Inspection on 08/01/08 for Seymour House

This inspection was carried out on 8th January 2008.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Seymour House 07/01/09

Seymour House 17/09/07

Seymour House 17/05/06

Seymour House 04/01/06

Seymour House 05/09/05

Seymour House 11/01/05

Seymour House 24/08/04

Seymour House 17/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Seymour House 13-17 Rectory Road Rickmansworth Hertfordshire WD3 1FH Lead Inspector Jeffrey Orange Unannounced Inspection 8th January 2008 08:15 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.V357317.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 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.V357317.R01.S.doc Version 5.2 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 Ms Yasmin Rhemtulla Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Old age, registration, with number not falling within any other category (38) of places Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 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. 17th September 2007 Date of last inspection Brief Description of the Service: Seymour House is a care home providing personal care and accommodation for 38 older people who may also require dementia care. The home was opened in 1997 and consists of a purpose built three-storey building. All the bedrooms are single and have toilet and wash hand basins en suite. There are two passenger lifts to access all floors. The home has a small garden and paved patio accessible to people living in the home. The home is located close to the centre of Rickmansworth, within walking distance of shops, the post office and other community facilities. There is parking available to the rear of the home and the home is also readily accessible by public transport. Copies of the latest inspection report from the Commission for Social care Inspection (CSCI) are available in the home together with a service user’s guide. The current weekly placement fee for each service user is between £407 and £470 (due to be reviewed in April 2008). Additional charges apply for newspapers, personal toiletries and hairdressing and also for chiropody, opticians and dentistry services where people living in the home do not qualify for free treatment under the NHS. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means people who use the service experience adequate outcomes. This was an unannounced inspection and included a CSCI pharmacist inspector. The last key inspection for this service was conducted on the 17 September 2007. The September inspection identified some concerns regarding medication practices and a pharmacist inspection was commissioned and took place on the 4 December 2007. Progress against the requirements made in the previous key and pharmacist inspection was monitored at this inspection. In addition to the CSCI link inspector for the home and the CSCI pharmacist inspector this inspection also included an ‘Expert by Experience’. Experts by Experience are people whose knowledge about social care services comes directly from using services and who, because of this, some people living in a care service may feel more relaxed speaking to than to an ‘inspector’. In the absence of the registered manager, the deputy manager assisted us, and thanks are due to her and her staff team for their patience and cooperation throughout. The inspection started shortly after 8 am and continued through to the early afternoon, which provided an opportunity to observe the early morning and lunchtime routines of the home. As well as looking at some key records and speaking to members of the staff team, time was taken to speak to people living in the home and to people visiting the home. This report also draws on information provided by the provider in the form of the completed Annual Quality Assurance Assessment (AQAA), which is a selfassessment tool that the service is required by law to complete, information received directly from people living in the home through surveys that were received during the period October to December 2007 as well as information obtained during the two previous inspections by the CSCI in September and December 2007 when that remains significant and relevant. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 6 What the service does well: 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 Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 8 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.V357317.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3 (Standard 6 does not apply to Seymour House) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that they will be appropriately assessed and therefore only be admitted to Seymour House if their care needs can be appropriately met there. EVIDENCE: The pre-admission assessment for a person recently admitted to Seymour House was seen and included the information needed to enable staff to identify and meet their care needs satisfactorily. One survey returned included the comment ‘ my daughter visited the home and was given a guided tour and shown the bedroom, lounges and received all the information about the care available. I then received a home visit to discuss my needs’. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 10 People living in the home and those responsible for them confirmed that their care needs were being well met. “I am very well looked after” was one, typical comment. The home’s Service User Guide needs updating as it included some out of date information and some conflicting details of current fee levels. This may leave people researching the information to decide whether or not to use Seymour House confused over the services provided. