Care Home: Seale Pastures House

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What the care home does well People living in Seale Pastures, their relatives spoken with, and the survey responses, all made positive comments about the home. One relative described the staff as `magnificent` and someone living at the home said they were `very kind`. Another person stated that they `liked living here` and that staff were `friendly`. Seale Pastures provided a comfortable and safe environment for the people who used the service and the cleanliness of the home was praised, with one survey stating that it was maintained to `a very high standard`. People living in the home and families were encouraged to personalise their rooms with their own possessions. There was a committed and competent staff team who were knowledgeable about the care needs and preferences of people living in the home. The staff receive regular mandatory training, such as fire safety, food hygiene and moving and handling, and training was also arranged for subjects such as pressure sore care and the administration of medication. Many of the staff have either completed National Vocational Qualification training to level 2 in care or were undertaking the training. People living in the home had formed good relationships with staff and the atmosphere was relaxed and friendly. A relative described the staff as `very kind` and that the home was `on the whole, very good`. There was a range of activities available to suit different tastes and abilities. What has improved since the last inspection? The service is classed as a new service due to having new owners. However, there were no requirements made at the previous inspection visit in February 2007. The written information supplied by the home stated that improvements during the last twelve months had included more activities and trips out, more staff gaining a National Vocational Qualification (NVQ) and the communal areas of the home had been refurbished. What the care home could do better: Greater attention must be paid to the prompt completion of care plans on admission to ensure that all care needs are known and met. Failure to do so has the potential to adversely affect peoples` health. Recruitment procedures must ensure that there are always two written references on all staff files. This is necessary to fully comply with the Care Homes Regulations 2001 and to safeguard people living in the home. Two people should always sign and date handwritten medication administration record (MAR) charts to ensure they are accurate and to minimise risk of errors. The survey findings of `more variety in meals` being wanted should be addressed by regularly reviewing menus in consultation with people living in the home. Quality assurance processes should be improved by obtaining the views of visiting professionals. Survey comments on staff shortages should be addressed by reviewing staffing numbers to ensure that there are always sufficient staff on duty to meet individual needs. All bedrooms should have a secure lockable facility to store valuables and personal items.The home should obtain the most up to date procedures on safeguarding adults from the Local Authority to ensure that the proper procedures are followed in the event of any allegation of abuse. CARE HOMES FOR OLDER PEOPLE Seale Pastures House Burton Road Acresford Swadlincote Derbyshire DE12 8AP Lead Inspector Janet Morrow Unannounced Inspection 10:15 18 February 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seale Pastures House Address Burton Road Acresford Swadlincote Derbyshire DE12 8AP 01283 762511 01283 763832 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) Southern Cross BC OpCo Ltd Margaret Leary Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Seale Pastures House DS0000071077.V356295.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 the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 40 The maximum number of service users who can be accommodated is: 40 N/A New service 2. Date of last inspection Brief Description of the Service: Seale Pastures is a Care Home, which is registered to provide personal care and accommodation for up to 40 older people. The home is situated near to the village of Netherseal. The original building dates from the 17th Century and has retained many of its original features and has since been extended and updated. The home is set in pleasant, spacious grounds with good car parking facilities. The home has 38 single and one shared room. All rooms have en-suite facilities with the exception of two single rooms. A variety of lounge and dining space is provided. There are sufficient bathing and toilet facilities to meet the needs of service users. The latest inspection report is on display in the entrance area of the care home. The current range of fees for 2008 is £305- £388 per week excluding hairdressing, private chiropody, toiletries and newspapers. This information was obtained following the inspection visit. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection visit was unannounced and took place over one day for a total of 6.5 hours. The operational functions of the home had recently been taken over by a new provider, Southern Cross. Care records, staff records and maintenance records were examined. Corporate policies and procedures applicable to all care homes operated by the new company were available in the office. Two members of staff, twelve of thirty-seven people currently accommodated, and two relatives were spoken with. Nineteen surveys were received prior to the inspection visit from people living in the home and there were also three relatives’ surveys returned and one from a member of staff. A tour of the premises was undertaken. One visiting professional and one relative were contacted by telephone following the inspection visit. The home had supplied written information in the form of an annual quality assurance assessment that informed the inspection process. What the service does well: People living in Seale Pastures, their relatives spoken with, and the survey responses, all made positive comments about the home. One relative described the staff as ‘magnificent’ and someone living at the home said they were ‘very kind’. Another person stated that they ‘liked living here’ and that staff were ‘friendly’. Seale Pastures provided a comfortable and safe environment for the people who used the service and the cleanliness of the home was praised, with one survey stating that it was maintained to ‘a very high standard’. People living in the home and families were encouraged to personalise their rooms with their own possessions. There was a committed and competent staff team who were