Inspection on 04/08/05 for The Seymour

This inspection was carried out on 4th August 2005.

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

The Seymour 29/08/07

The Seymour 08/06/06

The Seymour 09/03/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Seymour 327 North Road Clayton Manchester M11 4NY Lead Inspector John Oliver Unannounced 4 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Seymour Address 327 North Road Clayton Manchester M11 4NY 0161 220 8688 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Seymour Home Limited Responsible Individual - Mr A.K. Patel Mrs Susan Lloyd Care home only (PC) 26 Category(ies) of Old age, not falling within any other category registration, with number (OP) (26) of places F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 A maximum of 26 older people (OP) may be accommodated. 2 The staffing arrangements at the home must be maintained in line with the minimum levels set out in the guidance published by the Residential Forum,`Care Staffing in Care Homes for Older People`. The home must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 3 Date of last inspection 2 December 2004 Brief Description of the Service: The Seymour is a privately owned residential home providing personal care for up to 26 older people requiring personal care only. Since the last inspection the ownership of the home has changed. The new proprietor, Mr Patel, obtained registration on 17th May 2005. The home is located in Clayton, north of Manchester City Centre. The home is close to public transport links into Manchester, Oldham, Droylsden and Ashton. Bedroom accommodation is provided on the ground and first floors accessed via a passenger lift. Sufficient toilet and bathing facilities were provided within close proximity to bedrooms and communal areas. Accommodation is provided in 18 single rooms and 4 double rooms. Three of the single rooms were fitted with en-suite facilities. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 4th August 2005 over a four and a half hour period. The inspection was the first one conducted under the ‘new’ ownership of Mr Patel. The inspection involved spending time talking with the owner, the manager, staff on duty at the time and a number of residents who wanted to say how they found living in the home. Some time was spent looking at files and records. The inspector also had a look around the inside of the home as well as having a walk around the outside of the building. At the last inspection, which was done in December 2004, five improvements were identified to be carried out. At this inspection it was noted that two of these improvements still needed to be completed, and these have been identified in this report. Not all standards were checked at this inspection and it is strongly advised that this report should be read together with the last inspection report and any future inspection reports to get a full picture of how the service is meeting the needs of the residents living there. What the service does well: The manager and staff team of the home have worked hard to provide residents with a comfortable and safe place to live. Observing staff at work gave a good indication of their commitment to providing residents with a pleasant environment in which to live. Talking with a group of eight residents the inspector was told that “everything in the home is very good”, “the cook and the meals are great”, “I get up when I want and go to bed when I want”, “me and J …go across the road to the church”, “staff are wonderful”, “nothing, and I mean nothing, is too much trouble”. Four residents were very clear about how to make a complaint should they need to. During the inspection a number of visitors came into the home. Two particular visitors spoke with the inspector. These visitors were the daughters of a resident who has lived in the home for the past eight years. Comments were positive above the standard of care given to their mother and included: “we F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 6 can come at any time, it is always the same”, “it is comforting to know mum is well looked after”, “she (mum) is always dressed nicely even though she cannot walk around”, “we are kept well informed how mum is”, “the manager and staff are brilliant, nothing is too much trouble for them”. Talking with residents and staff it was apparent that the ‘take over’ of ownership of the home has been done sensitively and smoothly. 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. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,5 and 6 Prospective residents were being assessed prior to admission into the home. Trial visits to the home were made available to enable an assessment of the suitability of the services being offered to a potential resident. In addition, prospective residents were given significant information about the service offered prior to admission. EVIDENCE: The service had updated the Statement of Purpose and Service User’s Guide to reflect the new ownership and staffing structure of the home. Both documents were displayed in the hallway of the home and copies were made available to those who asked, including those residents living in the home. Information contained in these documents reflected the service being offered by the home and gave potential residents the opportunity to raise any concerns or ask any questions they may have about living in a residential setting. The files of three residents recently admitted to the home were examined. The files appeared to contain relevant information including the Care Management and the homes own pre admission assessment documents. However, the files F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 9 were inconsistent in how and what information was included in them. This could result in the care needs of a resident not being fully met. It is recommended that a standard format be used when compiling files for individual residents. However, observing the interaction between residents and staff and discussion with a number of residents indicated that the home was able to meet the needs of the residents currently accommodated. Speaking with one of the residents recently admitted confirmed that trial visits to the home had been offered. The Seymour does not offer the service of intermediate care and the manager confirmed this. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 and 11 Care plans were on file for each resident. These were inconsistent in their content and did not always reflect the way support should be given to the person. Policies and procedures relating to medication administration were not being adhered to which created a potential risk to the health of individual residents. EVIDENCE: Care plans and risk assessments had been completed for each resident living in the home. The files of three residents were examined. Although all three contained care plans, these were difficult to understand, two did not contain enough information to provide appropriate support and, were not signed or dated. Although some files indicated that other health care professionals also provided support, this information was difficult to find. Risk assessments were included on some files relating to issues such as smoking and falls. No clear information had been included as to how the risk was to be managed in the most appropriate way. Lack of such clarity of information could adversely affect the health and wellbeing of residents. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 11 A number of residents spoken to confirmed that they were able to see their doctor or other healthcare professionals in the privacy of their own rooms. This was evidenced during the inspection when a health visitor called. Medication administration records were checked and a number of ‘gaps’ were apparent on a number of days where medication had apparently been administered but no signature recorded at the time of administration. This posed a potential risk to the health and safety of residents. Discussion with the management team of the home indicated that it would be beneficial if the Pharmacist Inspector from the Commission carried out an audit of medication and medication practices in the home. At the time of the inspection one resident in the home was very ill and was receiving terminal care. Family had been kept fully informed of the residents’ condition. However, sadly on the day of the inspection the resident died. Observation of staff showed that they dealt with this in a dignified manner. It was comforting to note that the resident’s family were present during this difficult period. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 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 standard(s) 12,13,14 and 15 Residents have choice and support to meet their expectations and preferences regarding their daily lifestyle. EVIDENCE: The routine of the home was relaxed and informal. Residents had opportunity to spend time socialising in communal areas or in the privacy of their own rooms. Rooms that were viewed during the inspection indicated that the people who occupied these rooms had been given support to participate in activities of their choice and, in the privacy of their own rooms if they wished. Visitors seen coming into the home were welcomed and an opportunity arose to speak with two visitors who were the daughters of one of the residents’. Both daughters stated that they were ‘very happy’ with their mothers care and the support that they also receive from the home. A number of residents spoken to stated that the quality of food prepared and the choices offered was very good. They also stated that the cook offered choices on a daily basis to those people who did not like/want the main menu of the day. Plenty of fresh fruit was seen to be available. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 16 and 18 The home has relevant policies, procedures and systems in place to enable concerns to be raised and to protect residents from neglect and/or abuse. EVIDENCE: A record of complaints was kept. No complaints had been recorded since the inspection conducted in December 2004 and the manager confirmed that no other complaints had been received. The Commission for Social Care Inspection had received no complaints. Discussion with four residents demonstrated that they were clear how and who to make a complaint to. The home had a comprehensive abuse policy including the Department of Health guidance, ‘No Secrets’. However, the policy used by the home needs to clearly reflect that it must be used in conjunction with ‘No Secrets’ and not as a separate policy. No allegations or incidents of abuse had been made since the last inspection. Discussion with the manager indicated that she had a clear understanding of procedures to follow in the event of any allegations of abuse being made. However, it is recommended that all staff receive appropriate training in relation to the protection of vulnerable adults. The home had a policy regarding dealing with resident’s money and financial affairs. This gave clear directions to those staff with responsibility for dealing with these matters. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19 ands 26 The general environment of the home was clean, tidy and comfortable with systems in place to protect the safety of residents. EVIDENCE: Evidence available indicated that some routine renewal and maintenance of the home had taken place since the last inspection. A number of requirements identified during the inspection conducted in December 2005 had been addressed. Bedrooms viewed during the inspection confirmed that a programme of redecoration was taking place and that some furniture had been replaced with new. Those bedrooms seen were comfortable and personalised to varying degrees reflecting the character of the resident. At the time of the inspection, the owner was in the process of conducting an audit of all bedrooms to make sure that the decoration and the contents of the rooms met the individual requirements of the resident. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 15 Laundry facilities were fit for purpose and appropriate protective clothing and hand washing facilities were available. Policies and procedures were in place for the control of infection. This helped to protect both resident’s and staff from the potential spread of any possible infection. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 Staff were not being recruited in line with the policies and procedures for the home. This did not ensure the protection of the people living in the home. EVIDENCE: Staffing levels in the home met the minimum requirements of the previous registering authority. Staff were deployed in accordance with the requirements of the residents at peak times of activity during the day. The home also employs catering and domestic staff. On checking the files of two recently employed members of staff it was noted that not all pre employment checks had been carried out prior to commencing employment Criminal Record Bureau checks had been requested including POVA First checks. However, two written references were not available. This was fully discussed with the owner and manager at the time of the inspection. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) As there was a death in the home at the time of the inspection the management needed to deal with this as the priority and therefore no standard in this section was assessed on this occasion. However, all standards will be fully assessed at the next inspection. EVIDENCE: F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x x x x F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 19 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement Care plans must set out in detail the action which needs to be taken by care staff to ensure that all aspects of the residents health, personal and social care needs are met. These must be signed, dated and reviewed on a regular basis. Risk assessments must be completed for all residents where risks have been identified and must include how the risk is to be managed and reviewed. Information held on residents files must clearly indicate any interventions being carried out by other health care professionals. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Policies and procedures relating to the prevention of abuse must be reviewed and updated. Staff must not be employed in the home until all pre employment checks have been satisfactorily completed. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Timescale for action 28th October 2005 2. 7 15 16th September 2005 28th October 2005 28th October 2005 3. 8 15 4. 9 13 5. 6. 18 29 13 19 25th November 2005 30th September 2005 Page 20 Version 1.40 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 3 18 Good Practice Recommendations It is recommended that a consistent format is used when compiling information on individual residents files. It is recommended that all staff receives appropriate training in relation to the protection of vulnerable adults. F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 9th Floor, Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI F55 F05 s63622 The Seymour V242631 D040805 Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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