Inspection on 28/06/05 for Seymour Gardens (33)

This inspection was carried out on 28th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Seymour Gardens (33) 21/09/06

Seymour Gardens (33) 22/02/06

Seymour Gardens (33) 27/05/04

Seymour Gardens (33) 29/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Seymour Gardens (33) 33 Seymour Gardens Ilford Essex IG1 3LP Lead Inspector Harina Morzeria Unannounced Inspection 28 June 2005 09:30 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 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 Stationary 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. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Years Seymour Gardens (33) Address 33 Seymour Gardens, Ilford, Essex IG1 3LP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8518 4645 020 8554 0396 Norwood Ravenswood East Ms Vanda Karen Brand CRH Care Home 5 Category(ies) of LD Learning Disability (5) registration, with number of places Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom residential accomodation with both board and personal care is provided at any one time shall not exceed 5. Date of last inspection 27 May 2004 Brief Description of the Service: Seymour Gardens is a five bedded home for adults with learning and physical disabilities run by Norwood, a not-for-profit, Jewish organisation, providing services for people of the Jewish faith. Hence the ethos of the home is based around Jewish beliefs, customs and faith. Service users accommodated in the home have medium -- high dependency needs and may exhibit challenging behaviour. The home is a converted domestic dwelling in a popular residential area in Ilford and is close to public amenities as well as being served by good public transport links. All service users have their own bedrooms which are well furnished and decorated, with one of the downstairs rooms containing an ensuite facility. Appropriate communal space is provided and there is also a small well-kept garden, for the service users enjoyment. The manager and staff support service users to develop and maintain independent living skills, attend college for various courses as well as accessing community facilities locally and at the Leonard Steiner Centre (Jewish community centre) in Barkingside. Personal care is provided on a 24-hour basis, and health care needs are met by staff supporting service users to attend appointments with health professionals. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 9:15 a.m. and lasted for approximately 7 hours. The inspector spoke to three service users during the course of the day and three members of staff. The deputy manager was present during the visit. A tour of the home took place and a number of staff and care records were inspected as well as individual service user files. What the service does well: The standard of the décor, furnishings and fittings is being improved with an ongoing refurbishment programme in place. This provides the service users with an attractive and comfortable place in which to live. The home supports the service users to exercise choice and control over their lives in order to promote their independence. The routines of daily living and activities available are flexible and varied, to suit each persons expectations, preferences and capacities. The service users said that they are asked about issues that affect them in the home and are kept informed about any changes and events that take place. Regular discussions and service user meetings take place in order to facilitate this. All necessary health care services are accessed for service users in order to meet their assessed and specialist needs. Each service user has a daily programme of activities outlined in an activity chart. Hence, the service users are supported by staff to attend college, go shopping, swimming, walks, and attend activities at the Leonard Steiner Centre. Evening activities include going to restaurants, pubs, cinema, bowling and a weekly disco. Holidays are also arranged in consultation with the service users. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 6 Visiting times are flexible and visitors are welcome at any reasonable time, although a number of service users living in this home do not receive many visitors. What has improved since the last inspection? What they could do better: The manager and the responsible individual for the service to ensure that all unmet requirements from previous inspections are addressed immediately. Daytime activities for two of the older service users living in the home to be provided in consideration of their age and capacity. The organisation to implement a formal quality assurance system in order to continually monitor and review the development of the home, for service users’ benefit. Monthly monitoring visits must be carried out as required under Regulation 26, by the responsible individual, with copies of reports being forwarded to the CSCI, in order to demonstrate the internal quality monitoring of the service. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 7 Contractual agreements between the home and service users must be drawn up and agreed as required. 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. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3,4 and 5 Prospective service users’ individual needs are assessed and they know that these will be met within the home they are accommodated in. New service users are given an opportunity to visit the home and stay there for a trial period, before they decide if they want to live there permanently. Service users must have individual written contracts or a statement of terms and conditions with the home. EVIDENCE: An organisation policy and procedure regarding the admission of new service users is in place which is fully implemented to ensure that prospective service users have the information they need to make an informed choice about where to live and whether their needs and aspirations will be met by the home they enter. New service users would only be admitted on the basis of a full assessment undertaken by people who were trained to carry out assessments. Their family members and representatives are also involved in this process. New service users are informed that they will only be offered a place in a home which can meet their needs. There have been no new admissions to this home since the past three years. However the inspector was satisfied that this procedure would be followed should a vacancy arise at the home for a new admission. There was evidence on the service user files that the service users’ needs are reassessed regularly and care plans are updated if their needs change. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 10 Family members and other professionals involved in the care of each individual service user are fully consulted and involved. A requirement made at the previous inspection regarding each service user having an individual contract or statement of terms and conditions with the home has not been met. The inspector was informed that the legal services department of the organisation is involved in negotiations with the landlords of the property regarding this issue. However this requirement has been made over the past three inspections. This issue must now be resolved within the timescale stated otherwise the CSCI will consider enforcement action to secure compliance. See requirement number 1. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 11 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 standard(s) 6, 7, 8 and 9 Each service user has an individual care plan called - Individual Person Plan. This outlines the service users’ needs and personal goals. Service users are consulted about their likes and dislikes and encouraged to make independent decisions as far as possible. Appropriate risk assessments are in place for activities undertaken by the service users in order to promote their independence. EVIDENCE: As stated above, each service user has an individual person plan, which outlines their individual needs and how these will be met. The inspector looked at the individual person plans for three service users living in the home and noted that each plan outlines each service user’s needs and how these are to be met by staff. Service users spoken to said that they are given choices and asked by staff about what they would like to do on a daily basis. They said that they would talk to the staff or the manager if they had any problems. During the inspection, the inspector noted that the staff asked service users what they would like to do, discreetly directing them into activities or actions in a friendly/ caring manner. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 12 Service users were familiar with the daily routines in the home, the expectations of staff and were comfortable to seek reassurance and guidance throughout the day which was competently and willingly given to them. There are comprehensive risk assessments in place for the different activities that service users take part in and the service users are supported by staff to carry out their activities, within this framework. Daily records showed that staff write what the service user has done daily which showed that they are participating in a variety of activities which interest them and encourages them to develop independent living skills. The individual person plans (care plans) are reviewed monthly and updated by staff to reflect a service user’s changing needs and how these are to be met. Further reviews of the IPPs also take place six monthly and yearly, in a wider professional setting which are then adjusted according to any changes taking place in a service user’s life. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 13 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 standard(s) 11, 12, 13, 14 16 and 17 Service users have opportunities for personal development and are able to take part in age, peer and culturally appropriate activities. Service users are encouraged to engage in appropriate leisure activities within the local community, which are culturally appropriate. Staff respect service users’ rights and their responsibilities are recognised in their daily lives. The meals in this home are good offering both a healthy diet and variety. Special diets are catered for, for example, a kosher diet. EVIDENCE: The daily routine is set by the activities that the service users are involved in which are outlined in their daily activity plan. The service users confirmed that they do the activities that were listed on their activity plans. It also showed that these routines promote individual choice and freedom of movement. Service users also talked about going out in the evening to restaurants, the cinema, a disco, bowling and other such outings with the staff. During fine weather they also go on day trips in the van which has been donated to them by the Parry Group or organised coach trips. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 14 At the time of inspection, two service users were taken to college by a member of staff to attend a pottery class which was part of their daily activity plan. Upon return they told the inspector how much the enjoyed the session and what they did there. The manager and staff need to consider how they are going to provide activities for the two older service users, who currently spend a majority of the time in the home listening to music or watching television. Service users enjoyed their meals and are asked on a daily basis to choose from the menu, which they agree every Sunday. Some of the service users help the staff to prepare meals which are culturally appropriate i.e. kosher food and alternative choices are also offered. Service users also talked about their forthcoming holiday to Pontins and the inspector saw photographs of a cruise holiday that two of the service users went on with staff. The service users are encouraged to maintain contact with their family members. One service user goes home to stay with her mother every weekend, with another service user visiting her mother who lives in a care home on a regular basis taken by staff, whilst some of the others are encouraged to maintain contact via the phone and letters. The staff work hard to ensure that service users maintain their Jewish way of life and are provided with a culturally appropriate diet and are offered opportunities to follow their faith and customs in accordance with this. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 15 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 standard(s) 18, 19 and 20 Service users receive personal support in a way that they prefer and require. Service users physical and emotional health needs are met appropriately within the home by the staff The medication administration policy and procedure have been updated which ensures that the service users are adequately protected when staff follow the procedure when administering medication. EVIDENCE: Through case tracking and inspection of daily records and discussions with the staff and service users, the inspector is satisfied that the service users health is adequately monitored and any problems identified are dealt with quickly by the staff team. At the time of inspection, one of the service user’s had returned from hospital the day before following an admission for stomach complaint. Appropriate records were seen of his admission and action to be taken following his discharge. The care plans were being updated as required. Each service user has a designated key worker, who ensures that they receive the support and advice they need quickly. A record is maintained of current medication for each service user and all the staff working in the home have received updated medication administration training in order to ensure that they adhere to these procedures, which will ensure that all medication is safely and correctly administered to the service Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 16 users. None of the service users administer their own medication as they are risk assessed as not being competent to do so safely. The inspector observed the administration of medication during midday which followed procedure. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 17 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 standard(s) 22 and 23 There is an organisational complaints policy and procedure which is satisfactory. Their is an organisational adult protection policy and procedure which is satisfactory. EVIDENCE: The home adopts the organisational complaints procedure, which is also available in picture format for people who cannot read well. The service users said that they would be able to talk to their key worker or the manager if they had any problems. Upon examining the complaints log, the inspector noted that there have been no complaints recorded since October 2003. During discussion, the inspector informed the deputy manager that all complaints, no matter how minor, must be recorded, to show any emerging patterns of behaviour or actions which may result in a policy change to ensure full protection of the service users. See requirement number 2. The accident log was also checked and a number of accidents were recorded, however the inspector was not able to examine the any of these accidents because a carbon copy of the record was not available in the home. The manager is required to keep such a log for future reference as required. See requirement number 3. There is a written policy and procedure in place for the protection of vulnerable adults and all newly recruited care staff receive abuse awareness training during the induction period. The staff spoken to as part of the inspection process confirmed that they have received training regarding this and were clear as to their responsibilities to report any potential abuse and what the reporting lines should be. This is in order to ensure a proper response for reporting any suspected or witnessed abuse. The inspector was informed that verbal compliments are regularly received from service users’ family and representatives. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 18 Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 19 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 standard(s) 24,25,26,27,28, 29 and 30 Service users live in a homely and comfortable environment. Bedrooms and communal areas are spacious and meet their needs and promote their independence. Toilets and bathrooms provide sufficient privacy. However a requirement has been made in relation to adaptations and repair in one bathroom to meet service users needs. Shared spaces are spacious and sufficient space is available for the numbers of people living in the home. The home is clean and hygienic. EVIDENCE: The house is in keeping with other properties on the street and a tour of the premises showed that it is decorated and furnished in a homely manner. A new settee has been purchased for the lounge, although the room is yet to be redecorated. The kitchen and dining area is also awaiting refurbishment. All of the service users occupy single rooms, and a new carpet has been fitted in each room. Two of the service users have also purchased curtains and matching bedding, giving the rooms a luxurious look. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 20 The service users spoken to said that they liked their rooms and felt comfortable and safe in them. The downstairs bedroom has an en-suite bathroom and this room has been allocated to a service user with sensory impairment to maximise his independence. He told the inspector he likes his room and the home. All parts of the home were clean and tidy and so were the bathrooms and toilets. The bathroom upstairs is required to be adapted to meet the needs of one of the service users who now has difficulty accessing it. The manager has already sought an O.T. assessment before any adaptations are made. The toilet roll holder in the bathroom was broken at the time of inspection, therefore a new one is required to be installed urgently. See requirement number 4. There is a small garden at the back of the house accessed via the dining room. This space is safe and well used by the service users in fine weather. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 21 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34, 35 and 36 The organisation have a staff recruitment policy and procedure which is followed when new staff are recruited to ensure that service users are protected by suitable and competent staff. All the staff have job descriptions which clearly outline their roles and responsibilities in shorting that they understand the tasks required of them, and can need to service users and needs appropriately. Staff are competent and trained to acquire sufficient experience to carry out their tasks and a support service users effectively and appropriately. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the service users. Staff receive appropriate training and supervision and support to carry out their tasks efficiently in order to meet the needs of the service users. EVIDENCE: The home now has a relatively stable staff group. In discussion with staff, it was evident that they fully support the main aims and values of the home. They are able to understand, meet and review the needs of the service users. The information on the duty rota was consistent with the names and delegations of staff on duty. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 22 Service users said that the staff are kind and caring towards them and know what they need, particularly in relation to food choices, activities and boundaries. The deputy manager informed the inspector that following the recruitment of three new staff members the team is complete and is able to consistently deliver the type of care required by the service users living in the home. This has resulted in the service users being happy and an improvement in team morale. There is only occasional use of peripatetic staff who are familiar with the service users in the home and therefore are aware of their needs and how to meet these. Discussions with staff confirmed that following recruitment, they are required to attend the organisations induction training, after which certificates showed that staff are continually encouraged to attend training. They told the inspector that they receive good support and supervision from the management as well as the staff team, enabling them to carry out their jobs efficiently. A number of staff in the home have achieved their NVQ level 2 and level 3 qualifications. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 23 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 and 39 Service users benefit from living at Seymour Gardens because the home is run in their best interests. The manager and staff in the home are good at making sure that the service users are kept safe whilst living at Seymour Gardens. EVIDENCE: The current manager has been in post in this home since the past three years and has the qualifications and experience required to run the home efficiently. The service users are provided with a safe environment and the manager makes sure that the health, safety and welfare of the service users are met by the staff working in the home. Staff spoken to said that they receive a lot of support and encouragement from the manager, as well as the rest of the staff team, which helps them to carry out their jobs competently. The inspector spoke to three members of staff all of whom were satisfied with the level of support they receive. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 24 The inspector was satisfied that there is a good level of monitoring being carried out informally by lay monitors working within the organisation, who regularly undertake visits to the home and who are representatives of the relatives of the Parry Group(a group of parent representatives). A rabbi also visits the home in order to assess that the home operates within the Jewish laws. The inspector was informed that the manager and the deputy carried out an internal survey of the staff group as part of an NVQ assignment, resulting in a discussion with the responsible individual about issues concerning the staff within this particular home. An auditor appointed by the organisation also carries out regular financial audits. The organisation is required to implement a formal quality assurance and monitoring system based on seeking the views of service users, to measure success in achieving the aims and objectives of the home. The views of their family, friends and advocates must also be sought on how the home is achieving goals for service users. See requirement number 5. The inspector remains concerned that the monthly Regulation 26 visits are not being carried out by the Responsible Individual. Although the frequency of the visits to the home has improved, these visits are still not being carried out monthly. This requirement has been repeated over the previous inspections and must be fully complied with, otherwise enforcement action will be taken by the Commission for Social Care Inspection to secure compliance. These reports are necessary to demonstrate that the registered providers have in place satisfactory systems for monitoring the welfare and safety of service users and to ensure that the service is operating in accordance with the home’s aims and objectives and legal requirements. See requirement number 6. At the time of inspection the public liability insurance had also expired in March 2005. This is required to be renewed urgently. See requirement number 5. Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Seymour Gardens (33) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x x x G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 26 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. 1. Standard 5 Regulation 5 Requirement The registered person must provide each service user with a written and costed contract/statement of terms and conditions between the home and the service user. Previous timescale of 31/5/04 not met. The registered person must ensure that all complaints received, however minor, are recorded in the complaints log. The registered person is required to keep a copy of the accident log for future reference. The registered person is required to ensure that adequate bathroom adaptations are made in order to ensure that all service users can access the bath with ease. The broken toilet roll holder to be the place to urgently. The registered person to ensure that an organisational form of quality monitoring system is in place and implemented to measure success in achieving the homes aims, objectives and Statement of Purpose. The registered person must ensure that monthly monitoring Timescale for action 30/09/05 2. 22 22 30/9/05 3. 4. 22 27 22 23 30/09/05 30/09/05 5. 39 17/18 30/09/05 6. 39 26 30/09/05 Page 27 Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 7. 43 25 visits are being carried out as is required by regulation and the report forwarded to the CSCI promptly. The registered person to ensure that the homes insurance cover is renewed as required. 31/07/05 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 Good Practice Recommendations Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU 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 Seymour Gardens (33) G55_S0000025927_Seymour Gardens_V235546_280605_Stage 4.doc Version 1.40 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!