knowledgeable about the care needs and preferences of people living in the home. The staff receive regular mandatory training, such as fire safety, food hygiene and Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 6 moving and handling, and training was also arranged for subjects such as pressure sore care and the administration of medication. Many of the staff have either completed National Vocational Qualification training to level 2 in care or were undertaking the training. People living in the home had formed good relationships with staff and the atmosphere was relaxed and friendly. A relative described the staff as ‘very kind’ and that the home was ‘on the whole, very good’. There was a range of activities available to suit different tastes and abilities. What has improved since the last inspection? What they could do better: Greater attention must be paid to the prompt completion of care plans on admission to ensure that all care needs are known and met. Failure to do so has the potential to adversely affect peoples’ health. Recruitment procedures must ensure that there are always two written references on all staff files. This is necessary to fully comply with the Care Homes Regulations 2001 and to safeguard people living in the home. Two people should always sign and date handwritten medication administration record (MAR) charts to ensure they are accurate and to minimise risk of errors. The survey findings of ‘more variety in meals’ being wanted should be addressed by regularly reviewing menus in consultation with people living in the home. Quality assurance processes should be improved by obtaining the views of visiting professionals. Survey comments on staff shortages should be addressed by reviewing staffing numbers to ensure that there are always sufficient staff on duty to meet individual needs. All bedrooms should have a secure lockable facility to store valuables and personal items. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 7 The home should obtain the most up to date procedures on safeguarding adults from the Local Authority to ensure that the proper procedures are followed in the event of any allegation of abuse. 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. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 8 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 Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was sufficient admission information available to establish that the home was able to meet the needs of people living there. EVIDENCE: The care records of four people living in the home were examined. All the records seen included assessment information from a care manager, where appropriate, and the home had also undertaken its own assessment of need. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 10 This information included risk assessments for nutrition, falls and pressure sores. The information available established that the home was able to meet the needs of people living at the home and relatives spoken with also confirmed that individual needs were well met. All nineteen surveys received from people living in the home stated that they received enough information about the home prior to moving in, with one stating that ‘many homes were inspected and this was the best by far’. One person living at the home stated that it was ‘very welcoming’ when they were shown round prior to deciding to live there. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care needs were met and the care of people living in the home was planned and given in a way that respected individuality. EVIDENCE: Four peoples’ care records were examined. Three had a fully completed care plan in place and these were reviewed on a regular basis, usually monthly. The care plans seen covered all assessed needs, including emotional, social and spiritual needs. Where a risk was identified, there was a care plan to address the risk. For example, one file showed there was a risk of pressure sores and there was a care plan in place to address this. Pressure relieving equipment, such as cushions and mattresses, were also available. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 12 However, one person did not have a fully completed plan of care. Basic information was available but there was no detail on how the care was to be given. The manager stated that this was because staff were familiarising themselves with new documentation being introduced by the new company and the information had not been collated on the new document. This was rectified after the inspection visit and written confirmation that care details had been fully completed was provided. Records showed that residents had appropriate access to health care services. Records were kept of the visits and input of other health care professionals, such as General Practitioner (GP), District Nurse and chiropodist. Eighteen of the nineteen surveys received from people living at the home responded that they ‘always’ or ‘usually’ received the care and support needed and that staff listened and acted on what was said. One responded ‘sometimes’ when asked if staff listened and acted on what they said, if staff were available when needed and if they received the medical support they needed. All three relatives’ surveys received responded that the home ‘always’ gave the care that was expected. People living at the home confirmed in discussion that their privacy and dignity needs were met, giving examples such as staff speaking to them in a respectful manner, and it was observed that staff knocked on doors before entering bedrooms. One person described the staff as ‘kind’, another stated staff were ‘very good’, a relatives’ survey stated that there was a ‘good relationship between staff and residents’ and another survey stated that staff were ‘attentive to needs’. One relative spoken with stated that they thought the staff at the home had been ‘exceptional’ in dealing with sensitive issues and that they ‘couldn’t praise them enough’. Six medication administration record (MAR) charts were examined for accuracy of recording. This showed that the records were signed accurately with no gaps on the charts. Four medication administration record (MAR) charts were then examined in more detail and all were completed accurately and corresponded with the dispensing system (blister pack). All four had all the medication in stock that was required. However, two people were not signing and dating handwritten charts to ensure these were accurate. The record of controlled drugs was examined. Three records were examined and the record corresponded with the amount of medicines held. There was secure storage in a double locking facility and Temazepam was stored under controlled conditions. There were designated staff that administered medication and these staff had received training for the role. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 13 The home had a copy of the up to date Royal Pharmaceutical Society Guidelines on dealing with medicines in social care settings. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities, meals and contact with the community were well managed, which enhanced the daily lives of people living in the home. EVIDENCE: People spoken with stated that they had their own routines and had choice in how they spent their day. One person stated that they continued to pursue interests that they had had in their own home and another stated that they chose where they wanted to sit during the day. Observation during the inspection visit verified that routines were varied and there were a variety of activities on offer, such as card games. People spoken with confirmed that they were encouraged to make their own decisions about social interests, menu choices and daily routines. They felt Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 15 that they had control over their lives, as far as is possible. Many of the bedrooms had been personalised with personal items and furniture. An activities co-ordinator was employed and organised a variety of events throughout the year. One relative spoken with stated that they were pleased that there were games on offer and another stated that their relative had really enjoyed the outings on offer; for example, a canal trip, pub lunches and trips to the theatre. A photograph album of the trips and activities on offer was maintained by the home. Fifteen of the surveys completed by people living in the home responded that there were ‘always’ or usually’ activities on offer and four responded that there ‘sometimes’ were. One relatives’ survey stated that ‘efforts are made to provide entertainment and outside visits’. One relatives’ survey responded that the home ‘always’ supported people to live the life they chose and the two others received responded that it ‘usually’ did. People living at the home and their relatives said that visitors were always made welcome and that they felt able to approach the manager and staff about any issues or concerns. Visitors were observed arriving throughout the day of the inspection visit. The serving of the lunchtime meal was observed and those people spoken with enjoyed the food. The meal served was well presented and nutritious. One person commented that the food was ‘very good and varied’ and that they ‘really liked’ their meals and another commented that the meals were ‘excellent’. Sixteen of the nineteen surveys received responded that they ‘always’ or ‘usually’ liked the meals and three responded that they ‘sometimes’ liked them. One relative survey suggested that the home could improve by offering ‘a greater variety of food’. The dining areas were pleasant and bright and tables were well laid with cloths and condiments. People requiring assistance with eating and drinking were helped in a sensitive manner and encouraged to eat. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place to ensure that complaints and safeguarding issues were responded to appropriately, which ensured that residents were protected and their concerns handled objectively. EVIDENCE: The complaints procedure was examined and this showed that complaints would be responded to within twenty-eight days. It was on display throughout the home. The written information supplied by the home stated that one complaint had been received during 2007 and that this had not been upheld and examination of the complaints record verified this. It was clear from the record what action had been taken in response to the complaint. People spoken with were confident that any concerns they had would be dealt with in a courteous manner. Sixteen of the nineteen surveys received from people living in the home stated that they knew how to make a complaint but three said they did not know how to. All three relatives’ surveys stated that they knew how to make a complaint. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 17 The home had a comprehensive policy regarding safeguarding vulnerable adults and also a whistle blowing policy. There was also information available on how to refer to the Protection of Vulnerable Adults (POVA) list. However, the home did not have the Local Authority’s up to date procedures on safeguarding adults. Training records showed that safeguarding training had been undertaken in November 2007. Staff spoken with were aware of their responsibilities in reporting potential abuse. The written information supplied by the home stated that there had been no safeguarding referrals made via Local Authority procedures in the last twelve months. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well maintained, which ensured residents had safe, comfortable and homely accommodation. EVIDENCE: The home was clean, tidy and odour free at the time of the inspection visit. All nineteen residents’ surveys responded that the home was ‘always’ fresh and clean, with one commenting that it was to a ‘very high standard’. A staff survey received stated that ‘the home prides itself on cleanliness’. Fittings and furnishing were of good quality. The written information provided by the home Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 19 stated that the communal areas had been refurbished in the last twelve months. There was an ongoing programme of maintenance. People spoken with were pleased with their bedrooms and these were personalised with individual possessions. However, not all bedrooms had a secure lockable facility for valuables. The laundry was viewed and there were two washing machines, both with a sluice wash facility, and one drier. People living at the home stated that their laundry was dealt with well and one relative spoken with stated that their relative was ‘ kept immaculately and dressed beautifully’. Staff spoken with confirmed that they had undertaken infection control training during 2007 and there were also certificates on their files that verified this. They were knowledgeable on how to prevent the spread of infection and confirmed that there was always a plentiful supply of protective equipment, such as gloves and aprons. There was information available on the Control of Substances Hazardous to Health (COSHH). Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had sufficient staff, appropriately recruited and trained to ensure people living at the home were safeguarded and their needs were met. EVIDENCE: The staffing rota was examined for the weeks 11th – 17th February 2008. This showed that there were five care staff for the morning shift, three for the afternoon shift until teatime and four after tea time and two at night plus a sleep-in person. This corresponded with the number of staff who were on duty on the day of the inspection visit. In addition to these staffing numbers the registered manager was supernumerary. Discussion with the manager indicated that this was sufficient for care needs to be met. However, staff spoken with did not feel there were sufficient staff as a number of people living at the home needed two people to assist with their care. A staff survey received responded that there were ‘usually’ enough staff to meet individual needs but also commented that ‘at present we are short staffed at times and service users would like us to spend more time with them. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 21 More staff would create a more relaxed atmosphere’. During the inspection visit, the area manager of the new company for the home advised the manager that staffing would be increased to ensure that there were always four staff on duty during the afternoon. Written information supplied by the home stated that nine out of sixteen care staff had achieved a National Vocational Qualification (NVQ) at level 2 or above and a further four staff were undertaking the training. This meant that the home had achieved the target of having a minimum of 50 of staff with an NVQ at level 2. The training records showed that mandatory health and safety training was undertaken and staff spoken with confirmed that they had undertaken several courses related to care; for example, skin care and diabetes but that these had not been recent. Training records showed that pressure sore care had been undertaken during 2007. The written information supplied by the home stated that in the next twelve months the home also wanted to ‘develop a more extensive training programme in addition to mandatory training and to include dementia awareness’. Induction records were also in place and the staff survey received responded that the induction process at the home covered everything needed ‘very well’ and that relevant training to the care role was given. Four staff files were examined and showed evidence of good recruitment processes. All of the documentation required by Schedule 2 of the Care Homes Regulations 2001 was in place on three files, including a Criminal Record Bureau check and Protection of Vulnerable Adults (POVA) check, evidence of identity and qualification and two written references. However, one file had only one written reference. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well organised with good quality assurance procedures, which ensured it was run in the best interests of people living at the home. EVIDENCE: The registered manager had the relevant qualification (at NVQ Level 4) and was experienced in caring for older people. She was able to demonstrate in discussion that she was familiar with the conditions associated with ageing. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 23 The manager stated that staff supervision took place and this was confirmed by one staff file examined, which supervision sessions recorded on an apporximately two monthly basis, with the last session being recorded in December 2007. One staff survey received responded that they ‘sometimes’ met with the manager for support and to discuss work practice. The new company who had taken over the management of the home had corporate quality assurance procedures that incldued monthly visits from an area manager and regular surveys for people living at the home and their relatives. The most recent survey undertaken at the home showed that there were high levels of satisfaction with the home; one survey from someone living at the home stated they were ‘happy and quite satisifed’ and relatives’ surveys made comments such as ‘the overall atmosphere is excellent’ and praised the ‘high level of care’. However, there had been no feedback received from visiting professionals. Four financial records of people living at the home were examined and showed that there were secure systems in place for safeguarding peoples’ money. The records supported that that all accounts were balanced and all money was properly accounted for. Receipts were available for individual purchases. The health and safety of those involved with the home was addressed. Staff training in mandatory health and safety areas took place; for example, fire safety, infection control, food hygiene, first aid and moving and handling training had all been undertaken during 2007. Information on the Control of Substances Hazardous to Health (COSHH) was accessible to staff. The written information provided by the home stated that regular maintenance of equipment took place that included fire equipment in November 2007, gas safety in June 2007, the emergency call system in October 2007 and hoists in October 2007. The new company had undertaken a full fire risk assessment in September 2007 and a further audit was due to be done in March 2008. A valid insurance certificate was on display. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 24 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 3 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 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement Care plans must be completed promptly on admission to ensure that all care needs are known and met. Recruitment procedures must ensure that there are always two written references on all staff files. Timescale for action 01/03/08 2. OP29 19 (1) (b) 01/04/08 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 OP9 Good Practice Recommendations Two people should always sign and date handwritten medication administration record (MAR) charts to ensure they are accurate. Menus should be regularly reviewed to ensure that there is sufficient variety to suit most tastes. The home should obtain the most up to date procedures DS0000071077.V356295.R01.S.doc Version 5.2 Page 26 2. 3. OP15 OP18 Seale Pastures House on safeguarding adults from the Local Authority. 4. 5. 6. OP24 OP27 OP33 All bedrooms should have a lockable facility to store valuables and personal items. Staffing should be reviewed to ensure that there are always sufficient staff on duty to meet individual needs. The views of visiting professionals should be obtained to improve quality assurance procedures. Seale Pastures House DS0000071077.V356295.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Regional Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Seale Pastures House DS0000071077.V356295.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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