Inspection on 29/11/07 for Sunlight House

This is the latest available inspection report for this service, carried out on 29th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Sunlight House 412 Hill Cross Avenue Morden Surrey SM4 4EX Lead Inspector Adrian Gordon Unannounced Inspection 29th November 2007 10:00 Sunlight House DS0000067655.V355237.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 Sunlight House DS0000067655.V355237.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. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunlight House Address 412 Hill Cross Avenue Morden Surrey SM4 4EX 020 8286 3509 020 8286 3509 sunlighthouse@hotmail.co.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) Mr Moonesswar Jingree Vishul Seewoolall Care Home 4 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (4) of places Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2007 Brief Description of the Service: Sunlight House is registered with the CSCI to accommodate a maximum of four adults with mental health problems or a learning disability. The home is located in a residential road in Morden close to bus routes and local shops. Accommodation is over two floors, and includes a large kitchen, lounge and dining room. At the rear of the property is a large grassed area. The home is staffed twenty four hours a day. Further information about the service is available in the Statement of Purpose and Service User Guide. Sunlight House currently charges fees of £1000 per week, but fees vary according to the support required. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over the course of one day by one inspector. It consisted of a tour of the premises, observation of practice and examination of records. We spoke to people who use the service and the manager Completed surveys were received from all the people living at the home and five members of staff. What the service does well: What has improved since the last inspection? What they could do better: Sunlight House has been given no requirements following this inspection and has met all the required standards. It will further improve the service when the ground floor bedroom is completed which will provide wheelchair accessible accommodation. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 6 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. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 7 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 Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 8 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): 2, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good assessments are in place to help staff to understand the needs of individuals. New admissions are given the information they need about the service provided. EVIDENCE: A full needs assessment is carried out before anyone comes to live at the home. The assessment gives a clear picture of the needs of each individual and the reason for their referral. Information from the referring authority is clear and detailed which makes sure that staff have a good overall understanding of what support is needed. Copies of contracts and tenancy agreements are kept in the file for each person that uses the service. These are signed and include information about rights and responsibilities. A full breakdown of fees makes it clear what they are used for. The contract states the need for new admissions to have a trial period in the home before living there full time. One person confirmed on a questionnaire that they were given enough information about the home beforehand in order to decide if it was right for them. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 9 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, 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Written information held on people who use the service is of an excellent standard. It is clearly laid out, person centred and gives a good understanding of individual needs and goals, and how best to offer support. EVIDENCE: Person centred care plans are clearly written and contain very good information on how to support each person that uses the service. Areas covered include relationships, personal care, mental health and social/spiritual needs. The support needed is detailed and says what to do and when. Information on communication is very useful and explains what individuals might say, what it could mean and how staff can help. This helps to avoid misunderstandings and encourages good communication. Care plans were seen to be signed and dated. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 10 One staff member commented that ‘we empower our clients and keep them central to every process’. Individuals are encouraged to make decisions about their lives, for example, what to do in the daytime, what to wear and what to eat at mealtimes. Any limits on what they can do are explained and recorded on file. Risk assessments are specific to each individual and cover areas such as behaviour, fire safety and use of the kitchen. They are clearly written and showing the level of risk and any action needed. A risk management plan is also in place. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to take part in activities of their choice and are supported to take responsibility for their daily lives. EVIDENCE: People who use the service make use of the local community facilities which are available. For example, one person said they go to a local college to learn maths and creative arts. They also enjoy sporting activities such as tennis, gym and swimming. Attendance at church or Mosque is supported if someone wants to practice their religion. Individuals are also encouraged to learn living skills to develop their independence and confidence. Friends and relatives are made welcome if they want to visit. Because it is a small home there are no set menus at mealtimes. Instead individuals are asked what they want each day, and if they want to help out Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 12 with cooking. A record of meals eaten is maintained. Staff make use of the London Borough of Merton’s food hygiene monitoring pack which helps to make sure that all aspects of storage and cooking are safe. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service receive effective personal and healthcare support using a person centred approach. EVIDENCE: Each person who uses the service has a keyworker who meets with them regularly to discuss any issues in the home. The personal preferences of each person are recorded in their file. Individuals are registered with a doctor and receive additional support from a Community Mental Health Team and Community Psychiatric Nurse. The manager is committed to making sure that people get the services they are entitled to, particularly with regard to their mental health needs. This is demonstrated in letters to professionals outside the home. There is very good information about the health needs of people who use the service. A Health Action Plan includes information on important health checks such as visiting the optician, dentist or doctor. It is made clear who will help, Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 14 when it will happen and when it should be reviewed. There is also a Health Booklet for each person which is easy to understand and includes information on health conditions and allergies. Medication profiles include details of medication taken and the reason for taking it. Any possible side effects are recorded and it also confirms that individuals are aware of what these are. No gaps were seen on Medication Administration Record (MAR) sheets. Medication which is taken ‘as required’ is properly recorded and a reason is given for why it was taken. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good procedures and training for staff make sure that people who use the service are protected. EVIDENCE: Procedures for the Protection of Vulnerable Adults (POVA) are kept in the office. The procedures include local guidelines from the London Borough of Merton. A programme is in place to make sure all staff receive regular POVA training. A book is available to record any complaints. There have not been any since the last inspection. The complaints procedure is included in the Service User Guide. One person who uses the service said they knew what to do if they had a complaint. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 16 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, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people that live at Sunlight House benefit from the clean and comfortable surroundings. EVIDENCE: Sunlight House is located in a residential street in Morden and fits in with other houses in the area. On the ground floor there is a lounge, dining room and large kitchen. The garage is being converted into a bedroom which is accessible for wheelchair users. An extension from the dining room has been turned into a sun lounge with a pool table and dartboard. All shared areas were clean, tidy and well furnished. To the rear of the house is a large grassed area. There are four bedrooms on the first floor, two of which have ensuite bathrooms. The other two bedrooms share a toilet and separate bathroom. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 17 Bedrooms are spacious, bright and suitable for the people who live there. One person said that they were looking forward to getting a new, larger bed soon. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 18 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): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff receive the support they need in order to deliver an effective service. EVIDENCE: One member of staff said in a questionnaire that ‘we have a good team and work together’. Recruitment records for staff held all the necessary information. This included a photograph, proof of identification, two references and an enhanced criminal records check. Copies of signed employment contracts and job descriptions are also held. A good range of training is available either through a consultant who visits the home or externally. Examples of recent training include managing challenging behaviour, mental capacity act and working with women in mental health settings. Core training, such as first aid and food hygiene is mostly up to date although two staff need a fire safety update. In questionnaires received by staff, all said they are given training relevant to their role. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 19 Supervisions take place about every six weeks. Records are kept which are signed and dated by staff being supervised. The manager showed new appraisal forms which will be used to monitor staff progress and discuss needs and goals for the coming year. These are due to be completed in the near future. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 20 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, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run by a competent manager. People who use the service are given good opportunities to express their views. EVIDENCE: The registered manager has experience in working with adults with learning disability and mental health problems and has a good understanding of all aspects of managing a home. He is qualified as an NVQ assessor and is currently studying for the Registered Managers Award. He is committed to making sure that people with mental health problems get the support they need, both in the home and from other professionals. This was demonstrated by some of the letters seen in the records of people who use the service. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 21 Monthly visits are carried out by the registered provider, however not all of the reports from these visits are kept at the home. Service User comment forms have been developed to help individuals have a say about how the home is run. These include questions such as ‘Would you like to help interview staff?’ Information in files shows that people are also asked for feedback in meetings with keyworkers or at reviews. All of the relevant health and safety checks have been carried out, for example gas safety test and a portable appliance test. The manager completes a monthly health and safety monitoring form that includes checking the environment and fire safety. Health and safety checks are also carried out at each handover. Monthly fire drills are completed and fire call points are tested each week. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 22 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 X 2 3 3 X 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 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X 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 4 3 X 3 3 3 X X 3 X Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA35 YA39 Good Practice Recommendations To make sure all staff are aware of up to date responsibilities fire safety training should be completed. To make sure there is effective quality monitoring, monthly provider visit reports must be kept at the home. Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Sunlight House DS0000067655.V355237.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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