Inspection on 09/03/06 for The Seymour

This inspection was carried out on 9th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 04/08/05

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 The Seymour 327 North Road Clayton Manchester M11 4NY Lead Inspector Sue Jennings Unannounced Inspection 9th March 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 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. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Seymour Address The Seymour 327 North Road Clayton Manchester M11 4NY 0121 308 4180 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) The Seymour Home Limited Mrs Susan Jones Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 26 older people (OP) may be accommodated. 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. 4th August 2005 3. Date of last inspection Brief Description of the Service: The Seymour is a privately owned residential home providing personal care for up to 26 older people. Since the last inspection the ownership of the home has changed. The new proprietor, Mr Patel, obtained registration on 17 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. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of 3 hours on Thursday 9th March 2006. During the course of the inspection time was spent talking to the manager and some residents to find out their views of the home. Time was also spent examining records documents and the residents care plans. A tour of the building was also conducted. A number of requirements from the previous inspection had been addressed and there was evidence that the home was continuing to work hard to develop the service. The home or the Commission for Social Care Inspection had not received any complaints since the last inspection. During this inspection only a selection of the key National Minimum Standards were assessed therefore in order to gain the full picture of how the home meets the needs of residents this report should be read with the previous and any future reports. What the service does well: Prospective residents have a pre-admission assessment to ensure that the home can meet all of their needs. Where possible, prospective residents and their family/representatives were encouraged to view the home prior to making a decision about admission. One relative said “my husband and I came to look around the home we were welcomed and all the staff have been really helpful”. The home had a warm friendly atmosphere and staff were observed to be pleasant, courteous with residents, and were seen to be engaged in good interactions with residents as well as dealing with residents individual needs. A number of residents were spoken to during the inspection. One resident said that “staff are respectful” and another said “staff always ask what clothes you want to wear or what you want for dinner”. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 6 A number of residents were spoken to after lunch and one said “ the food is lovely we have plenty to eat, too much sometimes”. A complaints procedure was available to allow residents and their relatives to air their views and raise concerns and appropriate action was taken to investigate complaints. What has improved since the last inspection? What they could do better: There were a number of gaps in the home’s Controlled Medication Administration Record, which is thethat is signed to indicate that staff have given or have tried to give residents their medicine. The pharmacy inspector has been asked to visit the home to carry out a thorough inspection of the homes medication systems. The home must have a list of signatures and initials of all staff responsible for administering medication, which should be held on the Medication Administration Records (MAR). The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 7 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 Seymour DS0000063622.V278865.R01.S.doc Version 5.1 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 The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5 The home carries out an assessment of prospective residents’ care needs prior to their admission. They and their relatives/friends are able to visit the home before making the decision to stay. EVIDENCE: The home has a pre-admission assessment document, which is used to ensure prospective residents are only admitted on the basis of a full assessment. The assessment included the involvement of the prospective resident, his/her representatives and any relevant professionals. For residents who are referred through Care Management arrangements the home obtains a copy of the Care Management Assessment prior to admission. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 10 On admission to the home, residents have a further assessment period during which time the home formulates its own care plan. One relative was spoken to and confirmed that they were provided with information and invited to visit the home before making a decision regarding admission. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Overall the health and personal care needs of the residents were being identified and met at the home, however the system for recording the administration of prescribed medicines needed some improvement to provide an accurate audit trail of medication. EVIDENCE: Each resident had a detailed individual plan of care, which had been generated from a needs assessment and the homes own care planning process. A sample of care plans was inspected and it was commendable that the home had taken steps to improve the standard and usability of the individual plans of care. Care plans included nutritional screening, continence assessments and the oral hygiene needs of residents. Each resident was registered with a local General Practitioner (GP) where possible residents had retained their own GP. Residents could see their GP in the privacy of their own room. There was evidence to show that residents had been referred to other specialised services according to residents’ assessed needs. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 12 This included District Nurses, Dentist, Dietician and Chiropodists. Visits from healthcare professionals were recorded on the individuals care plan. There was evidence that the district nursing service had provided the home with advice regarding pressure care management for residents as and when required. The pharmacy inspector has been asked to visit the home to discuss the medication systems. This is in response to a request by the manager. A thorough inspection of the medication system will be conducted at the next inspection once the pharmacy inspector has visited the home. One resident spoken to said that “staff were respectful they are all very good and the new owner is lovely”. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section were assessed during this inspection. EVIDENCE: The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 There was a policy in place for the protection of vulnerable adults and staff had received training in what to do in the event of an allegation of abuse, thus ensuring the safety and well being of the residents. However, the homes Adult Protection Procedure required some amendments. EVIDENCE: The home had policies and procedures relating to the protection of vulnerable adults, however this required some amendments to reflect the action to be taken in the event of an allegation of abuse in line with the Department of Health No Secrets guidance and the Manchester Multi Agency Policy for the Protection of Vulnerable Adults. The home had a copy of the Manchester Multi-Agency policy for the Protection of Vulnerable Adults from Abuse and a ‘Whistle Blowing’ policy. Training for staff on what to do in the event of an allegation of abuse was reported by the manager to be ongoing. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The premises are safe and the home’s environment including the standard of hygiene was well maintained both internally and externally. EVIDENCE: All areas of the home were tastefully decorated and furniture was of a domestic nature and of a high standard. The home had a programme of routine maintenance and renewal of the fabric and decoration. The home has a large well-maintained rear garden with a lawn and mature trees. The manager reported that a marquee is erected in the summer months and residents spend the day sat in the gardens this was confirmed in conversations with residents. The front of the building is laid to tarmac and provides ample parking. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 16 The manager reported that a new hot water boiler had been fitted since the last inspection. Thermostatic controls had been fitted to the hot water taps and radiators to reduce the risk of accidental burns. The manager reported that a new medic bath was to be fitted later this week. At the time of inspection workmen were on site re-wiring a number of electric plug sockets. A random sample of resident’s’bedrooms was seen and appeared to be comfortable and personalised. One resident said, “I have a lovely room, I have brought in my own pictures and photographs”. Residents’ bedrooms had been fitted with a privacy lock suited to their capabilities and accessible to staff in emergencies. All rooms had a lockable storage space for medication, money or valuables. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 The home’s recruitment/vetting policies and procedures promoted the safety and wellbeing of the residents. EVIDENCE: The requirement made during the unannounced inspection on the 4th August 2005 relating to the home obtaining two written references for staff employed to work in the home had been addressed. Criminal Record Bureau checks had been requested and staff had been checked against the Protection Of Vulnerable Adults list therefore ensuring that people employed at the home are safe to work with vulnerable people. A sample of staff files were examined and found to contain an application form, two written references, evidence of Criminal Records Bureau checks, proof of identification and a Statement of Terms and Conditions of employment. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 38 Overall the home had systems and procedures in place, which promote the health, safety and welfare of the residents and staff. EVIDENCE: Hazardous substances were stored in line with the Controls of Substances Hazardous to Health (COSHH) guidance to ensure that there were no risks to residents. There was evidence to show that the fixed electrical and gas appliances had been serviced at regular intervals. Regular fire drills were held rotating the test area. A portable appliance test had been undertaken. The passenger lift and hoists were serviced on a regular contract. A contract was in place for the appropriate disposal of clinical waste. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 19 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 X X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 21 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 OP9 Regulation 13 Timescale for action The registered person shall make 05/04/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (previous timescale of 28.10.05 not met) The home must keep a list of 05/04/06 sample signatures of all staff responsible for administering medication. Policies and procedures relating 15/04/06 to the prevention of abuse must be reviewed and updated. (previous timescale of the 25.11.05 not met) Requirement 2. OP9 13 3. OP18 13 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 00 Good Practice Recommendations No recommendations were made as a result of this inspection. The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection CSCI, Local office 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 The Seymour DS0000063622.V278865.R01.S.doc Version 5.1 Page 23 - 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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