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Inspection on 01/02/10 for Shannon Court

Also see our care home review for Shannon Court for more information

This is the latest available inspection report for this service, carried out on 1st February 2010.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There have been improvements in the security of the building and on arrival an intercom system was answered by the homes senior administrator. The person in charge advised that the home will be employing a receptionist to meet and greet all persons entering the home and a notice board will be used to detail the staff members on duty including identifying the fire marshall and first aider on duty. To reflect good practise it has been recommended that the home consider developing a written policy and procedure regarding welcoming and vetting people visiting the home to ensure the safety and wellbeing of residents and staff. The person in charge advised that the organisation has reviewed the current care plan used by the home and a new person centred care plan has been developed and will be implemented within the home in April 2010. The redeployment of staff in the homes units has been improved to include dedicated shift leaders who oversee specific units and who work alongside staff during their shifts to support staff and mentor good practise. It was reported that this new way of working has been of benefit to residents as staff have been supported to provide a more consistent approach to the care and support needs of residents. The documentation of care plans has improved and is now undertaken during the shift or at the end of the shift prior to the midday handover to the next staff. The person in charge explained that audits are undertaken by the shift leaders to ensure accurate and factual information is reported throughout a twenty four hour period to ensure the safety, welfare and well being of residents in the home. There have been improved protocols regarding the completion of notifications which affect the wellbeing and welfare of residents in the home and the homes operations manager has sent to the commission retrospective notifications. A policy and procedure has been documented regarding actions to be taken following the incidents of residents falls and the homes management have improved the auditing of the incidences of unwitnessed falls in the home to ensure the safety and well being of residents. The person in charge confirmed that the procedures for informing relatives and friends of residents regarding occurrences in the home have improved and will be sustained by the homes staff.The home are implementing a document known as `grab sheet` to be used in the case of emergency admissions to hospital which contain relevant information about the resident in order to support the emergency service personnel to have a swift overview of the persons general health, medication and diagnosis. The person in charge advised that they had recently met with the local general practitioner and district nurse who visit the home in order to develop and maintain good professional working partnerships. The organisation have revised and republished the staff handbook which contained clear documented policy and procedures regarding the performance management of staff and included up to date disciplinary procedures, expectations of staff regarding their responsibility and duty of care to report any incidence or suspected incidence of abuse or harm to residents through the whistle blowing procedures. Clear safeguarding procedures and a documented bullying and harassment policy were also in place. It was confirmed with the person in charge that supervision of staff and team meetings, with both day and night staff, had been held and spot checks during the night shifts were continuing to be undertaken to monitor staff performance and ensure the safety and well being of residents. A significant number of staff have been employed since the previous inspection and it was confirmed that all staff had received their structured induction. It was confirmed that English lessons were made available to staff at a local college if the staff member needed additional support to assist in their communication with residents and staff in the home. The person in charge confirmed that residents meetings had been held and also that she had met with a number of residents relatives and friends. It is proposed that some of the meetings be combined to improve the overall communication in the home with residents, staff and their relatives and friends which would also improve and further promote the quality assurance process of the home. It was confirmed that the homes chef had undertaken a specific management course for residents with dementia and had been working alongside care staff to further promote staff skills regarding choice and participation at meal times. The person in charge confirmed that the culture of the home has been addressed and where shortfalls have been identified improvements have been implemented to improve the residents rights to choice and improved working practises. The safe handling of medicines was assessed by a Commission specialist pharmacist. They looked at the records kept in the home, staff training and policies and procedures, which all related to issues outstanding from the last inspection on 16th November 2009. We looked in detail at the medicines and records for 9 people living on three of the five units. People are supported to be as independent as possible. However when they need help with their medicines this is provided by designated trained care staff. Those staff who were in need of updating their training in medicine handling have completed a distance learning program and have had their competency assessed. Detailed written procedures are available to staff to provide guidance and to enable medicines to be handledconsistently by all staff. Up to date copies were available on the units. Clear records were kept to show when people were given their medicines. If a medicine was not given this was clearly recorded together with the reason why. These showed that people get their medicines correctly. Some people were prescribed medicines to be given only when needed. All of these people had clear and detailed plans describing to staff when the medicines are to be given. Records were being kept when any of these medicines were given together with whether they were effective. The service undertakes their own audits of medication handling processes. These are now being done regularly. They show that some minor issues have been picked up and that action plans have been put in place to deal with them.

