Inspection on 22/03/06 for Seeleys House

This inspection was carried out on 22nd March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Seeleys House 06/01/09

Seeleys House 16/04/08

Seeleys House 12/04/07

Seeleys House 28/12/06

Seeleys House 30/05/06

Seeleys House 06/09/05

Seeleys House 31/03/05

Seeleys House 30/11/04

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

CARE HOME ADULTS 18-65 Seeleys House Seeleys House Campbell Drive Knotty Green Beaconsfield Bucks HP9 1TF Lead Inspector Sue Smith Unannounced Inspection 22nd March 2006 10.50 Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 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 Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Seeleys House Address 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) Seeleys House Campbell Drive Knotty Green Beaconsfield Bucks HP9 1TF 01494 670902 Buckinghamshire County Council Mrs Wendy S Rutland Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Seeleys House is registered to provide respite care at any one time for up to 12 people with learning disabilities. There is a rolling programme for respite care. The home is sited in a residential area of Beaconsfield and is owned by Buckinghamshire County Council. It is an adapted old school and provides single accommodation for service users with shared social space. Half of the building provides Day Care Services and is also owned by the Council. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 22nd March 2006. The home had recently suffered an outbreak of Diarrhoea & Vomiting, which had temporarily closed the home to Service Users for a period of 1 week in line with its infection control measures. The home was able to open its doors to Service Users on the Monday 19th March 2006 after being free from symptoms for 48hrs and receiving confirmation these symptoms were due to the Influenza B virus. Unfortunately on the morning of the inspection there had been a further outbreak and the home were having to reintroduce stringent infection control measures to protect the remaining staff, service users and any necessary visitors to the home. With these further issues of concern discovered on arrival to the home the inspector made a decision to only assess the standards, which had received requirements during the September 2005 inspection. Fortunately all key standards have been assessed in the past 12 months, which has ensured the inspection programme for Seeleys house has been completed. Standards assessed during this inspection were 9, 13, 30, 32, 33, and 42. Of these 6 standards, 3 were assessed as fully met and 3 were assessed as partly met. As a result of these partially met standards the home has received 1 new requirement and 1 repeated requirement. In addition 1 new recommendation has been made. The Inspector will be writing separate correspondence to the Heads of Service to address the repeated requirement once legal advise has been sought. The Inspector would like to thank the staff team and Manager for their support in assessing the necessary standards to complete this inspection and would commend them for their continued dedication and commitment to providing care under difficult and stressful circumstances to the Service Users. What the service does well: The staff team continues to provide a high standard of care to its Service Users. Communication amongst the Staff team was seen as positive with a clear understanding of what was required of them during this crisis. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 6 Staff were observed ensuring the home was thoroughly cleaned to maintain their infection control measures and minimise further outbreaks of the sickness affecting the home. Staff were observed communicating with Service Users and ensuring they were aware of the issues of concern and what was required of them to minimise the spread of infection. What has improved since the last inspection? 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. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): x EVIDENCE: None of the above standards were assessed during this inspection, however standards 1, 2 and 3 were assessed as met at the previous inspection carried out on the 6th September 2005. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Necessary Risk Assessments are in place, which ensure the ongoing safety of Service Users and enable them to live as independent as is possible. EVIDENCE: The Service have now implemented risk assessments for the use of bed rails for those Service Users who are at risk of falls whilst in their beds. These were seen during the inspection and the Inspector is satisfied the requirement set during the September 2005 inspection is now met. The Service is advised to ensure a supporting signature of consent from the Service User or significant other is held on file. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13. Activities offered at the home ensure the Service Users are part of the local community and are reaching their full potential. EVIDENCE: The home continues to access the wider community, using local facilities such as shopping centres, cinema, leisure centres, pubs and restaurants. As has been mentioned in previous reports the Service does not plan activities on a weekly basis due to the changing population of the home. However activities that are implemented are in line with the individual or group needs of the Service Users in residence on any given day. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): x EVIDENCE: None of the above standards were assessed during this inspection, however standards 18, 19 and 20 were assessed as met at the previous inspection carried out on the 6th September 2005. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): x EVIDENCE: None of the above standards were assessed during this inspection, however standards 22, and 23 were assessed as met at the previous inspection carried out on the 6th September 2005. