Inspection on 05/06/07 for Seymour House

This inspection was carried out on 5th June 2007.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Seymour House 13/12/06

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 SL1 2NS Lead Inspector Sally Newman Unannounced Inspection 5th June 2007 10:25 Seymour House DS0000067341.V338389.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.V338389.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.V338389.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seymour House Address 21, 23, 25 Seymour Road Slough Berkshire SL1 2NS 01753 820731 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) seymourhouses@hotmail.com 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.V338389.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 13th December 2006 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. 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 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. The home has a statement of purpose and service users guide to inform prospective service users about the provision and scope of the home. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection conducted over the course of three days and included a visit to the service of 4 ½ hours duration. Information was provided by the service prior to the visit. Discussions were held with the manager and staff and five service uses were spoken to. A tour of the premises was undertaken and a range of records was seen. Surveys were sent to the service for them to distribute prior to the visit. At the time of writing this report six completed service user surveys had been returned and one from a relative of a service user. The results of these surveys have been incorporated into the findings of this report. Large-scale renovation work was being undertaken in number 23 at the time of the visit to the service. As a result service users normally resident in number 23 had moved temporarily into number 21. Once the work at number 23 was completed there were plans to carry out similar renovation work to number 25 during which those service users would move temporarily into number 21. At the last inspection a range of requirements had been made. It was evident from the outcome of this inspection that all previous requirements had been met. One requirement has been made in respect of fire safety. The Commission has not received any complaints about this service since the last inspection. The provider has a range of polices and procedures relating to equality and diversity. Care plans have been designed to take account of individual needs and cultural and religious choices. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service that meets the needs of individuals of various religious, racial or cultural needs. What the service does well: Provides a good standard of care to service users. Regular reviews ensure that service users needs are being met. Service users are encouraged and supported to make choices and decisions for themselves. Service users are fully involved with the running of the service. Service users are supported to maintain contact with relatives and friends. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users would have their needs appropriately assessed. EVIDENCE: No new service users have moved into the home since the last inspection. Evidence held by the Commission about the service indicated that any prospective new service user would have their needs and aspirations fully assessed prior to a place being offered to ensure that the service could meet their needs. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflected the changing needs and personal goals of service users. Service users are encouraged to make decisions about their lives and to take risks as part of furthering their independence. EVIDENCE: Evidence was obtained from care plans, talking to service users and management and from information provided by the service prior to the visit. Care plans were comprehensive and contained relevant and up to date information. Changes to needs are clearly documented and individual daily diaries contained detailed information about the service users’ mood and activities. It was suggested that short monthly summaries be incorporated to make the collation of information for annual reviews easier. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 10 The service is in the process of introducing person centred planning which identifies needs from a service user perspective. An annual review was being held for one service user during the course of the visit. This service user informed the inspector that his review had been very good and it was clear that he had participated in and enjoyed the process. In discussion with two service users it was evident that they were able to make decisions for themselves. One advised that he had decided to go into town later in the morning the other indicated that he preferred his own company and did not like to go out much. Without prompting both service users offered to show the inspector their bedrooms. They each held a key to their rooms and were clearly proud of their personal space and their possessions. From information provided by the service and in discussion with management it was evident that the decisions of service users are taken seriously and support is provided to enable service users to achieve their goals. An example was provided where a service user was working voluntarily but wanted to change their job. The service recognised that this was a specialist area and had supported the individual to engage with and seek assistance from employment agencies such as the Jobcentre. Risk taking is embraced as a natural step towards independence and continued development. Individual risks have been identified and documented. It was noted that two formats for recording risks was being used. Management agreed that one format was clearer in respect of the layout and review process and would implement this format across the service. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 11 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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to participate in activities both in the home and in the wider community. Appropriate relationships are supported and service users’ rights and responsibilities are promoted. The food provided is generally healthy and is chosen and enjoyed by service users. EVIDENCE: All service users are able and are supported to participate in a range of activities according to their needs, preferences and wishes. Activities include day centre attendance, voluntary work, shopping trips, social clubs, spiritual places of worship and annual holidays. The service has plans in the garden area to build a room that could be used to provide activities for those service users who are either unable or unwilling to access external facilities. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 12 A record of all activities undertaken by individual service users is maintained as part of their care plan. Service users spoken to were happy to recall memories from previous holidays and were enthusiastic about this years planned holiday to Butlins. One service user was being assisted by staff to watch a video he had obtained from the local library. The service user indicated that this was a regular activity he enjoyed and he liked choosing different films to watch. Service users are supported to maintain important relationships with friends and families. Service users spoke of relatives they visit and there was evidence of family occasions such as weddings in the form of photographs in individual bedrooms. Care plans contain details of important contacts with addresses and phone numbers. Daily routines are flexible with bedtimes and mealtimes arranged to meet individual needs and timetables. Service users are encouraged to take responsibility for daily household tasks and as previously mentioned hold keys to their rooms where able and want to. Healthy eating is promoted and is balanced with individual choices, which in them selves are not always healthy. A food folder has been introduced which contains a range of healthy recipes. Staff are encouraged to discuss meal options with service users on a daily basis and to make healthy choices. There are some service users whose food preferences are limited and lacking in nutritional value. It was evident in discussion with management that the service strives to balance these choices with healthy additions. One example provided concerned an individual who loved a particular type of tinned meat. This choice was acknowledged but was served with freshly prepared vegetables to provide balance. Records confirmed that fridge and freezer temperature checks are undertaken and food is temperature probed regularly before serving. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 13 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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support provided to service users meets their preferences and their physical and emotional needs are well met. The arrangements for medication are robust and protect service users. EVIDENCE: The personal support needs and associated risks are recorded in individual care plans and are updated regularly to take account of changes. Within the framework of the staff rota service users are able to choose which staff support them. There was evidence within care plans that individuals were referred to specialist such as Occupational Therapists and Physiotherapists where required. Due to the low number of staff there is not a dedicated key worker system operating in the home. However, the communication systems such as regular staff meetings, handovers and record books ensure that all staff are aware of changing needs. The service does not employ agency staff because it upsets service users. Therefore, absences are covered by the existing staff team or regular bank staff to ensure the consistency of support for service users. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 14 The health care needs of service users are monitored closely. It was evident from discussion with members of the management team that the health and emotional care needs of service users is well understood. Care plans contain details of appointments with health care professionals and the advice provided. There was evidence from care plans and in discussion that the home regularly accesses the services of General Practitioners, Dentists, Opticians, Psychiatrists, Chiropodists and Psychologists according to individual needs. The home uses the Boots monitored dosage system. All new staff are provided with training by the manager before they can undertake the administration of medication. Currently no Pharmacist visits the home to review the medication arrangements. Advice was given to explore with boots whether this could be arranged. One set of administration records was seen and was found to be up to date with no omissions. A previous requirement to provide individual written protocols for medication prescribed on an “as required” basis has been partially implemented. However, further advice was given to implement detailed individual circumstances to guide staff when administration of these medications is being considered. The service has identified that it could improve the system by implementing a regular review of the quality of the medication arrangements which would include refresher training for staff. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 15 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views are listened to and concerns are acted upon without delay. Service users are protected from abuse, neglect and self-harm. EVIDENCE: Evidence was obtained from records, information provided by the service, discussion with service users and management. There have been no complaints made about the service either directly to the service or to the Commission since the last inspection. Concerns are taken seriously and any issues raised by service users are recorded in daily records with the action taken. There are regular service user meetings where they are encouraged to voice their views and opinions. There are clear complaints procedures and the service has plans to introduce a more user-friendly format such as audio to enhance service users access to the material. All staff receive in house protection of vulnerable adults training from a designated manager. Staff are then expected to attend training provided by the local authority as soon as it can be accessed. The adult protection policy has been updated and includes more detail to ensure that all staff are aware of their responsibilities in safeguarding vulnerable people. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 16 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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from houses that are domestic in scale and homely and will be improved overall with the completion of building work. EVIDENCE: A tour of numbers 21 and 25 was undertaken. As previously stated number 23 was undergoing extensive refurbishment and was not fully accessible. The décor and furnishings including floor coverings in number 25 were well used. There was staining on carpets and walls. This house will be refurbished in line with number 23 when the work is completed. The rating for this outcome area reflects the ongoing work and it is anticipated improvements will be in evidence at the next scheduled inspection. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 17 Number 21 was freshly decorated and furnishings were of a good standard. It was noted that a door-closing device had been removed from a fire door and another fire door could swing freely open. It will be a requirement that the service consults with the local Fire Authority to ensure compliance with the fire safety regulations. A maintenance log is maintained for the service that records identified issues and repairs. These are signed off once the work is completed. There are cleaning rotas for staff to ensure that essential cleaning duties are undertaken. There are policies and procedures in place in respect of the control of infection. Machines for laundry are of an industrial standard. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 18 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 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by staff that are competent and qualified. Service users are protected by the home’s recruitment practices. EVIDENCE: The service understands the value of competent and dedicated care staff. Management are aware of utilising individual skills and supporting staff with areas of weakness. Four staff have completed NVQ training. All staff receive two monthly supervision which is recorded. The manager will consider attending a supervisors’ course if able to access training from the Local Authority. One of the managers is trained to deliver training in Manual Handling and Protection of Vulnerable adults. In addition, she trains all new staff in fire safety and medication but then accesses external training for staff when available. All staff have an individual training profile. It is now the responsibility of one member of staff to maintain staff training records to ensure that updates are booked as and when required. A plan to identify individual staff strengths in Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 19 order to support less experienced staff members is in the process of implementation. Three staff records were seen. The three staff had been recruited since the last inspection. All required documentation was in place. It was noted that interview records are maintained. The service does not routinely request confirmation from previous employers of their status by providing company stamps or headed paper. The manager undertook to implement this request and obtain authentication of professional references wherever possible. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 20 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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed home and their views influence the running of the service. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The home is managed on a daily basis by individuals who are qualified to NVQ level 4 standard and have obtained the Registered Managers Award. One manager is undertaking a degree in Learning Disability Studies. The managers are hands on and understand the needs of service users well. Managers ensure that the service is compliant with relevant legislation including health and safety matters and adheres to the organisations policies and procedures. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 21 Advice was given to ensure that all policies and procedures are dated and signed. Service users views are obtained through informal discussion, through the formal review process and from regular service user meetings. An annual quality assurance audit is undertaken by the service when surveys are sent to all stakeholders including relatives, health care professionals and local authority representatives. The results of these surveys have informed the service on where to make improvements and when the service is doing well. This positive feedback has been welcomed by staff who have been motivated to continue providing a good level of service-to-service users. A range of health and safety checks are undertaken in the home. Hot water outlets are checked regularly. Advice was given to include showers in checks. The fire warning systems are checked regularly and records are maintained. Fire drills are held approximately two monthly although they do not include the full range of staff. Advice was given to include all staff in fire drills to ensure that everyone is familiar with the practice. Staff are trained in general health and safety areas such as manual handling, food hygiene and control of infection. There are general risk assessments in place together with a fire risk assessment for the buildings. Accidents are recorded and are low in number. Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 YA24 Regulation 23 Timescale for action To consult with the Fire Authority 30/06/07 for advice with regard to the fire safety arrangements in the home. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Seymour House DS0000067341.V338389.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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