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using this service can be assured that they will be treated with respect and dignity. However, they are put at risk from the inappropriate management of the administration of medication. EVIDENCE: A specialist pharmacist inspector examined practices and procedures for the safe handling, use and recording of medicines. The storage facilities provided for most medicines are satisfactory and secure. The temperature is recorded regularly and is satisfactory so medicines are stored in a way that maintains their quality for residents. The inspection in September 2007 identified that there was not a controlled drugs cabinet in place. This had been addressed by the time of the pharmacist inspection in December. However, at that inspection it needed to be correctly Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 12 secured to a solid wall. The cupboard used to store controlled drugs was still not fixed in way that complied with the Misuse of Drugs (Safe Custody) Regulations 1973 (as amended) as it was screwed to the wall rather than bolted. An explanation of the correct type of fixing was given to the deputy manager and the handyman at this inspection. The provider has, since the inspection, reported that the cabinet is appropriately fixed to the wall. The way that controlled drugs are recorded also still does not comply with the Regulations as the records are kept in a loose-leaf folder rather than a bound book with numbered pages. A requirement was made following the December inspection with a timescale for compliance of 31 December 2007. The deputy manager informed the inspector that a book was on order. It is good practice to record Tamazepam in a controlled drugs register. Where a controlled drugs register is used this must meet the required standard. The AQAA completed by the provider shows that the provider has some misunderstanding about controlled drugs as they have indicated on some questions that they are not applicable to their service when in fact the questions are applicable and the response from a care home must always be either yes or no. There are good records made of when medicines are received into the home but the records of when medicines are given to residents showed a high number of gaps giving no indication of whether medicines have been administered or reasons why not. This may leave people at significant risk. The Nomad Cassettes used for the medicines are not permanently labelled with the names of the medicines they contain or the instruction for use. So there is a risk that the wrong medication could be given. We were informed that this had been discussed with the supplying pharmacist and would be addressed by the end of January. Some of the instructions for medicines on the Nomad Cassettes are different to the instruction for medicines on the printed form provided by the supplying pharmacist. This could mean that residents are given the wrong dose of medicine. Some residents hold their medicines in their own rooms but these are not listed on their medication record, a record is not always clearly made that they have been given the medicine and there is no documented assessment of the risks to themselves or other people in the home. The medicines round was observed and the member of the care staff who was giving medicines to residents left all the medication unattended on an open trolley when assisting residents in a different part of the lounge to take their medicines. This increases the risk that medicines may be taken by a person they were not prescribed for. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 13 An empty pack of ‘Lemsip’ Cold & Flu remedy was found in one of the residents’ lounges but there was no record of this being received into the home, who it was for, or who had taken the medication. This was discussed with the deputy manager who stated that it was a member of staffs. However, this is a concern that it was in a communal lounge and could have been taken by a service user. There is currently no written procedure for the use of home remedies. The deputy manager stated, “we do not really use these”. Taking homely remedies could adversely affect the wellbeing of people taking them if no record is kept of what was taken and if guidance regarding any adverse reactions with other prescribed medication is not sought. At the last inspection on the 4 December 2007 it was noted that training in the administration of medication was based on in-house information on the system and giving and receiving medication. Medication practices observed during this inspection raised concerns about the level of training and competency. A member of staff told us that they had once received training from an external source. Training records were not inspected on this occasion, as the timescale for the requirement made following the December inspection had not expired. Certificates to confirm medication training completed prior to this inspection have been submitted by the provider since the inspection for 5 members of staff. At the last inspection in September we reported that the care plans contained basic details of healthcare needs and how these were to be met. The format of the care plans had not been recently evaluated to take account of potential improvements that could be made to them. During this inspection we were informed that no further work had been undertaken on the care plans, therefore we did not look at care plans during this inspection. It is understood that work has started to look at an improved system of care planning for people living in the home; but this is not yet in place. The inspector observed 3 care staff in the lounge at 11:30 am and noted that the interaction was excellent; there was appropriate physical contact with handholding and staff stroking the hands of the people with dementia. People we saw were clean, and well presented with good attention paid to their personal care. Responses received from the service user surveys showed that five (5) people felt that they always receive the care and support they need and that three (3) people felt that they usually did. People living in the home have access to the healthcare services they need in the home and in the community, and are treated with respect and their right to privacy is generally well respected. One survey returned included the comments ‘when I have not been well the staff have been able to attend to my Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 14 needs and if not have called the GP. They have advised my daughter of any problems and any medication prescribed and liaised with my family on my recovery’. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service experience a lifestyle that does not consistently enable them to exercise choice. EVIDENCE: There is no designated activities co-ordinator, care staff provide any group or one-to one activities for people living in the home as their care duties allow. Eight people in total responded to the surveys we sent out. One (1) person indicated on the survey that they felt that there were always activities arranged by the home that they could take part in, five (5) people felt that there were usually and two (2) responded that sometimes there were activities they could take part in. One person’s comments on the surveys said ‘The carers sometimes put on tapes of music and do bingo, occasionally we have an outside entertainment person who comes to the home and there is a monthly little church service’ They also commented that ‘it would also be good to have some chair exercises Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 16 to music to help mobility’. Another person in their survey commented ‘I enjoy singling along, I enjoy talking with the staff, we also play cards a lot’. The provider stated following the inspection that activities are person centred and include hand massage and manicures, speaking to people, body exercises and watching TV. The completed AQAA received from the provider notes that they could do better by ‘to try to encourage service users to initiate their own communal activities’. The AQAA also states ‘activities are based on person centred care needs, e.g. we do one to one conversation, manicures and massages’. ‘We are going to do 2 hour sing-alongs twice a week rather than once a week’. The AQAA also includes that the provider’s plans for improvement in the next 12 months are to ‘purchase a high tech sing a long for service users to sing with each other’. Although activities are provided on a one to one basis, there is little evidence that these are tailored to meet each person’s needs or abilities. A discussion took place with the deputy manager and the administrator about useful sources of information available regarding the provision of activities, including those for people living with dementia, in order to improve activities further. The expert by experience noted that ‘all the service users were sitting in one of the two lounges….. The carers were interacting with the service users all the time by touch as well as talking to them….. although they were sitting around the room with no organised activity they were happy and contented’…...One person had been out to the shops and came back with items for others too. Although there were lists of activities for each day on the doors of the lounges I only saw some knitting and a newspaper being read….. There were board games in this room (the small lounge) which some said they enjoyed playing at times…..After lunch those who wanted to were able to go to their rooms for a rest. This wasn’t possible for the people in the bigger lounge because their rooms were on the other floors and there weren’t the numbers of staff to cope with this with so many dependent people’. There was a religious service taking place during this inspection that was attended by approximately ten people. Very positive comments were made by several visitors about the welcome and the support they receive from the home, and one person living in the home noted that “My family visit very often and the home welcome all visitors at all times”. The menu for the home is a fixed two-week cycle and some choice was seen to be available. One person spoken to by the expert by experience said that they “had what they were given” and another “there is no choice, but it is tasty”. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 17 However, all people spoken to by the expert by experience said that they enjoyed their food. One survey returned included the comments that ‘the food cooked is varied and healthy, we also have fresh fruit and there is always juice available through the day, tea and biscuits midmorning and afternoon. Also the puddings are nice’. The menus on display in one dining area were several days out of date, which may confuse people. One survey received included the comment ‘it would be helpful if the menu be displayed as the family can see it I can’t always remember all the choices when my daughter asks me’. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured that staff training in safeguarding, together with the home’s safeguarding and complaint policies and procedures provide a good level of protection for them and that issues will be recorded and acted upon appropriately. EVIDENCE: We have not received any complaints about Seymour House since the last inspection. In the past the home has always co-operated fully with us and other agencies in addressing any concerns or complaints made. The manager, staff and people living in the home have indicated an ability and willingness to address any concerns and complaints as they arise. Each of the surveys received from people living in the home indicated knowledge of the complaints process and expressed confidence that they could approach the manager of the home freely at any time to discuss any concerns that they might have. Staff training records include details of safeguarding training undertaken by staff, this should provide confidence for people living in the home that staff have the knowledge and skill to recognise what constitutes abuse and the appropriate action to take if it is seen or suspected. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured that Seymour House provides a safe and well-maintained environment that meets their needs. EVIDENCE: The expert by experience made particular note of the cleanliness and lack of unpleasant odour in the home and this view is borne out by the surveys received from people living in the home, with typical comments like “ The home is always clean and tidy”. The programme of replacing worn and stained flooring is nearing completion and where it has been completed we noted that this has significantly enhanced the environment for people living in the home. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 20 Previous problems identified with the provision of soap and the quality of some towels have been satisfactorily addressed. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use they service cannot always be assured that there are enough staff on duty in the home to satisfactorily meet their needs and preferences. EVIDENCE: On the day of this inspection with 37 people resident in the home, there was a deputy manager on duty together with 1 senior carer and four care assistants. There was also a cook and a domestic on duty for the morning. The standard of care experienced by people living in the home is generally very good. However, it could be improved by increasing the number of staff on duty at key times. One person spoken to by the inspector at approximately 8:30am stated that they had been up since six o’clock and were waiting for their breakfast. This was drawn to the attention of a member of staff on duty who then dealt with this shortly afterwards. Staff are working long hours, which could potentially jeopardize the well being of people living in the home. Shift patterns inspected indicate that it is common for ‘long days’ to be worked, (8 am to 8 pm). It was reported to the inspector by a service user that one member of staff had worked over 20 hours on one occasion. This could not be confirmed one way or another from the records available at the time of this inspection. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 22 Five (5) people responding to the surveys felt that staff were always available when they needed them and three (3) said that they were usually available. Comments from one service user to us on the day of the inspection included; “they are very busy” and they are “short staffed”. As already discussed in the previous section the expert by experience noted that the ability of people to go to their rooms after lunch was compromised by the staffing ratio. Care staff are responsible for the activities programme in the home as well as providing any other care required at the same time. The home’s recruitment practice has previously been found to be robust and thorough and this should offer reassurance to people living in the home that they are protected from the employment of unsuitable people to provide care for them. The AQAA completed by the provider shows that there are a total of 19 staff employed in the home, 7 have NVQ level 2 or above and 2 are currently working towards this qualification. This does not meet the National Minimum Standards recommended ratio of 50 . One member of staff spoken with confirmed that they continue to receive regular supervision, and have had training in dementia care and moving and handling in the last 9 months. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service cannot be confident that the service is run in their best interests and that issues raised during inspections will be addressed in a timely manner which may leave people at risk. EVIDENCE: As was noted following the inspections of September and December 2007, failures in medication practice should have been picked up and addressed with a more effective and robust management and monitoring system in place. It is acknowledged that in many ways the care experienced by people living in the home remains good and this was again confirmed from comments received Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 24 from people living in the home and visitors during this inspection. There is however little evidence that potential improvements are being given genuine priority and this is reflected in the home’s rating with us, which has remained static in several inspections over recent years. Staff indicate that they are well supported and regularly supervised and this has been confirmed from records seen. One survey returned stated ‘perhaps is would be helpful to have a management meeting with the families once a year. Notwithstanding this the management are available for any personal problems regarding your own resident’. The AQAA completed by the provider indicates that the service does not have policy or procedure on the management of service users money, valuables and financial affairs. In the absence of the registered manager this was not explored at this inspection although previous inspections have not highlighted any concerns in this area The AQAA submitted by the provider is generally poorly completed and we would expect that the next AQAA returned to us contains more supporting evidence and evidence to support that the provider has listened to the people who use the service. Seymour House DS0000019520.V357317.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 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 2 Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 6 Requirement Timescale for action 31/03/08 2. OP9 13(2) 3. OP9 13(2) The home’s statement of purpose and service user’s guide must be reviewed and where appropriate revised. The Commission must be notified of any revision. This ensures people are provided with up to date relevant information when making a choice to use the service. 31/03/08 Residents must be protected by having clear and detailed written procedures for the safe handling of medicines which are available for staff at all times. This is a repeat requirement. The previous timescale of 15/01/08 had not expired at the time of the inspection. A new timescale has been provided. Enforcement action may be taken if compliance is not forthcoming. To ensure people are kept safe 31/03/08 temazepam, and other controlled drugs, must stored and recorded correctly. The medication cabinet must be appropriately fixed and the controlled drugs record must meet the regulations. DS0000019520.V357317.R01.S.doc Version 5.2 Seymour House Page 27 4. OP9 13(2) 5. OP9 13(6)18(1 ) 6. OP9 13(4) This is a repeat requirement. Previous timescales of 31/10/07 & 31/12/07 not fully met. Enforcement action may be taken if compliance is not forthcoming. To safeguard service users a 28/02/08 robust system must be put in place for the monitoring of the records for the administration of medication in the home to ensure any gaps are identified and appropriate action taken at the earliest possible opportunity. To ensure service users safety all 31/03/08 staff authorised to administer medicines must undertake a robust training program and be assessed as competent to administer medicines. This is a repeat requirement, but was not fully assessed, as the timescale made at the previous inspection had not yet expired. A documented risk assessment 31/01/08 must be in place for all residents who administer their own medication in order to minimise the risks to people in this service. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations The availability of resources, information and advice on the provision of activities within care homes, particularly in respect of people with dementia should be researched. This information and advice should then be used to inform the future development of activities within Seymour DS0000019520.V357317.R01.S.doc Version 5.2 Page 28 Seymour House 2. OP15 3. OP29 House. A copy of the CSCI report Highlight of the Day should be obtained to see if any changes or improvements to the mealtime routines at Seymour House could be made (in consultation with people living in the home). Consideration should be given to reviewing the reference request form and the health declaration section of the application form currently in use to provide more useful information in a more structured format. Seymour House DS0000019520.V357317.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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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