welcomed by the home. What has improved since the last inspection? The home has employed a person as acting manager who has expressed intention to apply to become the registered manager. New processes and record keeping associated with care planning and review have been introduced so that all staff have available accurate and sufficient information to guide their work and ensure residents receive the care they need. Implementation of an expanded recreational and social activity programme provides residents with leisure activities suited to their abilities and preferences. What the care home could do better: The home has been without a registered manager since April 2008; to ensure compliance with the Care Standards Act within the timescale stated in this report a suitable person must apply to the Commission to become the registered manager. To ensure the safety of vulnerable residents from potentially unsuitable staff, the provider must ensure that all staff, including persons attending on a self employed and sessional basis, are subject to a reliable recruitment procedure. The use of bed rails, alarm mats and any other items which if used improperly might constitute a form of restraint should be supported by evidence of consent by the particular resident or their representative. When used, bed rails must be safely positioned to minimize risks of accidental entrapment. Two Immediate requirements were issued relating to staff recruitment practices and the safe use of bed rails. A visit was completed following the inspection and it was found that appropriate action had been taken to comply with these Immediate requirements. Key inspection report CARE HOMES FOR OLDER PEOPLE Seacliff Care Home 9 Percy Road Bournemouth Dorset BH5 1JF Lead Inspector Gloria Ashwell Key Unannounced Inspection 28th December 2009 11:00 DS0000068785.V378739.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seacliff Care Home Address 9 Percy Road Bournemouth Dorset BH5 1JF 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) 01202 396100 Mr Munundev Gunputh Mrs Dhudrayne Gunputh Manager Post Vacant Care Home 24 Category(ies) of Dementia (24) registration, with number of places Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Dementia (Code DE) The maximum number of service users who can be accommodated is 24. 30th June 2009 (random inspection) Date of last inspection Brief Description of the Service: Seacliff Care Home is a detached property in a residential area of Boscombe, Bournemouth. The main shopping area of Boscombe with all its amenities including bus services is less than half a mile away. Seacliff Care Home is registered to accommodate up to 24 persons with dementia. The accommodation is arranged over three floors, with stairs or a passenger lift to aid access between the floors. There are two double and twenty single bedrooms. Approximately half of the bedrooms are equipped with en-suite hygiene facilities. There is dining room with adjoining sitting area and large conservatory and a separate lounge. The conservatory has views over the rear garden, which includes a lawn and paved patio area surrounded by mature trees and shrubs. Twenty-four hour care is provided. Laundering of personal clothing is carried out on the premises. The fees for the home, at the time of inspection, range between £490 and £575 per week. Additional charges include hairdressing, chiropody, dry cleaning, toiletries and newspapers. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.2 Page 5 Up to date information on fees can be obtained from the care home. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a statutory inspection required in accordance with the Care Standards Act 2000. This inspection was carried out by one inspector, but throughout the report the term we is used, to show that the report is the view of the Care Quality Commission. This inspection was unannounced; the inspector arrived at 11:00 on 28 December 2009, and together with the care worker in charge of the home at that time discussed and examined documents regarding care provision and management of the home, and alone toured the premises and spoke to residents, staff, observed staff interaction with residents and the carrying out of routine tasks. During the inspection, particular residents were ‘case tracked’; for example, for evidence regarding Standards 3, 7 and 8, records relating to the same residents were examined and the residents spoken with. In advance of the inspection the home completed and returned to us an Annual Quality Assurance Assessment identifying the improvements they have made during the last 12 months, and the aspects they intend to improve in the next 12 months. During this inspection compliance with all key standards of the National Minimum Standards was assessed. Immediate Requirements relating to aspects of employment and the safe use of bed rails were issued. What the service does well: Pre-admission assessment is recorded in advance of any prospective resident being accommodated in the home. Seacliff meets residents’ expectations, provides access to health care professionals and staff treat residents with kindness. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.2 Page 7 The home is clean and comfortable, and provides residents with nutritious and appetising food. Residents are encouraged to maintain contact with the local community and visits by their friends and relatives are welcomed by the home. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.2 Page 8 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 9 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 Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prior to admission, the needs of each proposed resident are assessed to ensure the home will be properly able to meet them. EVIDENCE: The records of a resident admitted since the last inspection included details of pre-admission assessment carried out while visiting the prospective resident at their previous address. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 11 In advance of making the decision to enter the home the closest relative of the prospective resident had visited the home to view the premises and meet residents and staff. Following pre admission assessment of each prospective residents needs and circumstances the home writes to them confirming the agreement and ability to provide accommodation and care. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and social care needs of residents are met by suitably trained staff; doctors and other professionals visit as necessary and residents receive the medicines they have been prescribed. The standard of care is in accordance with each persons individual needs but some aspects of care planning and associated record keeping must be improved to ensure staff have available the necessary information to guide and direct their work and thereby minimize risks of inappropriate care or other danger. EVIDENCE: Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 13 Care records of 3 residents were examined and found to be of generally good standard, based on up to date and relevant risk assessments, and reflective of the changing conditions of residents e.g. identifying a potential chest infection and recording all associated communications with doctors and other health professionals. However, Care records of one person known to have non insulin dependent diabetes, for whom visiting district nurses carry out periodic blood tests, provided no indication of the results of these checks and no guidance to staff on what action to take if the condition of the person changes. There was evidence that accidents to residents are investigated with findings recorded in the care plan, to ensure that future risks are minimised. For some people who are known to be at risk of accidental falling, alarm mats are used to alert staff when if the residents get out of bed at night. The potential risks associated with the mats have been assessed and the care plans refer to the use of the mats. It is recommended that a record be kept to provide evidence that the consent of the resident or their representative has been obtained to the use of the alarm mat, because these items might constitute a means of restraint if used improperly. Medicine handling is carried out by staff trained in this work. Medication records were properly kept indicating that residents receive prescribed medicines at the correct times and in correct amounts. We watched them give medicines to residents at lunchtime and saw that system was safe; staff followed procedures but managed to give everyone the time and individual attention they needed. The information about medicines and medicine audits was good. For medicine handling the home uses a monitored dosage system, whereby most of the medications are stored in blister packs, to simplify the process of administration. Staff trained in this work carry out all medicine handling; none of the currently accommodated residents manage their own medicines. Medication records were properly kept indicating that residents receive prescribed medicines at the correct times and in correct amounts. In the presence of staff residents appeared relaxed, confident and at ease; staff interactions with residents were of a friendly and polite manner and the atmosphere throughout the home was calm and unhurried. Residents we spoke to felt that staff are always kind and considerate of their needs. Residents and visitors spoken with during the inspection said that residents are treated with respect and their privacy and dignity is protected at all times. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have opportunities to engage in social and recreational activities and are encouraged and supported to pass the time according to individual preference. A choice of menu is provided and meals are nutritional and appetising. EVIDENCE: There is a weekly programme of recreational and social activities including handicrafts, exercises to music, one to one and small group activities in addition to seasonal events and celebrations. Most activities are arranged and led by care staff but occasional visiting entertainers attend the home to provide musical sessions. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 15 Visitors are welcome at any time and those spoken to during the inspection said they are always made to feel welcome and placed at ease by the staff. Most residents take meals in the dining room on the ground floor while those who wish to receive them in their bedrooms. We saw lunch taking place in the dining room and noted it to be a pleasantly social time, with staff assisting residents to eat, in a relaxed and unhurried manner. The food was well presented, plentiful and appetizing and was seen to be enjoyed by the residents. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know how to complain and are confident their complaints would be listened to. Residents are safeguarded against risks of abuse in its various forms. EVIDENCE: The home has a complaints policy and procedure. From discussion with staff and examination of records there was evidence that there is a reliable process ensuring that any complaints received would be competently managed to ensure that if weaknesses in service were identified they would be unlikely to recur. All staff receive training on the safeguarding of vulnerable persons and the home has a written policy and procedure for the protection of vulnerable adults. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 17 Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is comfortable and generally well maintained but to minimise risks of harm to vulnerable residents, improvements must be made to aspects of infection control and for the safe use of bed rails. EVIDENCE: Seacliff is a traditionally built detached house, with gardens to the rear and car parking spaces at the front of the premises. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 19 On the day of inspection the home was comfortably warm, clean and free from unpleasant odours. The overall aspect of the home does not present an environment ideally suited to the confused elderly people living there because the home has a complex layout over 3 floors and signage is poor. Bedrooms seen during the inspection were decorated to an acceptable standard. All bedrooms have a wash hand basin, most have en suite en suite hygiene facilities and all are close to a toilet. There are bathrooms equipped for the benefit of residents with impaired mobility. We saw two baths with attached shower hoses, which could be placed into the bath water, and thereby presented a risk of cross infection to later users of the bath, because bath water from earlier users could be inadvertently discharged into the fresh bath water. This report contains an associated recommendation. Resident accommodation is on the ground, first and second floors. A passenger lift provides access to all floors. Residents can bring items of their own furniture and belongings to keep in their bedrooms, in accordance with the agreement and safety checks of the home. All laundry is carried out on the premises using a machine that will wash to high temperatures, has a sluicing facility and complies with the relevant legislation. Adequate supplies of clean linen were seen to be available. In one persons bedroom we saw an improperly positioned bed rail. Both sides of the bed have rails, one side is against the wall. The other side had a bedrail close to the foot of the bed, leaving a gap of approx 18 inches from the bed head, which presented a risk of entrapment and resultant injury. We asked the care worker in charge of the home at the time of the inspection if she thought the rail was satisfactory, she said she thought it was. Before installing the bed rails the home had recorded a risk assessment and reflected the decision to use rails in the care plan, but nowhere was guidance on the positioning of the rails recorded and there was no recorded evidence of the resident or representative having consented to the use of these items, which when used improperly, might be considered to constitute restraint. During the inspection we described related good practice aspects to the in charge carer and the provider who attended the home during the inspection, and before leaving the home we received assurances that before the resident again used the bed the rail would be repositioned to ensure it did not present a risk of accidental entrapment. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 20 At the end of the inspection we issued an Immediate Requirement for the safe use and regular checking of bed rails, to protect residents from the risks of injury that are presented by improperly fitted rails. On the day after the inspection the acting manager telephoned us and confirmed that the rail had been repositioned and we provided to the home a weblink for up to date information about the safe use of bedrails. Following the key inspection a further visit was completed to check compliance with the Immediate requirement issued. The bed rail had been re-positioned in accordance with good practice guidelines. The risk assessments relating to the use of bed rails for this person had been updated. As part of the ongoing monitoring of safety of this equipment, the home plans to check the bed rails on a weekly basis. It was suggested a written record is maintained to evidence this process. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from adequate staffing levels being provided and the staff receiving suitable training. However, failure to ensure that all staff have been subject to all the recruitment checks of the Regulations could mean that residents are at risk from unsuitable members of staff. EVIDENCE: Staffing levels are provided in accordance with the assessed needs of residents to ensure that at all times sufficient staff are available to properly meet their needs. The records of two recently employed staff members were examined and found to contain all essential information including written references, evidence of Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 22 identity and Criminal Records Bureau CRB declarations which had been obtained in advance of employment. The care worker in charge of the home at the time of this inspection told us that the home had only the contact telephone number and forename of the hairdresser who has recently attended the home but has not obtained a CRB or any other details. An Immediate Requirement was issued for the safeguarding of vulnerable residents from potentially unsuitable people about whom the home does not possess essential background information. Records showed that new staff received induction training, all staff receive training in core subjects including safe moving and handling and formal staff supervision is routinely carried out. Staff meetings have taken place during July, October and November 2009 and Minutes recorded show that relevant subjects relating to good care practice have been addressed during the most recent meetings e.g. responsibilities for safeguarding vulnerable people from harm, management of accidents and the importance of appropriate recreational and social activities. The home was recommended to keep a record of the process of risk assessment if an adverse CRB is received i.e. a declaration of criminal history is received. Following the Key inspection, a visit was completed to check compliance with the Immediate requirement issued. It was found that appropriate information had been obtained for the hairdresser, including a Criminal Records Bureau disclosure. The recruitment file was examined for a further staff member employed since the key inspection visit. All required documentation had been obtained by the service prior to the staff member commencing employment at the home. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home should not operate indefinitely without a registered manager and improvements to employment processes must be made to safeguard vulnerable residents against the risks presented by potentially unsuitable staff. EVIDENCE: The service has been without a registered manager since February 2008. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 24 Previous inspection reports have included a requirement for the providers to “appoint an individual to manage the care home and submit an application to the Commission for their registration” by 31 July 2009. Compliance with this aspect is now long overdue and although we have been informed that the recently employed acting manager is in the process of applying to us to become the registered manager the requirement is repeated to ensure that application is made within the stated timescale. The home periodically issues survey forms to residents, their relatives and other stakeholders, to gain their opinion of the standard of the home. Since the last inspection the home has introduced additional processes for quality assurance, including regular audits of medicine, to ensure that safe standards are continually maintained. The home manages the personal finances of some residents, and keeps records and receipts of all related transactions. In general, there are satisfactory processes for staff recruitment and induction but some weaknesses in employment practices were identified in the Staffing section of this report; we found that the hairdresser attending the home had not been recruited in line with the Regulations, and the home did not have available the necessary information including a Criminal Records Bureau disclosure. The home does not have a designated room in which hairdressing is carried out; hairdressing takes place in the bedrooms of the individual residents and so the hairdresser would invariably be alone with the resident to whom they were attending. This places residents of the home at potential risk because full information about all people working unsupervised at the home has not been sought or held by the provider. Accordingly we feel the management had not ensured that a robust system of checks was in place for all people working at the home. A related requirement is included in this report. Records are kept of all accidents and there is subsequent review of the care plan. To minimise risks of accident recurrence it is recommended that periodic audit e.g. of time, place, person, activity, be recorded to identify any trends or high aspects of risk. Records of equipment servicing and maintenance indicated that fire safety and various other equipment had been subject to routine checks and tests but the latest gas safety certificate was from 2007, and a Warning Notice identifying an unsafe aspect had been issued during March 2008. Gas safety certification must be obtained annually and all records required at inspection must be kept in the home and available for examination. Therefore, this report contains a Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 25 requirement for an up to date gas safety certificate to be obtained and forwarded to us within a given timescale, to ensure the safety of this aspect. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 26 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 27 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 OP7 Regulation 15 Requirement Timescale for action 01/02/10 2. OP29 19 The registered person shall prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. This plan must include all relevant information and instruction to ensure that staff have available to them the information they need to provide consistent and appropriate care. The registered person shall 28/12/09 not allow an individual to work in the care home unless he has obtained in respect of that person the information and documents specified in Schedule 2, to protect vulnerable people from the risks of abuse if they are in contact with potentially unsuitable staff. To comply with Section 11 of the Care Standards Act the registered person shall appoint an individual to manage the care home and this person shall apply to the DS0000068785.V378739.R01.S.doc 3. OP31 8 01/03/10 Seacliff Care Home Version 5.3 Page 28 Commission to become the registered manager to ensure that the home is managed by a suitable person. Similar requirements were included in the inspection reports of 29/07/09, 23/1/09 and 30/06/09, with a timescale for compliance of 31/07/09. 4. OP38 13 5. OP38 13 The registered person shall ensure unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. This means that measures must be in place to ensure the safe use of bed rails, to protect residents from the risks of injury that are presented by improperly fitted rails. An up to date gas safety certificate must be obtained and forwarded to the Commission to ensure the safety of this aspect. 28/12/09 01/02/10 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 OP7 Good Practice Recommendations It is recommended that a record be kept to provide evidence that the consent of the resident or their representative has been obtained to the use of bed rails or an alarm mat, because these items might constitute a means of restraint if used improperly. Signage should be improved to assist people to find their way around the building. The home should ensure that shower hoses attached to DS0000068785.V378739.R01.S.doc Version 5.3 Page 29 2. 3. OP19 OP26 Seacliff Care Home baths cannot be placed in the bath water because this presents a risk of cross infection to a later user of the bath, if water from the previous bath is inadvertently stored in the hose. Seacliff Care Home DS0000068785.V378739.R01.S.doc Version 5.3 Page 30 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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