Inspection on 14/05/07 for Pamela Barnett

This inspection was carried out on 14th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Pamela Barnett 16/11/05

Pamela Barnett 19/04/05

Pamela Barnett 07/12/04

Pamela Barnett 24/06/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Shelanu Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ Lead Inspector Sally Newman Unannounced Inspection 14th May 2007 10:05 Shelanu DS0000033981.V330913.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 Shelanu DS0000033981.V330913.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. Shelanu DS0000033981.V330913.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shelanu Address Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ 01344 755523 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) bucketsandspades@norwood.org.uk Norwood Ravenswood Ltd T/A Norwood Mrs Leahanne Black Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Shelanu DS0000033981.V330913.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th November 2005 Brief Description of the Service: Shelanu is part of the Norwood organisation based at the Ravenswood Village. The home is established to accommodate up to eight service users aged between 18 and 65. The home accommodates service users with moderate, severe, complex learning and physical disabilities, persons with autism and/or severe communication difficultie, persons whose behaviour challenges services and persons with complex epilepsy. The home provides 24-hour staff support. Fees currently range from £4561 to £7426 per month. The fees do not include the cost of chiropody, hairdressing and toiletries. Shelanu DS0000033981.V330913.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was conducted over the course of three days and included a visit to the service of just below five hours. Information was provided by the service prior to the visit and documentation held about the service by the Commission was reviewed. A range of surveys was sent and three were completed and returned from general practitioners, one from an occupational therapist and one from a relative. Interactions between service users and staff were observed throughout the course of the visit, a tour of the premises was undertaken and a range of records was seen. Time was spent with the manager, and staff on duty were spoken to. Two staff were interviewed in private. The provider has a range of polices and procedures relating to equality and diversity. All staff attend relevant training at the commencement of employment. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service that meets the needs of individuals of various religious, racial or cultural backgrounds. The Commission has received no complaints about this service since the last inspection. What the service does well: Provides a high quality service for service users. Meets the complex needs of service users well and is flexible in response to changing needs. Benefits from a dedicated and well-trained staff team. Utilises individual staff skills to the benefit of service users. Encourages staff to question and be proactive. Provides robust health and safety systems. The service is managed to a high standard. Shelanu DS0000033981.V330913.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Shelanu DS0000033981.V330913.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 Shelanu DS0000033981.V330913.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 Quality in this outcome area is good. Prospective service users have their aspirations and needs assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence was obtained from discussion with the manager and staff and from looking at the file of the latest service user to move into the home. This service user was moved from another home on the village that was not able to meet her needs. A transition plan was put into place that included a thorough review of needs and included input from family members, a psychiatrist, psychologist, care manager, speech and language therapist, advocate and the home managers from both homes. Documentation seen was clear and easy to read and provided evidence of the reasoning for decisions. In this particular situation an overnight stay was not considered appropriate because of the distress it was likely to cause to the service user. This service user was reported to have settled well by the service and a relative and the information obtained during the course of the assessment period had proved invaluable in developing a comprehensive care plan. Shelanu DS0000033981.V330913.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflect assessed and changing needs and personal goals. Service users are supported to make decisions and to take risks wherever appropriate so that they can be as independent as possible. EVIDENCE: Four care plans were seen, staff and the manager were spoken to and observation of interactions between service users and staff was undertaken throughout the course of the visit. Care plans follow the corporate format and are clearly sectioned, ensuring that the information is easy to access. The home is in the process of changing the current care plan formats to person-centred planning that takes account of individual needs and preferences in a more dynamic way. The work undertaken to date for one service user was seen by the inspector. Shelanu DS0000033981.V330913.R01.S.doc Version 5.2 Page 10 The home operates a keyworker system and it is the responsibility of nominated staff supported by co-workers to ensure that information contained within care plans is kept up to date. Care plans were comprehensive and it was clear that they were working documents, referred to by staff regularly. Information included health details, family contacts, preferences and activity timetables. Daily records were comprehensive and provided a detailed overview of the person, how they were feeling and what they had been doing. Care plans are reviewed at least three-monthly and relevant changes were clearly in evidence. The relative of one service user indicated in a survey that staff always notify her of changes and she is confident that they are meeting her daughter’s needs. It was clear from talking to staff, the manager and from observations undertaken throughout the visit that the home is mindful that service users must be supported to make decisions for themselves as far as they are able. However, there was a sound awareness that some service users could become anxious when presented with too many choices and, in order to manage these situations effectively, clear guidelines were evident in care plans. The home fully supports the concept that risks are a normal part of everyday life and growth and development rarely occur in the absence of risk. Risk assessments seen as part of care plans were clear, concise and cross-referenced with relevant sections of the care plan. The management of risks was clearly documented and reviews are undertaken regularly. Shelanu DS0000033981.V330913.