CARE HOMES FOR OLDER PEOPLE
Seymour House 13-17 Rectory Road Rickmansworth Hertfordshire WD3 1FH Lead Inspector
Mrs Alison Butler Unannounced Inspection 4th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Seymour House Address 13-17 Rectory Road Rickmansworth Hertfordshire WD3 1FH 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) 01923 778 788 Mr M Rhemtulla Miss Yasmin Rhemtulla Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. This home may accommodate one (named) female service user currently 59 years old. The manager must inform the CSCI when the above (named) service user leaves the home or reaches the age of 65, whichever comes first. This variation applies only to this (named) lady and ceases to be in force when the lady leaves the home or reaches 65, whichever comes first. 5th September 2005 Date of last inspection Brief Description of the Service: Seymour House is a care home providing personal care and accommodation for 38 older people. A variation to the registration allows the home to accommodate one service user who is below the age of 65. It is privately owned by Mr M Rhemtulla and Miss Y Rhemtulla. The home is located close to the centre of Rickmansworth, within walking distance of the shops, post office and other community facilities. It was opened in 1997 and consists of a purpose built three-storey building. All the home’s bedrooms are single and all have en-suite facilities. There are two passenger lifts. The home has a small garden and paved patio that are well maintained and accessible. Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and early afternoon. It was conducted with the manager, deputy, staff and residents in the home. The inspection concentrated on the requirements and recommendations and the core standards that were not covered during the last unannounced inspection. Where the standards remain the same the information has been brought forward. What the service does well: What has improved since the last inspection?
The manager has updated the Statement of Purpose and a copy is to be sent to the Commission For Social Care Inspection. Residents meetings have commenced, one of these discussed the menu choice and brief minutes were taken. The complaints procedure has been updated although this was not on display within the home. The manager has conducted in house training an adult protection and the inspector gave details of further training available. The main corridor carpets to one side of the building have been professionally clean and the other side are due to be done. Plans are in place for the replacement of carpets and redecoration these are to be forwarded to the Commission For Social Care Inspection.
Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 6 Crockery that was chipped has been replaced and the cook has enrolled on a course to complete her food hygiene certificate and she is due to finish at the end of February 2006. The manager stated that a fire risk assessment had been completed and was being bound at the time of this inspection a copy will be forwarded to the Commission For Social Care 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. Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 A comprehensive Statement of Purpose is in place to provide residents with information to make an informed choice. A service users guide has yet to be completed with all the required information. A full assessment is carried out prior to admission to ensure they are able to meet the resident’s needs. EVIDENCE: The Statement of Purpose has been updated to include all the information and a copy is to be forwarded to the Commission For Social Care Inspection office. A discussion took place with the manager regarding the information that is required within the service users guide as stated under regulation 5 of the Care Home Regulations 2001 and a copy will be forwarded to the Commission For Social Care Inspection once this has been completed. The manager carried out a pre-admission assessment during the inspection and the residents had been to visit the home prior to today. This is carried out as per the company’s admissions and referral procedure.
Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 9 The initial admission is on a trial period for a mutual agreed length of time, which can be extended if necessary. This allows the staff ample opportunity to further assess the resident’s needs and to formulate a care plan. Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 The quality of information recorded is good. Residents receive a good quality of care and are supported by knowledgeable and experienced staff. EVIDENCE: Care plans were generated from the pre-admission assessment, and provide the basis of the care to be given. The care plans detail specific actions to be taken by staff to ensure all aspects of the resident’s personal, health and social care needs are met. Care plans are reviewed periodically to ensure monitoring and changing needs are addressed. All residents spoken to during the inspection appeared well kempt and were very happy with the care they received, they stated, “They are lovely girls”. All necessary equipment is provided within the home to meet the resident’s needs. The home uses the NOMAD system for medication. On examination of the medication it was found to be well kept and no errors were found. No liquid medication, controlled drugs or individual boxes were being stored at the time
Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 11 of this inspection. No residents were self-medicating. It is recommended that a thermometer be purchased to ensure the temperature within the medication storage room is kept below 25°C and a further compressed gas sign is obtained for the medication room as an additional oxygen bottle was being stored. Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Autonomy and choice is promoted within the home. Visitors are welcomed and contact is maintained with the local community. EVIDENCE: All residents are actively encouraged to maintain positive links with family, friends and representatives. Feedback from the residents regarding the food provided at Seymour House was very complimentary, although on the day of the inspection nobody could remember what was on the menu for the day. Boards were available for the menu to be written on but these were not being used on the day. The manager stated she would ensure that staff remember to use them in the future. The menus had been discussed at one of the recent residents meetings. The staff should look at ensuring this is a regular item on the agenda to demonstrate and encourage choice for the residents. Residents confirmed they are supported with their daily routines as appropriate. One resident felt they were treated with respect and staff are kind and caring. Good interaction was observed between staff and residents. Residents have access to all parts of the home and grounds. Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 13 Residents meetings have taken place since the last inspection and it is recommended that the minutes are made available to the residents. It was suggested that they might like to provide further meetings/ 1-1 sessions for those residents who need extra support to ensure their views are sought or any issues raised. Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Policies and procedures are in place to ensure the protection of the residents A complaints procedure is in place although this is not displayed within the home. EVIDENCE: The complaints procedure is available within the updated Statement of Purpose. This should be displayed within the home to promote an active, transparent approach to the management of complaints. A central recording system is held within the home. The manager has carried out some training with staff on the adults at risk procedure. The inspector passed on details of further training opportunities for staff to attend. All staff are subject to an Enhanced Criminal Records Bureau check prior to commencing their employment at Seymour House. Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home is clean and is reasonably maintained although some renewals and redecoration is required to ensure it maintains its homely, comfortable and safe environment for the residents and maintain compliance with the relevant legislation. Appropriate hand washing facilities must be available in all bathrooms and toilets to prevent the spread of infection. EVIDENCE: The home was clean to a high standard. A number of areas have been highlighted for redecoration and carpet replacement. A plan has yet to be developed although the deadline has yet to be reached this will be brought forward and a copy of the plan will be forwarded to the Commission For Social Care Inspection. The manager stated that a professional carpet cleaner had been brought in to carry out the main corridors to one side of the home and would be carrying out further cleaning on the other side of the home. The home offers suitable light, heat and ventilation.
Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 16 A number of bathrooms and toilets contained bars of soap and towels; the manager must ensure that liquid soap and soft disposable towels are available to provide adequate hand washing facilities to prevent the spread of infection Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 The procedures for the recruitment of staff are robust and offer protection to the people living in the home. The numbers of staff and their deployment are sufficient to meet the personal care needs of the residents. EVIDENCE: From the two files examined all the relevant checks had been carried out prior to them commencing employment which ensures the protection of the residents. Examination of the rotas showed adequate numbers of staff were deployed to meet the personal care needs of the residents at the time of this inspection. Residents spoken to say that the staff were “kind, caring and gentle”. Residents were actively encouraged to maintain their independence where possible. Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, & 38 The management within the home is secure and effective ensuring that the needs of the residents are met and the home is meeting its aims and objectives. Some work is still required to ensure that the health welfare and safety is maintained within the home. EVIDENCE: Feedback from the residents showed that the management and the ethos of the home is open and transparent. There was a clear sense of direction and leadership which both the residents and staff are able to understand. The residents benefit from this well structured and well run home. There is a need to ensure that a quality assurance report is made available to all interested parties and the Commission For Social Care Inspection receives a
Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 19 copy. This report should include an action plan in order to make the necessary changes from the feedback received. A discussion took place between the manager and the inspector at looking at ways of receiving feedback from residents, visitors and other professionals in line with regulation 24 of the Care Home Regulations 2001. The cook has enrolled on a Food Hygiene Course and is due to complete this in February 2006. All chipped crockery has been replaced this promotes good infection control management. A copy of the fire risk assessment is to be forwarded to the Commission For Social Care Inspection, as this was not available at this inspection although the manager confirmed this had been completed but was being bound. A sign was in situ on the resident’s room door that requires oxygen. An additional sign must be purchased for the medication room where additional supplies are stored. Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 2 Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP17 Regulation 22 Requirement The complaints procedure must be displayed within the home. Timescale for action 04/01/06 This has been brought forward from the previous inspection 8. OP19 23 (2) (d) The home must complete a 01/04/06 detailed redecoration and renewal programme to ensure a minimum standard internal and external decoration is maintained. Foyer and malodours carpets to be replaced. A copy is to be forwarded to the Commission For Social Care Inspection. This has
been brought forward from the previous inspection as the timescale has not yet expired 3 OP33 24 9. OP38 13(3)&(4) The manager must ensure that a quality assurance system is set up to consult with the residents, families and other professionals and produce a report and action plan with the findings The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff.
DS0000019520.V272912.R01.S.doc 31/03/06 31/01/06 Seymour House Version 5.0 Page 22 A detailed premises fire risk assessment to be completed and forwarded to the Commission For Social Care Inspection. The cook to complete food hygiene by end of February 2006. Compressed gas sign to be erected on the medication room where it is stored.
This has been brought forward from the previous inspection Appropriate hand washing facilities must be available in all toilets and bathrooms to prevent the spread of infection. 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 Refer to Standard OP9 OP14 Good Practice Recommendations The manager should purchase a thermometer to ensure that the medication room remains below 25°C. The minutes of resident’s minutes should be made available to the residents. The manager should consider further meetings and/or 1-1 sessions to provide additional support to those requiring it and ensure there views are heard. The whiteboards should be used to display the menu of the day to keep the residents informed. 3 OP15 Seymour House DS0000019520.V272912.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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