Care Home: Seymour Gardens (33)

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What the care home does well Opportunities for social and leisure pursuits and personal development are actively promoted and supported by staff, to enable residents to participate in the wider community in which they live. During the inspection, staff were observed providing residents with assistance, support and guidance and were respectful of their right to make decisions. Staff support residents to maintain and establish links with family and friends, inside and outside the home and their involvement is encouraged with individual residents` agreement. A relative stated, "my daughter has matured considerably in the five years she has been at Seymour Gardens, they do everything to meet my daughter`s needs". The following comment was received from a healthcare professional, "The residents at Seymour Gardens are all treated with care and respect. It appears that all of their individual needs are met. They lead a full and happy life together within a caring community spirit". Residents are involved in the day-to-day running of the home via regularly participating in meetings. What has improved since the last inspection? There have been improvements to the home since the last inspection. A considerable amount of work has been carried out to the home`s physical environment, new carpets and curtains have been purchased, along with new furniture. The inspector was pleased to note that the residents were involved in choosing this. What the care home could do better: The manager and staff team continue to work to provide a good service for the residents and to meet each person`s needs. All except one of the requirements in the previous inspection have been met. One new requirement has been made, that comprehensive risk assessments must be in place for all health issues and activities residents take part in and residents must be supported by staff to carry out their chosen activities within this framework. The registered person to ensure that an organisational quality monitoring system is in place and implemented to measure success in achieving the homes aims, objectives and Statement of Purpose. The Expert by Experience states in her report, Seymour Gardens is a nice home. She felt that the following recommendations could be made. Residents, to be asked if they want to help in the kitchen with cooking, washing up etc. The lounge and dining area had nice furniture but could look more homely as there were no flowers or pictures up. Picture menus need to be introduced for S who is non verbal so she may have choice and control. The fire drill and instruction to be in picture format. More fruit bowls available in the dining and lounge area. Some activities such as books, puzzles, arts and crafts to be available for residents. Residents should be encouraged to use the garden to grow food which is healthy. It was suggested to the manager that she uses the Key Lines of Regulatory Assessment (KLORA) to assist and continue to identify and evidence the good quality of the service provided and explore how to achieve an excellent rating. CARE HOME ADULTS 18-65 Seymour Gardens (33) 33 Seymour Gardens Ilford Essex IG1 3LP Lead Inspector Ms Harina Morzeria Unannounced Inspection 11th February 2008 10:15 Seymour Gardens (33) DS0000025927.V358868.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 Gardens (33) DS0000025927.V358868.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 Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seymour Gardens (33) Address 33 Seymour Gardens Ilford Essex IG1 3LP 020 8518 4645 020 8554 0396 vandabrand@norwood.org.uk 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) Norwood Ravenswood East Ms Vanda Karen Brand Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom residential accommodation with both board and personal care is provided at any one time shall not exceed 5. 21st September 2006 Date of last inspection Brief Description of the Service: Seymour Gardens is a five bedded home for adults with learning and physical disabilities run by Norwood, a not-for-profit, Jewish organisation, providing services for people of the Jewish faith. Hence the ethos of the home is based around Jewish beliefs, customs and faith. Residents accommodated in the home have medium -- high dependency needs and may exhibit challenging behaviour. The home first opened in 1993 and is a converted domestic dwelling in a popular residential area in Ilford. It is close to public amenities as well as being served by good public transport links. All residents have their own bedrooms which are well furnished and decorated, with one of the downstairs rooms containing an en - suite facility. Appropriate communal space is provided and there is also a small well-kept garden, for the residents enjoyment. The manager and staff support residents to develop and maintain independent living skills, attend college for various courses as well as accessing community facilities locally and at the Leonard Seiner Centre (Jewish community centre) in Barkingside. Personal care is provided on a 24-hour basis, and health care needs are met by staff supporting residents to attend appointments with health professionals. The fees range from £3000 - £4,300 per month approximate. Additional charges are made for personal items such as hairdressing, chiropodist, newspapers and toiletries. A Statement of Purpose and Residents Guide are available to the residents and their representatives. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and a key inspection of the service for the inspection year 2007/2008. This meant that all key standards were covered as well as any other standard for which a requirement was made at the last inspection. The inspector was accompanied to this inspection by an “Expert by Experience” who looked around the home with a member of staff and a resident. She spoke to the residents and staff, observed the lunchtime routines at the home and provided a report of her findings to the inspector, part of which have been incorporated in this report. The inspection found that the service was well managed with the residents at the heart of its operations. Both the management and staff worked closely with individuals to ensure that they enjoyed good quality living at Seymour Gardens. As part of the inspection a number of records were assessed and they included looking at residents’ files, staff files, health and safety records, risk assessments, the accident/incidents log, complaints, the staffing rota and the policy and procedures file. The inspection also considered feedback received from relatives and individual members of the staff team. Verbal feedback was also received from the staff and residents during the inspection. The manager completed an Annual Quality Assurance Assessment (AQAA) prior to this inspection, at the request of the CSCI, which formed part of the overall inspection process. The Commission has not received any complaints about this service. The inspector would like to thank the residents, staff, relatives and the expert by experience for their input during the inspection. What the service does well: Opportunities for social and leisure pursuits and personal development are actively promoted and supported by staff, to enable residents to participate in the wider community in which they live. During the inspection, staff were observed providing residents with assistance, support and guidance and were respectful of their right to make decisions. Staff support residents to maintain and establish links with family and friends, inside and outside the home and their involvement is encouraged with individual residents’ agreement. A relative stated, “my daughter has matured considerably in the five years she has been at Seymour Gardens, they do everything to meet my daughters needs”. The following comment was received from a healthcare professional, “The residents at Seymour Gardens are all treated with care and respect. It appears that all of their individual needs are met. They lead a full and happy life together within a caring community spirit”. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 6 Residents are involved in the day-to-day running of the home via regularly participating in meetings. What has improved since the last inspection? What they could do better: The manager and staff team continue to work to provide a good service for the residents and to meet each person’s needs. All except one of the requirements in the previous inspection have been met. One new requirement has been made, that comprehensive risk assessments must be in place for all health issues and activities residents take part in and residents must be supported by staff to carry out their chosen activities within this framework. The registered person to ensure that an organisational quality monitoring system is in place and implemented to measure success in achieving the homes aims, objectives and Statement of Purpose. The Expert by Experience states in her report, Seymour Gardens is a nice home. She felt that the following recommendations could be made. Residents, to be asked if they want to help in the kitchen with cooking, washing up etc. The lounge and dining area had nice furniture but could look more homely as there were no flowers or pictures up. Picture menus need to be introduced for S who is non verbal so she may have choice and control. The fire drill and instruction to be in picture format. More fruit bowls available in the dining and lounge area. Some activities such as books, puzzles, arts and crafts to be available for residents. Residents should be encouraged to use the garden to grow food which is healthy. It was suggested to the manager that she uses the Key Lines of Regulatory Assessment (KLORA) to assist and continue to identify and evidence the good quality of the service provided and explore how to achieve an excellent rating. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 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 summary of this inspection report can be made available in other formats on request. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 8 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 Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide provide prospective residents and their relatives/ representatives with all the information they need to enable them to make an informed choice about whether they wish to live in the home. Assessments undertaken by the home and the information and reports received from health and social care professionals means that staff have detailed information to enable them to determine whether or not the home can meet a prospective residents’ needs. Residents have individual contracts or a statement of terms and conditions with the home, so that they are clearly aware of the services that the home can offer. EVIDENCE: The home has a Statement of Purpose and Service User Guide. These are informative, well presented and provide residents and their representatives with a good understanding of the service and facilities. All prospective residents are given a copy of the Service User Guide. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 10 There are currently no vacancies at the home. A number of the residents have lived in the home since it first opened. The most recent resident was accommodated in October 2002. Examination of her file showed that she was not admitted until a full needs assessment had been undertaken. The assessment is conducted professionally and sensitively and involves the individual and their family or representative where appropriate. Where the assessment has been undertaken through care management arrangements the service insists on receiving a summary of the assessment and a copy of the care plan. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Hence, from viewing pre-admission assessments/ documentation it was evident that a full assessment is undertaken, prior to the admission of any resident to the home. There is always a planned, phased introduction to the home and with the other residents. The length of this process would be dependant on the individual’s needs. Each resident has a contract, which sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. There was evidence to show that where capable, residents and/ or their representatives had signed the contract. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 11 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, 8, 9 & 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans are detailed and provide staff with the information they need to identify and meet residents personal, social support and health care needs. The home maximises independence wherever possible and staff provide residents with information, assistance and support to make decisions about their own lives. Residents know that the staff handle information about them appropriately, and their confidences are kept. EVIDENCE: The service involves individuals in the planning of care that affects their lifestyle and quality of life. Staff understand the importance of residents Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 12 being supported to take control of their own lives. Individuals are encouraged to make their own decisions and choices. Evidence was seen that residents are informed of any changes or issues arising within the home via weekly resident meetings. The expert by experience reported as follows: N said he could choose his own clothes. All residents were dressed very nicely. J the male resident told us that they visit the doctor. A male member of staff R told us when residents are unwell the doctor will come to the house. R also told us that the residents visit the dentist regular. Residents were able to choose their colour for their rooms. The home has had new carpet laid. R was asked if she had helped with the choosing of the carpet, we were told by the assistant manager that the resident s did have a choice with the colour of carpet. The care plans, called Individual Personal Plans(IPP) are person centred and agreed with the individual. these are reviewed and updated as required. Individual files were available for each resident and the records of two residents were case tracked. Individualised care plans (IPP) are developed for each resident following the principles of person centred planning and each resident has a plan that has been agreed with them. It identifies needs, likes, dislikes and considers all areas of the resident’s life including health; personal and social care needs. Staff support and encourage residents to be involved in the ongoing development of their plan. The inspector was informed that these are currently being reviewed and updated for each resident. A key worker system allows staff to work on a one-to-one basis and contribute to the care plan for the individual. The manager is aware that care plans must be updated when required or follow-up action outlined when they attend any health appointments or if their health condition changes for any reason. Each care plan includes a comprehensive risk assessment, which is reviewed regularly. Management of risk is positive, addressing safety issues whilst aiming for a better quality of life for the residents. When limitations are in place, the decisions have been made with the person and are recorded. The inspector viewed the risk assessments of the people who were case tracked and noted that these focused on maintaining and promoting residents’ independence whenever possible and individual staff were observed providing residents with information, assistance and support and were respectful of their right to make decisions. However for one person an up-to-date risk assessment was not in place for allergies he suffers from and precautions to be taken when he uses the kitchen. This was brought to the managers attention and a requirement has been made. Comprehensive risk assessments must be in place for health matters and the different activities that residents take part in and residents must be supported by staff to carry out their chosen activities, within this framework. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 13 There are procedures in place to ensure that people using the service are informed of their right to confidentiality. Individuals understand when staff may have to share personal information and can access advocacy services for support. The home ensures that residents are consulted on a regular basis to gather information about their satisfaction with the service and care provided. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 14 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): 11,12,13,14,15,16,17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Opportunities for social and leisure pursuits and personal development are actively promoted and supported by staff, for all residents to enable them to participate in the wider community in which they live. Residents have appropriate relationships and their rights are recognised in their daily lives. Residents are offered a varied and balanced diet and are consulted about their choices of food and participate in shopping. EVIDENCE: Each resident has a planned activity programme, which takes account of the residents’ preferences, interests, experiences, age and capabilities related to their particular condition. The home has sought the views of the residents and considered their varied interests when planning the routines of daily living and arranging activities both in the home and community. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 15 Routines are very flexible and residents can make choices in major areas of their life. The routines, activities and plans are resident focused, regularly reviewed and can be quickly changed to meet individuals’ changing needs, choices and wishes. This was observed on the day of the inspection when residents independently decided the activities they wanted to pursue. All residents are supported to participate in leisure activities in the community and at the local Jewish community resource at the Leonard Seiner centre. These are both specialist and mainstream for example, regularly going to a pub, shopping, eating out and at the centre for music and dance, drama and participating in the Jewish cultural events and festivals/celebrations. Residents have an annual holiday or short breaks/ days out together or in small groups. Residents have the opportunity to develop and maintain important personal and family relationships. Some of the residents regularly go out with their friends and family including overnight stays. The practice of staff promotes individual rights and choice, but also considers protection of individuals, supporting people to make informed choices. Where appropriate residents are involved in taking some responsibility for their own room. One resident said: “ I look after my own room, but staff need to help me sometimes”. All the residents spoken to said that they were “happy” living in the home and they felt staff looked after them well. The expert by experience reports as follows: N said he was a student who was learning spellings and computers; he has his own computer in the dining area. The residents do attend clubs. Monday – Thursday they attend the Performing Arts, Tuesday N attends college he likes college, on Fridays the residents attend the Mencap club. In the evening R said they go to the pictures and bowling. R told us she did not like bowling. There is a garden at the home, N said he does not want to help with the gardening; S (expert by experience) feels the residents should be encouraged to plant vegetables or flowers. We were told residents can help with the cooking and the household chores, on our visit we observed N taking his bed sheets down stairs to be washed. The two members of staff were observed making lunch for the residents, while we were there staff was not seen to encourage or ask the residents to help with making lunch. S felt all residents should be given the choice to help or prepare their food. Residents go the pool and go on walks to stay healthy. We were told residents did help with cooking. Menus were decided by residents during team meetings. The menus are not in picture format. Fruit was available in the kitchen for residents to have snacks. Residents could access the kitchen independently to help make tea or get juice. There was a variation for breakfast. The ‘Expert’ S was concerned that the home was very warm and the temperatures high. S(expert) felt that the residents were not engaging much with the staff and more activities would improve their health and well being. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 16 During the inspection, the residents were observed accessing all areas of the home independently. The home has limited facilities for private meetings but residents are able to use their bedrooms. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 17 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, 21 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and their physical and emotional needs are closely monitored to ensure that their needs are recognised and met. There are clear medication policies and procedures for staff to follow. EVIDENCE: All of the care and health plans examined, clearly recorded referrals to specialist health care professionals and that appointments were being kept. Records indicated that residents have attended routine health appointments including GP, dentist and chiropodist and see consultants for specific health concerns. Residents have regular reviews of their medication undertaken by their GP/consultant. Staff have access to extensive training provided by the organisation and are encouraged and given time to attend seminars/training on specialist areas of work. Hence, staff are alert to residents’ changes in mood, behaviour and general well being and fully understand how they should respond and take Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 18 action. The aims and objectives of the home reinforce the importance of treating individuals with respect and dignity. There was evidence that support is in place to help residents with their personal care. Staff were observed to be providing residents with sensitive and flexible personal support and all such support is provided in private. Residents are supported and helped to be independent and can take responsibility for their personal care needs. Only one of the residents requires support with personal care and an appropriate risk assessment is in place for this person. Residents spoken to confirmed that they are happy with the support they receive around personal care needs. The expert by experience reports that: Residents who needed the help with bathing or showering had this support given. The residents who wished to shower/bath alone could do so. The residents could choose what time they go to bed and wake up. They said they felt safe in the home. There are policies and procedures in place for the handling and recording of medication. Medication is stored in a locked medicine cupboard and is appropriate to ensure the safekeeping of medicines in the home. An audit was undertaken of the management of medicines in the home and Medication Administration Record (MAR) charts were examined. Only staff who have completed and passed appropriate medication training administer medication. An assessment has been carried out to ensure each member of staff is competent to handle, record and administer medication properly. This was evidenced on staff training records examined during the visit. All the care plans indicate wishes at times of severe illness and death. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 19 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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager and staff make every effort to sort out problems and concerns by acting upon and resolving any issues. All staff working in the home have received training in adult protection/ abuse awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: There are policies and procedures for dealing with complaints, which is accessible to the resident group. The complaints procedure is pictorial and is clearly displayed throughout the service and is given to all other involved agencies or professionals in the local community. The complaint log was examined and this recorded the number of complaints/ concerns, action taken and the outcome for the complainant. The manager also ensures that staff routinely record all verbal issues of concern or dissatisfaction expressed, and all such concerns have been acted upon and resolved. The home learns from complaints in order to improve its service. There is a written policy and procedure for dealing with allegations of abuse and whistle blowing. All staff have received training in safeguarding adults and this is included in the induction training for all new staff. Those staff spoken to during the inspection, were aware of the action to be taken if there were concerns about the welfare and safety of the residents. People using the Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 20 service and all their representatives are made aware of what abuse is and the safeguards in place for their protection should they need them. Training folders evidenced that staff had received safeguarding adults training and the manager is aware that all staff must update this training as soon as possible. Access to external agencies or advocacy services is actively promoted. The home is clear when an incident should be referred to the Local Authority as well as other agencies as part of the local safeguarding procedure. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 21 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, 25, 26, 27, 28, 29 & 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The residents live in a purpose built home that is suitable for their needs. Bedrooms and communal areas are spacious, meet their needs and promote their independence. Toilets and bathrooms provide sufficient privacy. Shared spaces are spacious and sufficient space is available for the numbers of people living in the home. The home is clean and hygienic. EVIDENCE: The home was toured as part of the inspection process by the expert by experience accompanied by a resident. The whole house has been redecorated including external areas and this makes it a pleasant environment for the residents. All the bedrooms are single. One bedroom is located on the ground floor which has en - suite facilities and the rest of the bedrooms are upstairs. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 22 These rooms were furnished and decorated to suit individual preferences and particular needs and are reflective of the residents’ interests and lifestyles. All the bedrooms have been redecorated and the residents were involved in choosing the furnishings they wanted. Sufficient communal space is available for the residents. New carpets, sofa and curtains and some furnishings have been purchased for the living room. The residents were fully involved in decisions about the décor and any changes to the accommodation. The residents spoken to said they like their rooms and were comfortable and feel safe in them. There are sufficient numbers of shared bathrooms and toilets for the residents and these are suitable to meet their needs. A requirement made at the last inspection for one resident who needs specialist equipment for bathing has now been met by providing a king Michelle facility in the upstairs bathroom. The home is clean, safe and comfortable. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 23 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): 31,32, 33, 34, 35 & 36 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. All staff have job descriptions which outline their roles and responsibilities, ensuring that they understand the tasks required of them in order to promote and protect the well being of residents. There is a procedure for the recruitment of staff, which is robustly implemented to provide safeguards for people living in the home. The home employs staff in sufficient numbers, to meet the needs of the residents. The manager provides good day-to-day support to all staff via regular supervision. The staff team receive training that is appropriate to meet the specific needs of residents. EVIDENCE: The home provides 24-hour support, including sleeping in night staff. An emergency on-call procedure is in place. There was a staffing Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 24 rota on display, which accurately reflected the staffing situation on the day of inspection, and indicated who was in charge of the home at any given time. Staff have been given a copy of their job description. Through observation and discussion there was evidence that staff have a good understanding of their roles and responsibilities. Staff were seen to interact with the residents in a friendly and respectful manner and demonstrated a good ability to communicate with them. Staff employed at the home have successfully achieved an NVQ Level 2/3 in Care or equivalent qualification. All staff undertake structured induction provided by the organisation before commencing work at the home, which includes shadowing more experienced members of the staff team. Staff also undertake other regular training and recent training has included the Jewish way of life, food hygiene, infection control, health and safety, medication administration as well as any other specialist training required to meet the needs of the residents. The organisation has various employment related policies in place, including equal opportunities and a disciplinary procedure. Staff employment records are held centrally by the organisation, with the agreement of the CSCI. The CSCI carries out an annual audit of these records, the last audit found them to be satisfactory. The inspector viewed three staff files and evidence was seen on summary sheets that copies of two written references were received and new staff are only confirmed in post following completion of satisfactory police checks and POVA registers. The following feedback was received from staff, “all new information is disseminated to staff. New ways of working are discussed at staff meetings. Organisational team briefs are read and discussed with the team”. “The service puts the needs of the residents first, offers excellent training to the staff ensuring that they gain the skills to support the residents well, in line with organisational and legal requirements. Seymour Gardens offers a safe, warm, homely environment giving the residents choices re: the decoration, furniture etc. They are involved in menu planning, trips etc”. Staff spoken to confirmed that they receive regular formal supervision from either the homes manager or senior support worker. Records are kept of supervision and these evidenced that supervision covers performance, training needs and resident issues. Annual appraisals take place although some are outstanding and staff meetings are held monthly with written minutes being kept. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 25 Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 26 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): 37,38,39,40,41,42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home’s management are suitably qualified and experienced and that appropriate health and safety checks are in place. The home is run in a way which ensures that the residents’ best interests are safeguarded by the home’s record-keeping. Staff are aware of the lines of accountability and monitoring systems within the home are robust enough to ensure that the manager is fully appraised of any issues relating to the day-to-day running of the home and the specialist needs of the residents. An organisational quality assurance system must be in place. Appropriate management arrangements are in place to ensure that a good quality of service is provided to the residents. The health, safety and welfare of the residents are promoted and protected by the systems in place which ensure that overall there is a safe environment for the residents. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 27 EVIDENCE: The manager has completed the Registered Manager Award qualification and NVQ Level 4 training and also holds a qualification as an NVQ assessor. The home also has a senior support worker who has responsibility for some of the administrative duties as well as providing managerial support in the managers absence. Staff informed the inspector that they found the manager to be approachable and accessible. The organisation/home have various policies and procedures in place in line with the National Minimum Standards. Those checked by the inspector included medication administration and safeguarding adults and these were of a satisfactory standard. Record keeping in the home was of a generally good standard. Confidential records are stored securely. Staff can access their records as appropriate. Staff and resident meetings and staff supervisions all contribute to the quality assurance within the home. Residents and their relatives are issued with questionnaires to gain their feedback on the home. Completed questionnaires seen by the inspector contained generally positive feedback. However, an annual quality assurance review of the whole service should take place about the operation of the home and opinions from residents, relatives and any health professionals as well as other representatives involved in the care of the residents must be sought. This quality audit should be analysed and the findings should form part of the residents guide. The inspector was informed by the responsible individual that as part of this process a “user lead focus group” has been formed to seek the views of the residents, indicating that this process has begun. See requirement. Copies of previous inspection reports are available to view in the home. Monthly unannounced Regulation 26 visits by the responsible individual take place and a copy of the report of these visits are maintained within the home. The home provides sufficient assistance to ensure effective safeguarding and management of individuals money including record-keeping. The expert by experience (S) states that: Resident’s money is kept in the office. S (expert) felt the residents should keep their own money in a lockable money tin in their rooms. N did go to the bank to get his money with support. N told us he likes to spend his money on, toys, drinks and crisps. We were told the residents have control over their money. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 28 The service manager as part of his monthly remit checks the residents’ finances. A daily check of each residents’ finances is also undertaken during each hand over. Fire extinguishers are situated around the home. These are serviced annually and the fire safety system is checked on a quarterly basis by an independent company. The fire alarms are checked by the home on a weekly basis, and regular fire drills are held. The home has in date certificates for PAT testing, gas safety and electrical installation. COSHH products were stored securely. The home tests fridge/freezer and hot water temperatures. The home has in date employer’s liability insurance cover in place. Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 29 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 3 2 3 3 3 4 3 5 3 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 2 3 3 3 3 Seymour Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 30 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 YA9 Regulation 4 Requirement Timescale for action 31/03/08 2. YA39 17/18 The registered person to ensure that comprehensive risk assessments are in place for all health issues and activities residents take part in and residents must be supported by staff to carry out their chosen activities within this framework. The registered person to ensure 30/11/08 that an organisational quality monitoring system is in place and implemented to measure success in achieving the homes aims, objectives and Statement of Purpose. Previous requirement not met 30/06/06. 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 Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Gardens (33) DS0000025927.V358868.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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