Care Home: Sefton Hall

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What the care home does well Sefton Hall is well managed and provides a safe, comfortable and homely place in which individuals can live their lives. Everyone looked clean and well cared for. There is a good assessment process that assures people thinking of moving into the home that their needs will be met. Everyone living at the home has a care plan that sets out their needs and is reviewed regularly. There is variety and stimulation for people throughout the day and there is entertainment and trips out if people wish to join in. There is a simple complaints procedure and people knew who to raise any concerns with. Communal areas of the home are bright, airy and well maintained and individual rooms reflected the personality of the occupant. Staffing levels are sufficient to meet the needs of people currently living at the home and staff are well trained. People living at the home said that staff were helpful and friendly. Staff said that they felt well supported by management and the owners. When we asked the staff what they thought the home did well, they said ‘look after our residents well’, ‘there is a good atmosphere’ and ‘lots of choices’. One person commented via their survey form that there were ‘good entertainments and a good manager’. What has improved since the last inspection? No requirements were made at the last visit. However, we were told by staff and the owners of several improvements, including, refurbishments to the building, better cleanliness and the appointment of the activity co-ordinator What the care home could do better: No requirements were identified during this visit. However, some recommendations were made in discussion with the manager. These included ensuring all assessments and care plans focussed more on social and emotional needs, ensuring care plans gave more specific directions to staff on meeting people’s needs and ensuring all complaints are recorded separately. CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Sefton Hall 11 Plantation Terrace Dawlish Devon EX7 9DS Lead Inspector Sue Dewis Key Unannounced Inspection 17 and 20 July 2009 09:40 X10029.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 Sefton Hall DS0000064054.V377320.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 and 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. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sefton Hall Address 11 Plantation Terrace Dawlish Devon EX7 9DS 01626 863125 01626 864952 enquiries@southernhealthcare.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) Southern Healthcare (Wessex) Ltd Manager post vacant Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (26), Physical disability (28), Physical disability of places over 65 years of age (28) Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th August 2007 Brief Description of the Service: Sefton Hall Nursing & Residential Care Home is situated in the seaside town of Dawlish in just a short walk from the town centre. The home is registered as a 52 bedded Care Home with Nursing to provide personal and nursing care to meet the needs of adults and older people who can no longer live independently. The home has been designed and adapted to provide access to all areas by way of shaft lifts and ramping. The home is laid out over three floors with the ground floor offering two large multipurpose lounges and a large dining room which has two distinct areas to its layout. Also on this floor there are seven single rooms, all with en-suite facilities. The Registered Managers office and the Administration Office are situated near the main entrance. There is a fully equipped kitchen, a hair dressing salon and various storage spaces also on the ground floor. The first floor has 23 bedrooms (most with en-suite), three of which are doubles. A tea kitchen, for use by Service Users, plus two nurse stations and further storage space can also be found on this level. The second floor has 20 single bedrooms most with en-suite facilities. Each floor is adapted to meet the needs of people living there, with toilets and bathrooms that have disabled persons facilities, wide floor areas with handrails, specialist Parker baths and suitable hoisting facilities. There are large grounds that have ramped access to facilities at the front and rear of the home. Current fees range from £322- £781 per week dependent on the care needs of the individual. Additional charges are made for hairdressing, chiropody, physiotherapy (if private), personal toiletries, newspapers and books. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at http:/www.oft.gov.uk . A copy of the CQC inspection report on the home is available on request from the manager. Sefton Hall DS0000064054.V377320.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 two star good service. This means the people who use this service experience good quality outcomes. This unannounced visit took place over 15 hours, on two days in the middle of July 2009. The home had been notified that a review of the home was due and had been asked to complete and return an AQAA (Annual Quality Assurance Assessment). This shows us how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. Although only one inspector undertook this inspection, throughout the report there will be reference to what we found and what we were told. This is because the report is written on behalf of the Care Quality Commission (CQC). During the inspection 3 people were case tracked. This involves looking at peoples individual plans of care, and, where possible speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process CQC likes to ask as many people as possible for their opinion on how the home is run. We sent questionnaires out to 10 people living at the home 10 staff and 3 healthcare professionals. At the time of writing the report, responses had been received from 6 people living at the home and 1 member of staff. Their comments and views have been included in this report and helped us to make a judgement about the service provided. During the inspection 4 people living at the home were spoken with individually and a further 4 in a group setting, as well as observing and speaking with staff and people living at the home throughout the day. We spoke with 5 staff, the manager and the owner of the home. We also spoke with a care manager via the telephone. A full tour of the communal areas of the building was made and a sample of records was looked at, including medications, care plans and staff files. All key standards were inspected. A new manager has been appointed by the owners. This person has submitted an application to the Commission to be registered as manager of the home. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 6 Some people living at the home have limited verbal communication skills, and as we are not skilled in their other methods of communication it was difficult for us to have any meaningful communication with these people. However, the interaction between the people living at the home and those who care for them was closely observed. What the service does well: What has improved since the last inspection? No requirements were made at the last visit. However, we were told by staff and the owners of several improvements, including, refurbishments to the building, better cleanliness and the appointment of the activity co-ordinator. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 (Older People) and 2 (Adults 18-65) Quality in this outcome area is good. The admission procedure ensures that there is a proper assessment prior to people moving into the home, and that they can be assured that their care needs can be met. This judgement has been made using available evidence including a visit to this service. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home’s Statement of Purpose, Service User’s Guide and Brochure have recently been updated. A copy of the Statement of Purpose is provided in each bedroom. The manager told us the procedure when a referral for admission is made to the home. They told us that most referrals come via the local Social Services team and that usually the individual’s family would look around the home in the first instance. The manager told us that people were welcome to look around the home at any time and that individuals who had been referred could spend the day at the home to see if they liked it. At the initial visit a brochure about the home is given to families and if they decide they wish to proceed with the referral, either the manager or their deputy would visit the person to complete a pre-admission assessment. The files of three individuals were looked at and all contained detailed preadmission assessments. However, they tended to focus on the person’s physical needs and abilities and there was limited information about any social, emotional or psychological needs. The home does not write to people before they move in, to say that their needs can be met by the home. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to provide a ‘virtual tour’ of the home with a DVD for those who are unable to visit the home, or who would find it difficult getting around the home. At the time of this visit Sefton Hall did not provide intermediate care. However, they do provide short stay respite care when requested. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 (Older People) and 6, 9, 16, 18, 19 and 20 (Adults 1865) Quality in this outcome area is good. Everyone who lives at the home has a care plan which provides staff with information to enable them to meet peoples health and social care needs on a day to day basis. The management of medication is good and helps ensure people are protected from the risk of not receiving their prescribed medication. This judgement has been made using available evidence including a visit to this service. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 12 EVIDENCE: We looked at the care files for three people living in the home. The care files were very comprehensive and sections included the initial assessment, a continence assessment, pain assessment, inappropriate behaviour chart and a nursing care plan as well as information relating to last wishes and daily recordings. The files also contained detailed risk assessments covering a range of topics including choking, bedrails, nutrition, moving and handling and pressure areas. There was evidence that Mental Capacity Act assessments had been completed for everyone. However, there was no evidence to show how decisions taken by staff in people’s ‘best interests’ were made. There was good evidence to show that care plans are reviewed monthly and some signatures to show that people were involved in reviewing their plans. However, there was conflicting information in one care plan. For example one area stated that there was no history of depression, but another that the Mental Health team had been involved because of a history of depression. Not all areas of the care plans contained detailed directions to staff on how to meet people’s needs for example one plan highlighted that there was a risk of ‘challenging and unpredictable behaviour’ but there were no instructions to staff on how to deal with this should it occur. However, staff spoken with had a good knowledge of peoples needs and associated risks and were able to describe in detail the care needed by individuals. Much of the information concentrated on meeting people’s physical needs and there were good directions to staff on how to meet these needs. Information about visits from and to health care professionals had been recorded in individual care plans, showing clear evidence that people are supported to maintain access to specialist medical services. These included GP’s, chiropodists and the SALT (Speech And Language Therapy) team. We saw a variety of daily recordings made by staff, including, bathing, fluid intake and general information. Much of the general information was of a poor quality and consisted mainly of ‘no problem’. There was little evidence in these recordings that people’s identified needs had been met. All of the people seen during this visit were treated with respect by the staff and their right to privacy was upheld. Personal care was offered in a discreet manner. Staff told us how they respect peoples privacy when helping them with personal care, assisting them to bath or dress or assisting them with personal needs when in the lounge or dining room. We heard staff speaking to people in a kindly, friendly way. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 13 Medication administration was well managed and policies and procedures relating to this area were in place. We were told and records show that staff who administer medications have received training that tested their competency. Staff were seen administering medication appropriately. There is a ‘homely remedies’ policy for the home that was seen to be approved and signed by a GP. Records show that medicines are counted when received into the home and records relating to Controlled Drugs were well maintained. Hand written entries on the MAR (Medication Administration Record) sheets from when extra medication had been prescribed had been signed by two members of staff, which is good practice. The MAR sheets showed that several people had been prescribed creams and ointments and there is a record kept of the application of these topical creams. Containers are marked with the date of opening, which reduces the risk of people having creams applied that are past their expiry date and therefore ineffective. People are supported to manage their own medication if they choose to. We were told that risk assessments are completed and staff discretely check to ensure medication is taken as prescribed. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to continue to transform the culture of the care service, by understanding individual lives and needs more sensitively. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 (Older People) and 12, 13, 15 and 17 (Adults 18-65) Quality in this outcome area is good. Social interaction and activities are available, and there is good daily variation for people living in the home. This judgement has been made using available evidence including a visit to this service. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 15 EVIDENCE: People at Sefton Hall are encouraged to continue to take part in activities in the local community as well as in the home. Staff are available to take people out if they wish to go and one person visits a local pub every week. Several people have motorised wheelchairs and use they for going out as well as for getting around the home. An Activities Organiser is employed for 30/35 hours per week. They told us how they are trying to build up the level of social interaction and stimulus for all individuals at the home. We saw a copy of a typical weekly activities programme which included an exercise group, a newspaper and discussion group and a sensory exploration group as well as quizzes and entertainments. Regular religious services are also held. One person told us that there is a piano in the home that they play when several people gather together for a bit of companionship. We were told that everyone now has a social activity plan and that seven people have goal plans in place. This is to ensure everyone receives some sort of social stimulus that they enjoy, especially if they do not like to join in group sessions. We were told that the organiser spends a lot of time with people on a 1:1 basis to ensure no-one becomes isolated in their room. Staff told us that they thought that the organiser was ‘brilliant’ and that they had really noticed a difference in individuals since they had been at the home. Individuals that we spoke with also praised the organiser, one said ‘he is very effective in what he does’ and that they had been on a coach trip with him and had found that very enjoyable. Regular meetings are held with families to ensure they have an input into the running of the home. The manager told us that visitors are welcome at any time and people told us of their many visitors and how welcome they are made to feel. We looked at how people are offered choices during the day. People who we spoke with told us that they chose what time they get up and go to bed and whether they had their breakfast in the dining room or in their own room. One person told us they preferred to have their breakfast in their own room and staff provided this for them. Staff told us that they always remembered that people were ‘still capable of making up their own minds’. The care plans included details of personal preferences and choices for individuals relating to the food they liked and the time they like to get up and go to bed. The persons preferred form of address was also recorded in the individual plans of care seen during the inspection and staff were heard using the individual’s chosen name when speaking with them. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 16 The meal times at Sefton Hall are a pleasant experience for people who live there. Menus are provided each day and a weekly menu is available for those who wish to see this. When we asked people about the meals they said that they were able to choose what they wanted the next day. They also said that if there was nothing on the set menu they liked then alternatives would be offered. We saw people with a variety of meals at both lunch and tea time. The menus showed that each day there is a choice of meals, which includes a vegetarian option. However, one person commented via a survey form that the home could relate to their preferences on food better. The meals seen were attractively presented and nutritionally balanced. Those who needed a soft or pureed diet had this prepared in a way that enabled them to experience the different tastes of the foods. We spent lunch time on one day of the visit observing staff during this time. Staff were seen assisting people with their meals in a gentle and supportive way, they were speaking to the person about the meal while they were assisting them. All the meal times we observed were unhurried with people eating their meals at their own pace. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to further develop care plans to incorporate rehabilitation and skill retention and to improve on trips out to areas of interest. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 (Older People) and 22 and 23 (Adults 18-65) Quality in this outcome area is good. There is a good complaints procedure and people can be confident that their concerns will be listened to. Adequate procedures are in place to ensure that people are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a simple, formal complaints procedure for the home that is displayed in the hallway. We looked at how the home has responded to complaints. A complaints file is maintained that records any complaints that have been made, how the home has dealt with the complaint and what the outcomes were. However, several complaints were recorded on the same page. This means that people would not be able to see information about themselves without seeing information about others and thus contravenes the Data Protection Act. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 18 Not all people living at the home who were spoken with during this visit were able to tell us whether they knew about the homes complaint procedure or whether they would feel comfortable making a complaint. However, everyone was clear about who they would speak with if they were unhappy about anything and felt sure that their concerns would be dealt with. Two complaints have been received by the Commission since our last visit to the home. Both were passed to the home for them to deal with through their own complaints procedure, which they did so appropriately. Records show, and staff told us that they had received training in Protection Of Vulnerable Adults (POVA) issues. All four staff that we spoke with were able to discuss different forms of abuse and said that they would report any suspicions they had to the manager. They were also able to tell us who they would report any concerns to, outside of the home, if necessary. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 (Older People) and 24 and 30 (Adults 18-65) Quality in this outcome area is good. The home provides a pleasant, comfortable and safe environment for those living in, working at and visiting the home. This judgement has been made using available evidence including a visit to this service. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 20 EVIDENCE: A full tour of all the communal areas of the home and some of the individual bedrooms were looked at. All areas of the home were clean and fresh smelling. The programme of refurbishment throughout the home is ongoing. Peoples bedrooms contained many individual items and reflected the personality of the occupant. People told us that they had been able to bring things from their home when they had first moved in. There were some building works being undertaken during the visit and we were told that these were to provide more accessible toilets and a further lounge on the ground floor. Communal areas consist of a large comfortable lounge and large separate dining room. There is also a library/quiet room for people to use. All areas were pleasantly decorated and have a comfortable and homely feel. People told us that they thought the communal areas of the home the home were very comfortable. One person commented via a survey form that they would like a ‘sheltered smoking area’. There is level access to the outside of the premises, at the front there is a summer house and pleasant garden, and to the rear a safe decked area is provided. People can leave the home easily as there is no lock to prevent them doing so. However, there is a coded key pad to prevent unauthorised people entering the home. The home has a good range of equipment available to staff including grab rails, handrails and moving and handling equipment. All areas of the home were clean, well ventilated and there were no unpleasant odours. One staff member told us that in the past there had been a problem with the cleanliness of the home, but that while they felt there was still room for improvement, the home was much cleaner. The laundry area is situated in the basement and has commercial equipment installed. An impervious floor covering is fitted to minimise the risk of cross contamination. One person commented that they had had problems with items of clothing going missing at the laundry. The manager told us that they are aware of the problems and are doing their best to address the issue. Staff confirmed that disposable gloves and aprons were available to them in order to minimise the risk of cross infection and we saw them being used. Staff also confirmed and records show that they have received training in this area. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 (Older People) and 32, 34 and 35 (Adults 18-65) Quality in this outcome area is good. A wide range of training is provided and the numbers and skill mix of staff on duty are sufficient to meet the needs of people currently living at the home. People are protected by recruitment procedures that ensure people who may be unsuitable to work with vulnerable people are not employed at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the second visit there were 47 people living at the home. On duty during this time were the manager, assistant manager, registered nurse, 7 care staff, a head carer, 5 ancillary staff (kitchen staff and domestics) plus an administration assistant and two maintenance people. People that were Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 22 spoken with felt that there were enough staff at the home to meet their needs. Although they did say that staff were always very busy and one member of staff commented via a survey form that the home could do better by ‘putting more carers on the floor’. Staff were praised by people living at the home when we spoke with them and one person commented that ‘we get treated individually – not as a member of a herd of sheep’. Staff that we spoke with demonstrated a good awareness and understanding of peoples needs. They were able to describe people’s personal preferences in the way they received care as well as displaying a good knowledge of their individual needs. People have photographs of their named nurse and key-worker responsible for personal care, in their room. We asked one lady if they minded receiving personal care from a male carer, they told us ‘no, they are very good, don’t make you feel embarrassed at all’. Four staff files were looked at. Each file contained all the required information including satisfactory CRB (Criminal Records Bureau) checks, two written references and proof of identity. This robust recruitment practice ensures that people are protected from the risk of harm by people who may be unsuitable to work with vulnerable adults. Training has a high priority at the home. Records show and staff confirmed that they receive a wide variety of training, including Fire procedures, Moving and Handling, Food Hygiene, First Aid and Infection Control. Staff are also encouraged to work for NVQs (National Vocational Qualifications) and 15 staff currently have NVQ level 2 or above. All staff have received training in POVA (Protection Of Vulnerable Adults) issues and all new staff receive a full induction in line with Skills for Care recommendations. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 24 31, 33, 35 and 38 (Older People) and 37, 39 and 42 (Adults 18-65) Quality in this outcome area is good. The home is well managed resulting in practices that promote and safeguard the health, safety and welfare of people who live and work in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A new manager has been appointed who has many years experience of working in a care environment. The home is managed efficiently and the manager and staff team work together well. Staff told us that they felt supported to do a good job and were able to put forward suggestions for alternate ways of working. One staff member told us that the manager wanted to make positive changes and for the home ‘to be the best’. Another told us that things had got a lot better at the home since he had been appointed. The manager told us that there was no-one living at the home that is subject to a deprivation of liberty authorisation and we saw no evidence to show that anyone living at the home is having their liberty deprived without an authorisation. We spoke with the owner of the home and they outlined the quality assurance systems in place. Survey forms are sent to representatives and social and health care providers to obtain their views on the quality of care provided at the home. Meetings for people living at the home and their representatives are also held as a way of obtaining their views on the service. The owner also visits the home regularly and talks with staff and people living at the home. He also completes a variety of audits which are used to produce an action plan for the manager. The home is currently undergoing reassessment for the Investors In people Award. These quality assurance systems ensure the home is being run in the best interests of the people living there. We looked at the way finances are managed on behalf of people living at the home. We saw that all records and monies are kept separately and that all are checked regularly by the manager. However, not all transactions are double signed which is good accounting procedure. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Sefton Hall complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. Policies and procedures are not Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 25 always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to people living and working at the home. So that the risk of burning from hot surfaces is minimised, most radiators within the home have been covered and there is an ongoing programme to ensure all are covered by the end of August 2009. All windows above ground floor level are fitted with restrictors, in order to minimise the risk of anyone falling from these windows and all taps are fitted with thermostats to minimise the risk of people being scalded. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 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 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 27 NO 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. Standard Regulation Requirement Timescale for action 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 You are recommended to ensure that all assessments and care plans include good details of social and emotional needs. This is to ensure that good person centred care is provided. You are recommended to ensure that care plans contain specific directions to staff on how to meet people’s needs. This is to ensure people’s needs are met in a consistent manner. You are recommended to ensure that all complaints are recorded separately. This is so people wishing to see details of their complaint could not see details of other people’s complaints. 2. OP7 3. OP16 Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 28 Care Quality Commission South West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.southwest@cqc.org.uk Web: www.cqc.co.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. Sefton Hall DS0000064054.V377320.R01.S.doc Version 5.2 Page 29 - 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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