CQC report explained · a residential care home
What the CQC found at 2 Seymour Terrace
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors looked only at infection prevention and control under this question. They were assured that the home was using protective equipment safely, following social distancing and shielding rules, and had arrangements for testing and managing outbreaks.
- Effective?
- Good
- People were supported to make choices and staff understood the Mental Capacity Act. Staff were trained and supported, people's health needs were assessed, and people were helped to access health professionals. One person's records still contained inaccurate information about restrictions.
- Caring?
- Good
- This question was not covered by this focused inspection, so no new rating was given in this report.
- Responsive?
- Good
- This question was not covered by this focused inspection, so no new rating was given in this report.
- Well-led?
- Requires improvement
- People, relatives and staff had confidence in the manager. However, quality checks had not identified inaccurate and misleading information in a support plan, so the governance system could not always be relied on to drive improvements.
What inspectors found, October 2020
Rated Good overall; inspectors found effective, supportive care, but the well-led rating Requires Improvement because records and quality checks were not always reliable.
This was a focused, planned inspection on 9 September 2020. One inspector spoke with a person living at the home, the registered manager and a senior manager. The inspector also reviewed three people's care records, staff training, infection control and quality checks, and received feedback from relatives and staff.
People were described as feeling safe and supported. Staff understood people's needs, received training and support, and helped people access health professionals. Inspectors were assured that infection prevention measures, including protective equipment, testing and visiting arrangements, were in place.
The Effective rating improved from Requires Improvement to Good. However, Well-led remained Requires Improvement. Some care records contained inaccurate or misleading information about restrictions, and the home's quality assurance process had not identified this.
The overall rating changed from Requires Improvement to Good. The home was no longer in breach of regulations found at the previous inspection, but inspectors made recommendations about reviewing documentation and strengthening governance systems.
Supportive staff
Staff received the training, supervision and support needed for their roles. People told inspectors that staff understood how to support them.
“Staff continued to receive the training and support they required to do their job.” from the report
Health support
People's physical, emotional and mental health needs were assessed. The home worked with health professionals, including a consultant psychiatrist.
“People's physical, emotional and mental health needs continued to be assessed.” from the report
Choice and control
People were supported to make choices and control their lives, including having control over their finances. Staff had training in the Mental Capacity Act.
“People were supported to have maximum choice and control of their lives and the policies and systems in the service supported this practice.” from the report
Infection control
Inspectors were assured that the home had effective infection prevention arrangements, including safe use of protective equipment, testing and measures for visitors.
“We were assured that the provider was using PPE effectively and safely.” from the report
Inaccurate care records
needs fixingOne person's records contained misleading and inaccurate information about who could restrict their access to the community. The manager said this was historical information and took action after the inspection.
“records for one person living at the service continued to contain misleading and inaccurate information.” from the report
Quality checks missed problems
needs fixingThe home's audits and reviews had not identified the inaccurate information in a support plan. Inspectors recommended reviewing these systems so they reliably identify and address concerns.
“Some records were not accurate and the process in place could not be relied upon to identify and make improvements.” from the report
- 01What inaccurate or misleading information has been removed from people's support plans, and when was this checked?
- 02How do you now make sure every restriction on a person's liberty has the correct legal authority?
- 03What changes have been made to audits and quality checks since this inspection?
- 04How do you check that staff training, supervision and support remain up to date?
- 05How are infection control, testing, protective equipment and visitor arrangements currently monitored?
This was a focused inspection of Effective and Well-led, with an infection control review; the other ratings used in the overall rating were carried over from the previous comprehensive inspection. This explanation was written from the published report of 23 October 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2019
The Community of St Antony & St Elias - 2 Seymour Terrace was rated Requires Improvement; care was kind and generally safe, but legal rights and management systems were not always protected.
This was an unannounced inspection on 16 and 18 April 2019. The inspectors spoke with people living there, relatives, staff, managers and healthcare professionals. They reviewed care records, medicines records, staff records and quality checks.
People said they felt safe, happy and well supported. Inspectors found kind and respectful care, safe medicines practice, personalised support and good opportunities for activities and independence. The Safe, Caring and Responsive ratings were Good.
There were serious concerns about people's legal rights. One person with capacity was not making decisions about their money, and restrictions on another person's freedom to leave had no legal basis. The home also needed clearer training records and stronger systems for checking that legal requirements were met.
The overall rating was Requires Improvement. This was unchanged from the previous inspection. Safe and Responsive improved from Requires Improvement to Good, while Effective and Well-led remained Requires Improvement.
Kind and respectful care
Inspectors found that staff treated people with compassion and respect. People were involved in decisions about their care and supported to make choices.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Safe medicines
Medicines were stored, given and recorded safely. Staff were trained and their competence was checked regularly.
“Staff had received training in the safe administration of medicines and were having their competency regularly assessed.” from the report
Personalised support
Support plans reflected people's needs, preferences and interests. Staff supported people to attend appointments, maintain relationships and develop daily living skills.
“Support plans provided staff with descriptions of people's abilities and how they should provide support in line with people's preferences.” from the report
Activities and independence
People were supported to lead active lives and choose activities such as walking, cookery, art and music. They could also take part in shopping, meal preparation and other household tasks.
“People were encouraged and supported to lead full and active lifestyles, follow their interests, and take part in social activities.” from the report
People's legal rights
seriousOne person had capacity but staff were still managing some money and bankcards without involving them in the choice of account. Restrictions on another person's freedom to leave had no legal basis.
“We found the home was not taking appropriate action to protect one person's rights.” from the report
Unauthorised restrictions
seriousOne person's liberty was restricted without lawful authority, and they had not been told that the provider had no legal power to impose those restrictions.
“Depriving someone of their liberty for the purpose of receiving care or treatment without lawful authority is a breach for Regulation 13” from the report
Training records
needs fixingRecords did not clearly show whether specialist mental health training was still valid. Managers could not say how often it should be renewed.
“However, records we saw were not clear and as such we were unable to tell if the specialist training staff had received was still valid.” from the report
Window safety
needs fixingWindows above ground level had been assessed as a falls risk but did not have suitable restrictions. CQC recommended fitting robust, tamper-proof restrictors.
“windows above ground level that had been risk assessed as placing people at risk of falls from height, were not being appropriately restricted.” from the report
Management checks
seriousThe home's systems had not identified or fixed all the legal and quality problems. The annual survey for the year ending 2018 had also been overlooked.
“Failure to ensure systems were operated effectively to ensure compliance with the regulations was a breach of Regulation 17” from the report
- 01How do you make sure people with capacity make their own decisions about money and bank accounts?
- 02What is the current legal basis for any restrictions on a person's freedom to leave the home?
- 03How do you tell people about their legal rights when restrictions are being considered or used?
- 04How do you record specialist mental health training, and how often is it renewed?
- 05What changes have you made to window restrictors and to the guidance for physical intervention?
This was an unannounced inspection covering all five CQC key questions, including the care provided and the premises. This explanation was written from the published report of 26 July 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 2 Seymour Terrace
4 rated inspections over 5 years: the service has held its Good rating throughout.
- October 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019Requires improvementstayed Requires improvementEffective: Requires improvementWell-led: Requires improvement
- January 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
17 live-in carers within about an hour of Devon
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,270 a week. 15 can care for a couple. 13 years' experience on average.
“She is such a warm and gentle person while being professional and competent at the same time.”
“She looked after my mum, who can be incredibly challenging, so well and so gently, and we always felt confident that my mum was getting the best care available.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.