Inspection on 25/05/05 for 1 Sheppard Close

This inspection was carried out on 25th May 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

1 Sheppard Close 24/10/07

1 Sheppard Close 06/09/06

1 Sheppard Close 07/11/05

1 Sheppard Close 29/01/05

1 Sheppard Close 26/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Sheppard Close (1) 1 Sheppard Close Devizes Wiltshire SN10 2BT Lead Inspector Malcolm Kippax Unannounced 25th May 2005 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 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 Stationary 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. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sheppard Close (1) Address 1 Sheppard Close Devizes Wiltshire SN10 2BT 01380 725133 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) CARE (Cottage and Rural Enterprises Ltd) Vacant Care Home 7 Category(ies) of LD Learning Disability 7 registration, with number of places Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 29th January 2005 Brief Description of the Service: 1 Sheppard Close is run by Cottage and Rural Enterprises Ltd. (C.A.R.E.) and provides care and accommodation for up to seven people with a learning disability. The property is purpose built and located in a residential area of Devizes. The accommodation includes a self-contained flat, which is used by one service user. The other service users have their own rooms on the first floor of the main part of the home. There is a lounge and an open plan kitchen / dining area for communal use. During the week, service users attend the day facilities at another C.A.R.E. establishment that is located in the nearby village of Rowde. Support is provided by a management and staff team, although service users are independent in many aspects of their activities and personal routines in the home. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection started at 3.00pm and took place over three and a half hours. The service users came back from their day activities and quickly settled into their own routines – mainly spending time in their rooms or watching television in the lounge. The service users had tea together at 5.30pm. Seven service users and two members of staff were spoken to. The Residential Services Manager from C.A.R.E was also spoken with. The communal rooms and two bedrooms were seen, including the self-contained flat. Some records were examined, including two of the service users’ care records. The Pharmacist Inspector looked at medication arrangements in the home. The home’s manager has resigned since the last inspection and a new manager had not yet been appointed. What the service does well: What has improved since the last inspection? A new system of quality assurance system has been introduced. Service users are pleased that a new person has joined the staff team and they are also to benefit from additional staffing that has now been agreed. The garden looks a lot better than at the previous inspection and service users said that there are some nice seats that they can use in the Summer. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 6 What they could do better: 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. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion. EVIDENCE: Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 The systems in place for care planning and the setting of individual goals are not being consistently applied and the information is not all up to date. Service users are well consulted through individual review meetings and regular house meetings. Service users enjoy taking part in the home’s domestic activities and are encouraged to treat the home as their own. Risk assessments are helping to ensure that the service users can do this safely. EVIDENCE: The personal care plans were produced in February 2005 and had been signed by the service users. The plans showed a six-monthly review date. One service user’s action plan had not been updated since January 2004. The other plan seen was more recent although neither plan showed the progress that service users had made with their individual goals and whether these had been achieved. During the inspection, one service user helped to prepare the tea meal and another service user volunteered to help with the clearing up. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 10 Comments from service users confirmed that they are able to follow activities and routines without any undue restrictions. Following assessment, some service users are able to go out by themselves. Minutes are kept of the house meetings; these showed that service users’ views are listened to and that they like to take an active role in the home’s routines. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 16 and 17 Service users generally enjoy how they spend their time and are busy during the week. The house meetings are a good way in which service users can discuss their activities and what they want to do. Service users are looking forward to their summer holiday, which they have talked about during the meetings. Service users receive support from staff who respect their rights and encourage participation in the community. The meal arrangements reflect individuals’ personal choices and encourage the service users’ involvement. EVIDENCE: Service users returned home later in the afternoon and quickly settled into their own routines. During the tea meal the service users talked about their different activities . These are centred on the workshops and facilities that are provided at CARE Rowde. Some service users also have other occupation and activities in the community, including working in a shop and attending a Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 12 college course. New activities were being discussed. One service user attends a horse riding session each week and was proud to have recently won an award. Service users go out in the local community and like being able to walk to nearby facilities. The house meeting minutes show that a range of topics are talked about, including social events and holidays. A Butlins holiday is planned for July and two service users have chosen to do something different. There is a planned menu for the week. An alternative would be available if needed although the menu is based on a selection of meals that are popular with service users. During the tea meal the service users and staff member produced a menu for the week ahead. Ideas about the meals were discussed and a consensus was reached about what would be included on the menu. Service users said that they enjoyed being involved in the preparation of meals. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 20 Service users receive a basic level of support and are encouraged to be independent in much of their personal care. Service users are supported to maintain some independence in the handling of their medicines. The home’s procedures ensure their individual needs are met; however the records do not accurately reflect the assistance given. EVIDENCE: Service users said that they were happy with the arrangements for their personal support. The care and support plans show the areas in which support from staff is required. Staff support with personal care is usually limited to encouragement and advice. Appointments with dentists, GPs and chiropodist are reported in the service users’ personal records. The medicines were stored in a locked cupboard or held securely by selfmedicating service users. Most service users retain some autonomy over the administration of their medication. This was recorded in their care plans and regularly reviewed. Staff were able to show how they amended the procedure to cope with individual situations. The records of the self administration were not completely clear and records were not maintained for the quantities of medicines received into the home. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Service users know what to do if they are not happy with something. They are encouraged to share any concerns and have the opportunity to do this. Staff members have an understanding of abuse and its seriousness, which helps to protect service users. However, the procedures and written guidance for staff are not up to date and do not reflect the developments that have taken place in recent years. EVIDENCE: A copy of the home’s complaints procedure was on display. Service users have informal networks for discussing any concerns and said that they know someone they can contact outside the home if they have a problem. Some issues are resolved through discussion during the House meetings. A new member of staff confirmed her awareness of abuse and what to do if abuse is suspected. Staff members receive their own copy of the home’s policies and procedures file. This includes a lengthy section with guidance on abuse that had been produced over ten years ago. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26 and 28 Service users benefit from the home’s proximity to their regular activities. Service users like the accommodation and appreciate the improvements that have been made in the garden. Service users make good use of the bathrooms but the practical arrangements mean that hot water can be in short supply. The fire precaution arrangements are not always meeting the required standard. EVIDENCE: Service users know the local area well and spoke about places that they visit, including the town centre and the nearby canal leisure facilities. These are within walking distance and the service users make use of the home’s own transport for other journeys. Service users were using their own rooms as well as mixing with others in the lounge and the dining room. The lounge is comfortably furnished and has a television and video. A separate dining area is available for individual and quieter activities. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 16 The two bedrooms seen were well personalised and reflected the occupants’ interests. The flat occupant said that she was happy with her accommodation but found the fire doors heavy to open and was waiting for some storage shelves to be fitted in a built in cupboard. The garden has been tidied up since the last inspection and is now in a much better state. The home’s fire log book was looked at. Tests of the alarm system were not always taking place on a weekly basis. Following discussion, these tests are to be carried out at a set time each week. There was no record of agency and relief staff having received instruction in fire precautions. Requirements in respect of the fire precautions were confirmed in an immediate requirement notice. There are sufficient baths and toilet facilities, however the hot water system cannot cope with the high demand for baths at particular times of day. The installation of a walk-in shower could help to alleviate this and be popular with the service users. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Service users enjoy good relationships with staff, however the staffing level is not always meeting a service user’s needs. The presence of a deputy manager has maintained continuity in the running of the home, following the absence of the registered manager. Service users are benefiting from the appointment of a new staff member who is being given time to familiarise themselves with the home before having full responsibility. EVIDENCE: The deputy manager is in an acting manager role until a new manager is registered. Staff meetings have continued on an approximately monthly basis, with minutes kept. There was positive interaction between staff and service users, when working together in the kitchen and in passing conversations. A new support worker has been appointed since the last inspection. This staff member was supernumery and completing an induction, which involved a gradual introduction to the work and responsibilities. An in-house induction programme was to be followed by L.D.A.F. training. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 18 A staff rota showed a minimum of one member of staff working throughout the day and ‘double cover’ at particular times. At weekends there are two people working for a middle shift on one of the days. On occasions, a service user has had to fit in with what other people are doing because of the need to be with the one staff member who is working. The staff rota was up to date. Agency staff and relief staff are covering shift on a regular basis. Dependence upon non-permanent staff will reduce when the new support worker is able to work on her own. It was also reported that an additional 20 staff hours a week were shortly to be made available. Minutes are kept of the staff meetings that take place approximately monthly. The meetings focus on a discussion of the service users’ progress. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 41 Service users, as a group, are consulted about many aspects of the home but there is a risk that their individual views will not be followed up. The method used for the recording of service users’ finances could put service users at risk of financial abuse. EVIDENCE: A new system of quality assurance had recently been introduced. This includes consultation with service users as part of the house meetings, and obtaining their views about different aspect of the home. The system, as described, involved gaining the group’s shared view, rather than the views of each individual. It has previously been recommended that receipts for expenditure are crossreferenced to the entries in the personal money records. This is not happening although some receipts are being obtained on an irregular basis. Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 x 3 x x Standard No 11 12 13 14 15 16 17 x 3 3 x x 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sheppard Close (1) Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 21 YES Are there any outstanding requirements from the last inspection? 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 6 Regulation 15 Requirement Service users must receive more consistent support with the setting of objectives and care planning. Progress in meeting objectives must be monitored on a regular basis Records must be kept of all medicines received into the home. Administration records must accurately reflect the practice for individual service users and differentiate between administration, prompting and social leave. A record of fire instruction given to agency and relief staff must be maintained in the fire log book Tests of the fire alarm system must be carried out at least weekly Timescale for action FROM 26/05/05 2. 20 13(2) FROM 26/05/05 3. 24 23(4) FROM 26/05/05 FROM 26/05/05 4. 24 23(4) 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 Version 1.30 Page 22 Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc 1. 2. 3. 20 23 41 Written alterations and additions to the medication administration records should be dated and signed by two members of staff. That the contents of the policy file are reviewed in order to ensure that only the appropriate and up to date guidance on abuse is included That the receipts obtained for personal money expenditure are numbered and cross-referenced to entries in the account forms Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sheppard Close (1) D51_S28293_SHEPPARDCLOSE(1)_v228776_250505Stage4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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