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Standards of cleanliness at the Home are of a high standard meaning Service Users live in an environment that is clean, hygienic and protects their health, safety and welfare. EVIDENCE: On the day of inspection the home were experiencing an outbreak of Influenza B, which had caused a high percentage of Service Users and staff to suffer with symptoms, which included diarrhoea, and vomiting. The home had been closed temporarily in line with the Counties Infection Control measures. During this inspection the home had received notification that other staff members were now experiencing the same symptoms 48 hours after the last notification of symptoms. As the home had already admitted Service Users staff were ensuring all areas of the home were cleaned to an even higher standard than usual, wiping door handles, telephone receivers and implementing thorough infection control measures to any persons entering the home. Entry to the home in most cases was refused unless the business was of an urgent matter. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 14 Due to this outbreak the home did not receive a full environmental tour, however all environmental standards were assessed at the September 2005 inspection and were assessed as met. A recommendation was made as a result of the September 2005 inspection for a more realistic plan of decoration to be put in place, which will be assessed during the next inspection of the Service. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33. The home currently has a high proportion of vacancies within the staff team, which could lead to increased vulnerability and lack of consistency in maintaining care to Service Users. EVIDENCE: The Home is currently carrying 6.5 vacancies, this equates to a third of the staff team. Full time or relief staff is covering the majority of vacant hours, however some hours are being covered by Agency workers. The Manager is ensuring as far as she is able that all Agency staff attending the Service are familiar with its regimes and have worked in the home previously. The shortage of staff does have a knock-on effect to Service Users and the Inspector is concerned that there is no active recruitment programme taking place to fill these posts. The Inspector is making a requirement that an active programme of recruitment takes place for Seeleys House within 28 days of this inspection. It is also recommended in the interim that no further referrals be added to the list of Service Users for Seeleys House until there is an increase in staffing levels at the Home. The Inspector is greatly concerned that the shortage of full time staff is going to have an effect on the quality and consistency of care delivery at Seeleys House, and believes the Organisation needs to address this issue as a priority. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 16 Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42. The Organisation have not actioned Requirement Number 3 of the September 2005 inspection report, therefore they have not adequately protected the health, safety and welfare of the Service Users, leaving them at risk. EVIDENCE: The Inspector noted the requirement made in the September 2005 report for the fitting of the acoustic hold open devices to the two front offices, which have been recommended and approved by the Fire Authority in April 2005 have still not been fitted. Discussion with the Manager has ascertained that a designated Electrical Engineer did visit Seeleys House to assess the necessity for these and made a decision not to fit these required devises. During the inspection of the Service it was noted by the Inspector that the first office door was being propped open by a rubbish bin marked ‘paper only’, whilst the second office door was being propped open with an electric heater, which the Inspector is relieved to report was not switched on. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 18 As neither Authorities inspection reports have been acted upon within the recognised timescale the Inspector will be seeking legal advise as to the next option open to both Authorities. Correspondence to this effect will be sent to the Home at the same time as a copy of this draft report. A repeat of this requirement has been made in the interim. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X X 2 X Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 20 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 YA32 Regulation 18 (1) Requirement A requirement is made for an active programme of recruitment to begin for Seeleys House within 28 days of this inspection. Acoustic hold open devices must be fitted to the two front offices as described in the April 2005 Fire authority report and additional correspondence from the Fire authority giving permission for the fitting of such devices. This work must take place within 28 days of this inspection. PREVIOUSLY MADE REQUIREMENT NOT ACTED UPON. Timescale for action 26/04/06 2. YA42 13 (4) 06/10/05 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 YA 32, YA33. Good Practice Recommendations The Home does not accept any further referrals to its lists until such time as the recruitment of staff has taken place, to ensure the ongoing safety and consistency of care DS0000032334.V287245.R01.S.doc Version 5.1 Page 21 Seeleys House offered at Seeleys House. Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Buckinghamshire Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury Buckinghamshire HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Seeleys House DS0000032334.V287245.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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