Inspection on 13/12/06 for Seymour House

This inspection was carried out on 13th December 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 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Seymour House 05/06/07

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Seymour House 21, 23, 25 Seymour Road Slough Berkshire Lead Inspector Chris Schwarz Unannounced Inspection 13 & 15th December 2006 10:30 th Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 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 Seymour House DS0000067341.V317421.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 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. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seymour House Address 21, 23, 25 Seymour Road Slough Berkshire 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) 01753 824798 Committed Care Services Limited Mrs Jasvir Kaur Bajwa Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9) of places Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users must not be admitted over the age of 65 years. Date of last inspection Brief Description of the Service: 21, 23 and 25 Seymour Road comprise three properties in Chalvey, Berkshire. Each property can accommodate up to three adults with learning disabilities in small groups. All bedrooms are single and have been personalised by the occupants. House 21 had been registered a short while ago and was yet to admit any service users. The houses are near to the centre of Chalvey and a short drive to Slough where there are good shopping, leisure and transport links. The homes have been operational for some time but a change of provider to Complete Care Limited has meant that the services are classed as new registrations. The responsible individual for the provider and the manager and several staff are part of the same family unit. Fees for the service range from £664.02 per week up to £1478.33. Information supplied in the pre-inspection questionnaire states that there are no additional charges to service users. The home has a statement of purpose and service users guide to inform prospective service users about provision and scope of the home. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over the course of two days and covered all of the key standards for younger adults. Prior to the visit, a questionnaire was sent to the manager alongside comment cards for distribution to service users, relatives and visiting professionals. Any replies that were received have helped to form judgements about the service. The first visit was unannounced and involved speaking with the responsible individual for the provider with input from the manager and other staff. There were opportunities to speak with service users and to observe routines within the home. Some of the home’s required records were examined and a tour of the premises was undertaken. A key theme of the inspection was assessment of how the home meets needs arising from equality and diversity The second day of inspection was pre-arranged to meet with the responsible individual to cover remaining standards and to give feedback to her and the manager on the findings of the visits. Staff and service users are thanked for their co-operation and hospitality during these two visits. What the service does well: There is sufficient information available to prospective service users to help them decide on whether to live at the home. The needs of prospective service users are assessed prior to admission, to ensure that the service does not offer a placement to someone whose needs it cannot meet. Care plans have been produced for all service users, ensuring that needs have been identified and can be met. Service users are enabled to make decisions and be as independent as possible, providing them with choice and involvement. Service users are enabled to take responsible risks, ensuring that their independence is promoted. Service users take part in appropriate activities and make use of the local facilities, providing stimulation and variety. Service users are enabled to keep in contact with friends and family, maintaining important social links. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 6 The rights of the individual are respected, promoting fulfilment and affording service users respect. Personal support needs are recorded in care plans to ensure that service users receive the assistance they require. Needs arising from equality and diversity are well met, ensuring that each persons individual circumstances are taken into account. Physical and emotional health care needs are well managed to ensure that service users keep well. On the whole, competent and qualified staff work at the home, ensuring that service users are cared for by people with the skills and knowledge necessary to meet their needs. The home has qualified persons in charge, to ensure continuity of care and that needs are met. The provider is regularly present at the home, to ensure that standards of care meet the needs of service users. Health and safety is generally well managed, ensuring that staff, service users and visitors are not placed at risk of harm. What has improved since the last inspection? What they could do better: Contracts need to be developed and in place for each service user, to ensure that they know what to expect of the service. Some attention is needed where unusual expenditure is incurred by service users, to ensure that outside parties have agreed to this. A potential risk relating to one service user’s circumstances had not been assessed by the home, which could put others at risk of harm. Meals and the provision of food need to be better managed, to ensure that service users receive the nutrients they require to keep them healthy. Medication practice needs improving to ensure that storage, recording and administration of medicines is safe and consistent. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 7 The complaints procedure needs updating to ensure that people have the correct information. Adult protection requires better management, to reduce the risk of harm to service users. The environment in two of the three houses needs improvement to ensure that service users have well maintained, comfortable and homely surroundings in which to live. Recruitment practices are not robust enough, potentially placing service users at risk from unscrupulous persons working with them. Sufficient training has not been undertaken by all staff, to ensure they are equipped to meet the needs of service users. The whistle blowing policy is to be amended to remove the reference to “the council”, in order that staff are clear of the procedure. The missing person procedure is to be amended to reflect the change of regulator to the Commission for Social Care Inspection, in order that staff are clear who to report missing persons to. 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. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is sufficient information available to prospective service users to help them decide on whether to live at the home. The needs of prospective service users are assessed prior to admission, to ensure that the service does not offer a placement to someone whose needs it cannot meet. Contracts need to be developed and in place for each service user, to ensure that they know what to expect of the service. EVIDENCE: The service users in houses 23 and 25 have lived at Seymour Road for some time. It was possible to see from a couple of examples that pre-admission assessments had been obtained from the local authority Social Services Department which outlined care needs to a sufficient degree. The home had held review meetings at six weeks and then six months intervals and detailed notes were available recording these events. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 10 The home did not have any written records to show that previous admissions had included introductory visits but were advised to do this in respect of the current vacancies at house 21. One service user had been admitted via the local authority under emergency circumstances. The provider has since produced guidelines should they be asked to consider emergencies again. A statement of purpose and service users guide are in place outlining the aims of the home and the scope of its provision. There were no contracts in place between the provider and any of the service users. These need to be in place to set out the terms and conditions by which people are placed at the home. A requirement is made to address this. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans have been produced for all service users, ensuring that needs have been identified and can be met. Service users are enabled to make decisions and be as independent as possible, providing them with choice and involvement. Some attention is needed where unusual expenditure is incurred by service users, to ensure that outside parties have agreed to this. Service users are enabled to take responsible risks, ensuring that their independence is promoted. A potential risk had not been assessed by the home, which could put others at risk of harm. EVIDENCE: Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 12 A written care plan was in place for each service user, outlining background information and their care needs and how these are to be met. Information had been reviewed regularly and any changes noted. Risk assessments were in place which were dated and signed and also showed evidence of being updated. Review meetings chaired by the provider had been well documented with good summaries of the previous year’s health care needs. The only element of care plan folders that was queried was the lack of an assessment for a potential risk associated with one service user’s former contact with the probation service. The home needs to clarify the level of risk with the probation service and then put in place its own risk assessment. A requirement is made to address this. A missing person procedure was in place in the event of anyone being absent from the home. The document referred to notifying the National Care Standards Commission; this needs to be updated to the Commission for Social Care Inspection and a recommendation is made to attend to this. Service user meetings have taken place regularly and minutes reflected discussion on a range of topics, such as the complaints procedure, respect, equality and independence and the fire procedure. Service users have accounts with high street banks/building societies and the home holds a float of money for each person via the Imprest account. Receipts and individual transaction records were in place to explain expenditure and the balance is checked on a regular basis and signed for. The only matter queried was why a service user had been asked to reimburse the cost of damage to a glass panel rather than claiming on the insurance. An agreement had apparently been made by the service user’s care manager and parent that this was acceptable, as the damage was considered wilful. In such cases, the provider is to have a record on file to verify the agreement. A requirement is made to address this. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users take part in appropriate activities and make use of the local facilities, providing stimulation and variety. Service users are enabled to keep in contact with friends and family, maintaining important social links. The rights of the individual are respected, promoting fulfilment and affording service users respect. Meals and the provision of food need to be better managed, to ensure that service users receive the nutrients they require to keep them healthy. EVIDENCE: Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 14 Service users had enjoyed holidays to Bournemouth and Disneyland Paris and there were photographs in lounges capturing some of the moments. Most of the service users met during the inspection were keen to press on with their Christmas shopping and were being enabled to go into Slough on a one to one basis with a member of staff. At other times they attend day services where there is access to college courses, sports