What the care home could do better:

The person in charge confirmed that staff had not received any in depth training to support residents with Dementia and this has been an ongoing shortfall within the service despite previous assurances that the staff will be provided with the specific training to support residents within the homes specialist unit Alvernia. It has been required that arrangements must be made that all staff undertake Dementia training in order to have the understanding, skills and abilities to fully support the residents in their care.

Random inspection report Care homes for older people Name: Address: Shannon Court Portsmouth Road Hindhead Surrey GU26 6DA two star good service 27/07/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Suzanne Magnier Date: 0 1 0 2 2 0 1 0 Information about the care home Name of care home: Address: Shannon Court Portsmouth Road Hindhead Surrey GU26 6DA 01428604833 01428606422 Telephone number: Fax number: Email address: Provider web address: www.rmbi.org.uk Name of registered provider(s): Name of registered manager (if applicable) Royal Masonic Benevolent Institution Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 53 Number of places (if applicable): Under 65 Over 65 0 0 53 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Conditions of registration: 53 53 0 The maximum number of service users to be accommodated is 53. The registered person may provide the following category of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Dementia - (DE) Mental disorder, excluding learning disability or dementia (MD) Date of last inspection Care Homes for Older People 1 6 1 1 2 0 0 9 Page 2 of 9 Brief description of the care home Shannon Court is a care home for older people and provides care for Freemasons and the dependent females of Freemasons. The large house offers accommodation for residents on two floors and is separated into five units. Each unit has its own dining room and lounge facilities. Access to the first floor is via passenger lifts. The units named Alvernia and Davis are specfically designed to provide accomodation and care to residents with dementia. All bedrooms throughout the home are single occupancy and have en-suite facilities. There is a large communal lounge in the main building with a licensed bar and a shop. Residents can purchase goods, for example toiletries, stamps and sweets and spend time socialising with friends and visitors in the communal areas if they choose. There is an activities room, a library and a hairdressing salon in the main building, all of which are accessible to residents. The well maintained private grounds are accessible to residents and there is ample car parking available to the front of the building. Care Homes for Older People Page 3 of 9 What we found: The random inspection was carried out by Ms Suzanne Magnier Regulation Inspector who arrived at the service at 08.00 and left at 11.00. The reason for the inspection was to follow up some of the concerns raised during local authority safeguarding meetings and to ascertain the management arrangements and monitor improvements made by the home following the previous Key Inspection 27th July 2009 The service was represented by the person in charge who has been newly appointed as the manager to the home and will be seeking to apply for the position of registered manager with the Care Quality Commission. What the care home does well: There have been improvements in the security of the building and on arrival an intercom system was answered by the homes senior administrator. The person in charge advised that the home will be employing a receptionist to meet and greet all persons entering the home and a notice board will be used to detail the staff members on duty including identifying the fire marshall and first aider on duty. To reflect good practise it has been recommended that the home consider developing a written policy and procedure regarding welcoming and vetting people visiting the home to ensure the safety and wellbeing of residents and staff. The person in charge advised that the organisation has reviewed the current care plan used by the home and a new person centred care plan has been developed and will be implemented within the home in April 2010. The redeployment of staff in the homes units has been improved to include dedicated shift leaders who oversee specific units and who work alongside staff during their shifts to support staff and mentor good practise. It was reported that this new way of working has been of benefit to residents as staff have been supported to provide a more consistent approach to the care and support needs of residents. The documentation of care plans has improved and is now undertaken during the shift or at the end of the shift prior to the midday handover to the next staff. The person in charge explained that audits are undertaken by the shift leaders to ensure accurate and factual information is reported throughout a twenty four hour period to ensure the safety, welfare and well being of residents in the home. There have been improved protocols regarding the completion of notifications which affect the wellbeing and welfare of residents in the home and the homes operations manager has sent to the commission retrospective notifications. A policy and procedure has been