Inspection on 07/11/05 for 1 Sheppard Close

This inspection was carried out on 7th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Sheppard Close 24/10/07

1 Sheppard Close 06/09/06

1 Sheppard Close 25/05/05

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) Devizes Wiltshire SN10 2BT Lead Inspector Malcolm Kippax Announced Inspection 7th November 2005 09:30 Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 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 Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 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. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sheppard Close (1) Address Devizes Wiltshire SN10 2BT 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) 01380 725133 CARE (Cottage and Rural Enterprises Ltd) Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 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 on the ground floor, 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. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was arranged at short notice. The inspection started at 2 pm and finished at 6.40 pm. The home’s seven service users were met with in the communal rooms. As part of the inspection process, the Commission has also received several comment cards from service users and their relatives. The domestic areas and one of the service user’s rooms were seen. Two staff members were met with. Records, including care and support plans, health and safety, staffing and training were looked at. A new manager for the home has been appointed since the last inspection. The Commission is dealing with an application for registration. What the service does well: What has improved since the last inspection? What they could do better: Consideration should be given to finding further ways in which service users can be involved in decision making in the home. Comments received from relatives suggest that communication and the passing on of information could be improved. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 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. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 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 Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 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 the following standard(s): These standards were not looked at on this occasion. Standard 2 did not apply at this time, as there have been no changes in the home’s occupancy for a number of years. EVIDENCE: Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 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 the following standard(s): 6 Service users benefit from the information that staff members have about their personal support and goals. (Standards 6, 7 and 9 were assessed at the last inspection. Standard 6 was almost met and standards 7 and 9 were met). EVIDENCE: Examples of the service users’ care plans were looked at. It was reported at the last inspection that service users must receive more consistent support with the setting of objectives and care planning. This has received attention and the service users’ personal goals have been updated, some after discussion at recent review meetings involving other interested parties. Details of the service users’ current goals were readily available to staff when in the office. A new record for this had been produced, which gave a good means of highlighting the service users’ goals and the ‘achieve by’ dates. Service users’ spoke about things they like to do outside the home, including going into Devizes town centre and to sporting events. Some of the service users’ personal goals concern being more independent in some areas. One Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 Page 10 service user likes having a self-contained flat within the home and a move to more independent accommodation is being considered. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 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 the following standard(s): 15 Service users have some well established relationships and the opportunity to meet with people outside the home. Although staff members are in the role of keyworker, some relatives feel that they are not kept well informed. (Standards 12, 13, 16 and 17 were inspected and met at the last inspection). EVIDENCE: The service users’ personal records contained a section on ‘Family and Friends’. The examples seen contained personal and relevant information that would be useful for staff to know about the service users’ relationships. The care plans also included a ‘People and Relationships’ section. There are reminders for staff about birthdays that the service users would want to remember. Some service users have established friendships within the home and two people said that they like to go to football matches together. One service user said that she had a special friend at another C.A.R.E. establishment. This was also mentioned in her personal records. Each service user has a keyworker from the staff team, whose role includes support with family contacts and liaising with relatives. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 Page 12 Some service users said that they made regular visits to their parents and other family members. Comments cards were received from four relatives as part of the inspection process. Each person stated that they are satisfied with the overall care provided – one person had added the comment ‘mostly’, while another person commented that it was ‘excellent’. However, two relatives responded negatively in response to the questions: • Are you kept informed of important matters affecting your relative/care? and: • If your relative/friend is not able to make decisions, are you consulted about their care? Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 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 the following standard(s): 19 Suitable arrangements are in place for meeting the service users’ health needs. (Standards 18 and 20 were inspected at the last inspection. Standard 18 was met and standard 20 was almost met). EVIDENCE: Service users are independent in some of the practical arrangements. During the inspection, one service user went to the dentist by himself. A staff member said that all the service users had good general heath. It was seen from the minutes of staff meetings that the service users’ health needs and support are regularly discussed. Some referrals with specialists have been made, particularly concerning one service user. Other service users had appointments coming up with a neurologist and for dental treatment. Details of various health matters were recorded in the service users’ personal files. Following some recent specialist tests, one service user has been advised to maintain good fluid intake. The staff members spoken with were aware of the need to encourage this. Although it was documented under the health records, the care plan had not yet been updated to include this. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 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 the following standard(s): 23 Service users are better protected following changes in the guidance that is available to staff members. (Standards 22 and 23 were inspected at the last inspection. Standard 22 was met and standard 23 was almost met). EVIDENCE: It was reported at the last inspection that the contents of the policy file needed to be reviewed in order to ensure that only the appropriate and up to date guidance on abuse is included. This has received attention and C.A.R.E. have produced new guidelines on the protection of vulnerable adults. A staff member said that this had been discussed with staff members at a recent meeting. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 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 the following standard(s): 30 Service users are encouraged to take some responsibility for the domestic tasks and suitable arrangements are in place for maintaining cleanliness. (Standards 24, 25, 26 and 28 were inspected at the last inspection. Standard 24 was almost met and Standards 25, 26 & 28 were met). EVIDENCE: Service users said that they each have a different cleaning job in the home. This included vacuuming and cleaning toilets. Service users appeared to be happy with their jobs and what they are expected to do. A staff member said that staff overview standards of cleanliness and provide practical support. Cleaning schedules have been produced. Cleanliness in the areas of the home seen during the inspection was satisfactory. The communal rooms in particular looked tidy and clean. A bathroom floor will need replacing in the near future because of its general condition. The deputy manager has undertaken a course on hygiene and cross-infection. One matter was raised by an environmental health officer during an inspection Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 Page 16 in September 2005. This concerned the more frequent recording of refrigerator temperatures, which has since received attention. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 There is a well planned approach to the recruitment and induction of new staff. Various checks are well documented although evidence in respect of one important area needs to be available. There are good opportunities for staff development and service users benefit from the training that staff members undertake. (Standard 33 was inspected and met at the last inspection). EVIDENCE: There have been no changes in the staff team since the last inspection. The staff team includes support workers who know the service users well. The employment record for the most recently appointed staff member was looked at. This included application form, references and proof of identity. However, some personnel matters are dealt with at the nearby CARE Wiltshire offices and evidence of the carrying out of a P.O.V.A. / C.R.B. check was not available in the home. Induction using L.D.A.F. accredited training is provided. A staff member met with was undertaking one of the L.D.A.F. certificates. This is a relevant qualification and a shows a positive commitment to training by both the staff Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 Page 18 member and the organisation. Two members of the staff team have achieved NVQ at level 2. Examples of two staff members’ training and development records were looked at. These provided an up to date record of training that had been undertaken in areas that included first aid, food hygiene, bereavement and loss, fire, medication and sexuality & relationships. There is a training programme under which priorities are identified for staff training within their first two years of employment. Consideration is being given to including dementia within the training programme for staff. This would be a good development. The need for training in other care related subjects is to be discussed with the CARE Residential Services Manager. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 42 Service users are benefiting from a more settled management and staff team. However some service users wish to be more involved in decision making in the home. There are suitable arrangements in place for maintaining health and safety in the home. (Standards 39 and 41 were inspected at the last inspection. Standard 39 was met and standard 41 was almost met). EVIDENCE: Standard 37 was not fully inspected. The fit person process (for registration under the Care Standards Act 2000) has not yet been completed on the person who was appointed earlier in the year to manage the home. However the new manager has been working in the home for several months and the home’s deputy manager has continued in post. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 Page 20 Improvements were evident in the standard of administration / record keeping and in how information about service users is updated and presented. Service users were open in their comments and appear to get on well with the staff and management team. Five service users had completed comment cards, some with the support of staff. Questions about the care, respect for privacy, activities and food were all responded to positively. One service user commented that they did not want to be more involved with decision making in the home. However, three service users would like to be more involved (including one person ‘sometimes’). Service users currently attend house meetings and contribute to a system of quality assurance. Members of the staff and management team have responsibility for overviewing areas of health & safety. The deputy manager confirmed her role as the home’s fire precautions officer. Checks and testing of the fire precaution systems were up to date, as recorded in the fire log book. A fire drill took place on 1 November 2005. The deputy manager said that fire precautions are discussed at staff meetings. The fire log book included a record of instruction and other fire training events were recorded in the staff members individual records. The latter also needs to be recorded in the fire log book as confirmation that each staff member has received instruction at least once in every period of three months. The home’s fire risk assessment was due to be reviewed. The deputy manager said that risk assessments were to be reviewed on the day following the inspection, with a health & safety officer from CARE Wiltshire. The fire risk assessment was due to be reviewed and it was agreed with the deputy manager that this would be done within two weeks. Hot water thermostatic regulators are fitted to the baths and temperature checks undertaken monthly. The radiators are covered. A gas safety certificate for the home was issued in September 2005. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 Page 21 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 N/A X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sheppard Close (1) Score X 3 X X Standard No 37 38 39 40 41 42 43 Score N/A X X X X 2 X DS0000028293.V264800.R01.S.doc Version 5.0 Page 22 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. 1. 2. Standard YA34 YA37 Regulation 19(1) 12(2) Requirement Evidence of the completion of POVA and CRB checks must be documented in the home. The service users’ wishes in respect of decision making in the home must be followed up and acted on accordingly. All training and instruction in fire precautions received by staff members must be recorded in the fire log book. The fire risk assessment must be reviewed. Timescale for action 30/11/05 16/12/05 3. YA42 23(4) 08/11/05 4. YA42 23(4) 21/11/05 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 YA15 YA35 Good Practice Recommendations That consideration is given to how communication and information sharing with relatives should be improved. That the subject of dementia is included in the staff training programme. Sheppard Close (1) DS0000028293.V264800.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham 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) DS0000028293.V264800.R01.S.doc Version 5.0 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!