and recreational opportunities. One person had previously been employed and wanted to find another job and staff had been assisting with this. Through looking at service users’ finances, receipts showed that they make use of local and town centre shops on a regular basis and are enabled to enjoy indulgences such as coffee and cake when out. Those with spiritual needs are enabled to attend temple. Daily notes contained references to service users being in contact with their families and those met during the inspection confirmed that they see their relatives and some stay with them on occasion. The notes also provided evidence of flexible routines within the home, such as times of getting up and going to bed, meal times and going out, which were also observed during the visits. The menus supplied with the pre-inspection questionnaire reflected some reliance upon processed convenience foods such as hot dogs and meat pies, which was evident when looking in food cupboards. There was a reliance on economy range products, such as beans with sausages, hot dogs, tinned curry, chicken nuggets and meat pies, which caused concern due to the poor nutritional content of such products. There was little by way of fresh vegetables or fruit in the houses which was attributed to the weekly shop being done every Thursday and the situation was improved by the time of the second day of the inspection. The home will need to demonstrate that it is providing service users with a much better diet to ensure that they receive sufficient nutrients to keep them healthy and well and a requirement is made to address this. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal support needs are recorded in care plans to ensure that service users receive the assistance they require. Physical and emotional health care needs are well managed to ensure that service users keep well. Medication practice needs improving to ensure that storage, recording and administration of medicines is safe and consistent. EVIDENCE: Care plans contained details of any assistance required by service users and their health care needs were documented and up-to-date. Files of health care appointments were well maintained with evidence of involvement by other agencies such as community psychiatric resources, occupational therapists, dieticians and the Parkinson’s disease specialist. Appointments for routine health screening such as opticians and dentists were up-to-date and all doctors Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 16 and specialists appointments had been written up to reflect the outcomes. One doctor commented that a service user “has always been brought to the surgery in a timely, well co-ordinated manner. The managers/owners seem to be caring and dedicated. I have not had any concerns about care or the home.” Another doctor commented “very high standards” and a consultant psychiatrist said he was satisfied overall with care at the home, had not received any complaints and indicated that there was a good working relationship with the home and that there were professional standards. One doctor made a comment that staff had been crushing a slow release tablet, defeating its purpose, but has since stopped this practice. A monitored dose system of medication administration is used with storage cabinets in each house. Training records showed that some but not all staff had attended training on the care and control of medicines. Each medication cabinet was locked and not being used for any purpose other than medication storage but not all were securely bolted to the wall. The home must ensure that all medication cabinets are entirely secure by bolting to the wall according to the manufacturer’s instructions and a requirement is made to address this. Medication administration records were looked at and some gaps were evident alongside prescribed dose times. A requirement is made to ensure that accurate records are maintained of medicines given to service users. Where service users are prescribed “as required” medicines, the home had not produced any guidance for staff to ensure that they administer these medicines in a consistent manner and in accordance with the prescriber’s intentions. Individual written protocols need to be written for the “as required” medicines in use at the home, other than simple pain relief, and a requirement is made to address this. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place to listen to the views of service users and their representatives and needs updating to ensure that people have the correct information. Adult protection requires better management, to reduce the risk of harm to service users. EVIDENCE: A complaints procedure was in place although it was out of date and made reference to the Inspection Unit with old contact details. This needs to be updated to ensure that service users and their representatives have correct information to hand and a requirement is made to address this. The home’s complaints log did not contain any fresh complaints although staff had recorded incidents between service users such as fights and disagreements. The Commission is not aware of any complaints by service users or their representatives regarding this service. The home had a copy of the local inter-agency adult protection guidelines and most staff had attended Protection of Vulnerable Adults training, with the responsible individual being a certificated trainer. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 18 However, the home’s own adult protection policy was insufficient and contained no details of what abuse is, the different forms of abuse, indicators and prevention of abuse, what makes people vulnerable in care settings and staff responsibilities to safeguard and report. A requirement is made to address this to ensure that sufficient safeguards are in place. It is recommended that a service user friendly poster style version is then produced and discussed with service users, to increase their awareness. The home’s whistle blowing policy had been adapted from a local authority policy and still contained reference to “the council” which could confuse staff. This needs to be amended and a recommendation is made to attend to this. The Commission is not aware of any adult protection concerns regarding this service and none were indicated in the pre-inspection questionnaire. However, the service is placing service users at significant risk of harm through its recruitment procedure which is not compliant with the regulations. Details of this are under the section looking at staffing. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment in two of the three houses needs improvement to ensure that service users have well maintained, comfortable and homely surroundings in which to live. EVIDENCE: On a positive note, all bedrooms at the home are single and service users have been encouraged to personalise their rooms and make them as homely as possible. Where they wish, service users were keeping their rooms locked when out and one person had been enabled to bring his fish tank with him. Toilets all had soap, towels and toilet roll in place and standards of general cleanliness were good. Cleaning products which could cause harm were kept locked away. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 20 Each house blends in with other properties in the road and is indistinguishable as a care home to passers by. House number 21 is fresh, bright and with new furniture, waiting for vacancies to be filled. Houses 23 and 25 are in contrast to this, needing redecoration throughout to freshen up paintwork and conceal old water stains on some of the ceilings. Carpets in parts of the houses were stained and need to be shampooed or replaced if the stains are permanent. Staff were not turning lights on when it became gloomy mid afternoon and a radiator in the downstairs bedroom in house 25 did not have a cover fitted to it and was too hot to endure when touched. There was also no light switch or bedside lamp that the service user could reach from bed in this room, which meant that the person would need to get up and get in to bed in the dark, presenting a hazard to someone with poor mobility. The downstairs shower in house 23 needs some attention. Sealant is needed to the length of the corner junction where the tiles meet, to prevent water seeping behind the tiles and causing damage to the wall. The shower cubicle was stained where it is fixed in and needs to be re-sealed or grouted, whichever the material is. Outside, there are good sized gardens which need to be tidied up and made attractive for service users to use come the spring and summer. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. On the whole, competent and qualified staff work at the home, ensuring that service users are cared for by people with the skills and knowledge necessary to meet their needs. Recruitment practices are not robust enough, potentially placing service users at risk from unscrupulous persons working with them. Sufficient training has not been undertaken by all staff, to ensure they are equipped to meet the needs of service users. EVIDENCE: The home has a flexible rota with staff working across each of the houses. No agency staff were being used and most hours were filled with just one post being recruited against at the time of the visits. There were no current night time care needs identified in either house and the provision of a member of staff sleeping in at each house seemed appropriate and day time care needs were being met with current levels of cover. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 22 Staff were friendly and had gentle interaction with service users and had good understanding of care needs. Uptake of National Vocational Qualification was good at the home with six staff already possessing level 2, a further two with submitted portfolios at level 2, two further staff undertaking level 2, two doing level 4 and both the manager and responsible individual with level 4. Records showed that staff meetings are held on a regular basis with reminders about confidentiality, adult protection, healthy eating, promoting health and safety and personal presentation of service users amongst matters noted in the minutes. Staff had been asked to sign the minutes to show that they have read them. Recruitment practice was of concern. The files of four staff who started in 2006 were examined. One person has since left the service. In the first file, a gap of just over a year was evident on the work history, which had not been explored. A Criminal Records Bureau disclosure had been applied for but there was no Protection of Vulnerable Adults first check as a minimum safeguard whilst the disclosure was awaited. There was also no copy of a work permit on the file. This member of staff was working alone on shifts without the full range of checks being in place. The second file had most checks in place, including Protection of Vulnerable Adults first and Criminal Records Bureau disclosure, but there was no evidence of the student visa that would entitle the person to work up to twenty hours per week. In the third and fourth files, all required checks were in place. A requirement is made to ensure that all recruitment checks are carried out on a consistent basis, to ensure that service users are adequately protected from the risk of harm by unscrupulous persons. Training records presented a mixed picture but not one of the files examined showed the full range of mandatory courses had been undertaken and was upto-date. One file showed a good range of course attended and mandatory training up-to-date for all areas other than manual handling. In another, the person had only attended Protection of Vulnerable Adults training yet was working alone in the home. A third person needed updating in manual handling and some input on Protection of Vulnerable Adults although some elements of this had been covered as part of National Vocational Qualification level 2. The manager and responsible individual need to ensure that all staff are kept updated on mandatory courses and that staff have the necessary training before being left alone in the home. A requirement is made to attend to this. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has qualified persons in charge, to ensure continuity of care and that needs are met. The provider is regularly present at the home, to ensure that standards of care meet the needs of service users. Health and safety is generally well managed, ensuring that staff, service users and visitors are not placed at risk of harm. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager and responsible individual both have the Registered Managers Award and are registered with the Commission. Both work at the home regularly and have contact with service users, relatives and staff and have good understanding of care needs. A quality assurances exercise had been carried out in the summer with questionnaires sent to service users, families and outside agencies. Positive comments were expressed from some of the relatives, a representative from Mencap and the Skills for Care assessor at the home. Service users were generally happy with care and some of the things they raised were outside of the control of the home, such as wishing to see relatives more often. A range of health and safety checks is undertaken across the premises. Portable electrical appliances had been checked in August this year. Gas safety certificates were in place and a certificate of satisfactory electrical installation was in place for house 21. The home did not have evidence of satisfactory electrical installation for the other two houses and a requirement is made to address this. Fire logs showed that smoke detectors are checked weekly and drills conducted on a regular basis. Hot water temperatures and fridge and freezer temperatures are checked regularly and records did not reveal any concerns. A senior environmental health officer visited the premises in August this year and stated, “good health and safety practices and procedures were in place. Although you need to produce a generic risk assessment for the whole premises. Satisfactory specific risk assessments were in place and being implemented.” The generic risk assessment had been written and a fire based assessment was in place. Accident records were completed where injuries had been sustained, with remedial action taken where necessary. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 2 X Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 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 YA5 Regulation 10(1) Timescale for action Contracts setting out the terms 01/03/07 and conditions of placements are to be written and in place for all service users. Written verification is needed 01/03/07 where external parties agree to a service user reimbursing the home for the cost of damage to property. A risk assessment is needed in 01/03/07 respect of the risk associated with one service user’s previous contact with the probation service. Service users are to be provided 01/03/07 with nutritious meals through use of good quality products and improved use of fruit and vegetables. Accurate records are to be 01/03/07 maintained of medication administered to service users. Medication cabinets are to be 01/03/07 securely bolted to the wall, in accordance with the manufacturer’s instructions. Individual written protocols are 01/03/07 to be written on the use of each “as required” medicine, other than simple pain relief. DS0000067341.V317421.R01.S.doc Version 5.2 Page 27 Requirement 2 YA7 13(6) 3 YA9 13(4) 4 YA17 16(2)i 5 6 YA20 YA20 13(2) 13(2) 7 YA20 13(2) Seymour House 8 YA22 22(7) 9 YA23 13(6) 10 11 12 13 YA24 YA24 YA24 YA24 23(2)d 23(2)d 13(4) 13(4) 14 15 16 17 YA24 YA24 YA24 YA34 23(2)b 23(2)p 232b 13(6) 19(1) The complaints procedure is to be updated with the correct name and contact details of the regulatory body. A detailed adult protection policy is to be written to indicate what abuse is, the different forms, indicators and prevention, what makes people vulnerable and staff responsibilities to safeguard and report. A programme of redecoration is needed in houses 23 and 25. Carpets are to be shampooed or replaced where stains are permanent. A cover is to be fitted to the radiator in the downstairs bedroom in house 25. A light that can be reached when the service user is in bed is to be fitted or provided in the downstairs bedroom in house 25. The shower cubicle and tiling are to be re-sealed in the downstairs shower in house 23. The premises are to be properly illuminated at all times when daylight is poor. The gardens are to be tidied and made safe for service users. The full range of recruitment checks is to be undertaken in all instances before staff start work. Evidence of work permits are to be provided, where applicable, and gaps to work history explored and documented. No staff are to commence work without a POVAfirst check in place, then only under the supervision at all times of a person who has a satisfactory Criminal Records Bureau disclosure until the full disclosure is returned. 01/03/07 01/04/07 01/08/07 01/04/07 01/02/07 01/02/07 01/03/07 01/02/07 15/04/07 01/02/07 Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 28 18 19 YA35 YA35 YA35 18(1)c(i) 18(1)c(i) 20 YA42 23(2)b Mandatory training is to be 01/04/07 brought up-to-date or attended for the first time. Staff are not to be left in charge 01/03/07 of the home without the necessary induction/mandatory training in place. A certificate of satisfactory 01/04/07 electrical installation is needed for houses 23 and 25. 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 2 3 Refer to Standard YA9 YA23 YA23 Good Practice Recommendations The missing person procedure is to be amended to reflect the change of regulator to the Commission for Social Care Inspection. The whistle blowing policy is to be amended to remove the reference to “the council”. A service user friendly version of the adult protection policy is to be produced and discussed with service users to increase awareness. Seymour House DS0000067341.V317421.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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