documented regarding actions to be taken following the incidents of residents falls and the homes management have improved the auditing of the incidences of unwitnessed falls in the home to ensure the safety and well being of residents. The person in charge confirmed that the procedures for informing relatives and friends of residents regarding occurrences in the home have improved and will be sustained by the homes staff. Care Homes for Older People Page 4 of 9 The home are implementing a document known as grab sheet to be used in the case of emergency admissions to hospital which contain relevant information about the resident in order to support the emergency service personnel to have a swift overview of the persons general health, medication and diagnosis. The person in charge advised that they had recently met with the local general practitioner and district nurse who visit the home in order to develop and maintain good professional working partnerships. The organisation have revised and republished the staff handbook which contained clear documented policy and procedures regarding the performance management of staff and included up to date disciplinary procedures, expectations of staff regarding their responsibility and duty of care to report any incidence or suspected incidence of abuse or harm to residents through the whistle blowing procedures. Clear safeguarding procedures and a documented bullying and harassment policy were also in place. It was confirmed with the person in charge that supervision of staff and team meetings, with both day and night staff, had been held and spot checks during the night shifts were continuing to be undertaken to monitor staff performance and ensure the safety and well being of residents. A significant number of staff have been employed since the previous inspection and it was confirmed that all staff had received their structured induction. It was confirmed that English lessons were made available to staff at a local college if the staff member needed additional support to assist in their communication with residents and staff in the home. The person in charge confirmed that residents meetings had been held and also that she had met with a number of residents relatives and friends. It is proposed that some of the meetings be combined to improve the overall communication in the home with residents, staff and their relatives and friends which would also improve and further promote the quality assurance process of the home. It was confirmed that the homes chef had undertaken a specific management course for residents with dementia and had been working alongside care staff to further promote staff skills regarding choice and participation at meal times. The person in charge confirmed that the culture of the home has been addressed and where shortfalls have been identified improvements have been implemented to improve the residents rights to choice and improved working practises. The safe handling of medicines was assessed by a Commission specialist pharmacist. They looked at the records kept in the home, staff training and policies and procedures, which all related to issues outstanding from the last inspection on 16th November 2009. We looked in detail at the medicines and records for 9 people living on three of the five units. People are supported to be as independent as possible. However when they need help with their medicines this is provided by designated trained care staff. Those staff who were in need of updating their training in medicine handling have completed a distance learning program and have had their competency assessed. Detailed written procedures are available to staff to provide guidance and to enable medicines to be handled Care Homes for Older People Page 5 of 9 consistently by all staff. Up to date copies were available on the units. Clear records were kept to show when people were given their medicines. If a medicine was not given this was clearly recorded together with the reason why. These showed that people get their medicines correctly. Some people were prescribed medicines to be given only when needed. All of these people had clear and detailed plans describing to staff when the medicines are to be given. Records were being kept when any of these medicines were given together with whether they were effective. The service undertakes their own audits of medication handling processes. These are now being done regularly. They show that some minor issues have been picked up and that action plans have been put in place to deal with them. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 6 of 9 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 7 of 9 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 30 18 Arrangements must be made 31/08/2010 that all staff undertake Dementia training. In order to have the understanding, skills and abilities to fully support the residents in their care. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 38 It has been recommended that the home consider developing a written policy and procedure regarding welcoming and vetting people visiting the home to ensure the safety and wellbeing of residents and staff. Care Homes for Older People Page 8 of 9 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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