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): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in appropriate activities both inside and external to the home. Appropriate personal and family relationships are encouraged and service users’ rights and responsibilities are promoted. Service users enjoy a healthy diet. EVIDENCE: Evidence was obtained from discussion with the manager and staff and from looking at a range of records including care plans. Information provided by the service prior to the visit was also used. All service users have planned and timetabled activities that take account of their strengths, preferences and interests. Timetables were evident on a noticeboard and the inspector witnessed that this was looked at by some service users. Shelanu DS0000033981.V330913.R01.S.doc Version 5.2 Page 12 Throughout the visit service users were arriving and leaving for activities whilst being supported by staff. Activities included swimming, horse riding, restaurant trips, shopping, pottery and religious meetings. Inside the home special events were celebrated such as religious ceremonies and birthdays. In addition, home-based activities included aromatherapy, art and crafts, food preparation, music sessions and sensory sessions. The home supports service users to maintain contact with their families and friends outside of the home. Contacts were clearly recorded in care plans. Service users’ rights and responsibilities are recognised and those service users who are able are encouraged to undertake duties such as delivery of the post, helping in the kitchen and cleaning of bedrooms. The kitchen area was seen and the staff member responsible for food ordering was spoken to. There is an emphasis on preparing meals from fresh products. It was clear from discussions with staff that the preferences of service users are well known. Food preparation areas were clean and well organised. Food was appropriately labelled. A food safety inspection undertaken by the Environmental Health Department in February 2006 found the home fully compliant with the regulations. Fridge and freezer temperature checks are undertaken and recorded and high-risk food is probed prior to serving. The mid-day meal was observed by the inspector and was considered to be well ordered. Shelanu DS0000033981.V330913.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 and 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported in the way they prefer and their physical and emotional health needs are appropriately met. There are robust procedures for medication that protect service users. EVIDENCE: Evidence was obtained from talking to the manager and staff, from observation of staff during medication administration and from a range of records both held with the home and provided by the service prior to the visit. Care plans provide very detailed information about service users’ personal support needs. Some service users have complex physical and healthcare needs and these were clearly well understood by the those staff spoken to. Service users are encouraged to choose their own clothes and the manager advised that one service user had recently decided to have her hair dyed red. Specialist equipment was in evidence to support individual service users appropriately and care plans confirmed that the advice of specialist healthcare workers is sought promptly. Shelanu DS0000033981.V330913.R01.S.doc Version 5.2 Page 14 A survey from an occupational therapist with knowledge of the home confirmed her view that the service is particularly skilled at meeting the needs of service users with profound disabilities. Care plans contain a comprehensive section on individual health care needs and contacts. The services of general practitioners and other health care professionals is sought where needed and records are maintained. At the time of the visit one service user was ill and had been unwell for several days. A general practitioner had been called to see the service user for a second time and visited whilst the inspector was in the home. The home had clearly acted without delay when it was felt that the treatment originally prescribed had not worked sufficiently to allow the service user to feel more comfortable. Three general practitioners returned surveys to the Commission and although one did not feel they knew the home sufficiently well to comment, the other two provided positive comments about the home. The arrangements for medication were seen. All medication administrations are signed for by two members of staff. The inspector was shown how this procedure worked. In addition to the second signature it was the responsibility of this member of staff to undertake a brief stock-take to ensure that the appropriate medication had been given. This system ensured that any administration errors were picked up straight away. This member of staff reported that she had no knowledge of a medication error occurring in the home. A pharmacist had visited the home in March 2007 to undertake an inspection of the medication arrangements and had assessed the home as meeting required standards. Shelanu DS0000033981.V330913.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are listened to and their views are acted upon. The procedures for responding to the potential for abuse, neglect and self-harm protect service users. EVIDENCE: There have been no complaints received by the Commission about this service since the last inspection. The complaints record was seen and had no entries for the last twelve months. The organisation has a robust complaints procedure that is underpinned by clear information for service users and relatives. One relative confirmed that she did know how to make a complaint and that the service had always responded appropriately to any concerns. There is a comprehensive training programme for staff that includes protection of vulnerable adults. All staff receive regular updates that are programmed into the training schedule. Staff spoken to were clear about what action needed to be taken should an allegation or suspicion of abuse come to their notice. Shelanu DS0000033981.V330913.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is comfortable and safe and is maintained, clean and hygienic. EVIDENCE: This home provides comfortable accommodation for service users. It is acknowledged that the fabric of the building falls short of the required standard and there are plans for the reprovision of the building. Staff have made the home as domestic and homely as possible and any maintenance issues are acted upon promptly. Bedrooms seen were spacious and contained personal effects individual to the occupants. A tour of the premises was undertaken with the assistance of a member of staff. All areas were clean and tidy with no evidence of offensive odours. Shelanu DS0000033981.V330913.R01.S.doc Version 5.2 Page 17 The laundry facilities were seen and contained appropriate equipment to meet the needs of service users. The systems for the control of infection are robust and comprehensive records in relation to hazardous substances were in evidence. Shelanu DS0000033981.V330913.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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a competent and well-trained staff team. The recruitment polices and procedures protect service users. EVIDENCE: The arrangements for staff training are of a high standard. There is a comprehensive staff training programme in place for the home and all individual staff have their own training profile. The service provided training information prior to the visit and training records were seen in the home. Staff spoken to confirmed that they took part in regular training sessions held both within the organisation and outside. Staff are supported to undertake NVQ qualifications and the Learning Disability Award Framework training. Staff have regular monthly supervision and annual appraisals, where ongoing training needs are discussed. The inspector was informed that staff communicate well with each other and regular weekly staff meetings are held to ensure that important information is shared. Shelanu DS0000033981.V330913.R01.S.doc Version 5.2 Page 19 Staff recruitment records are held centrally within the administration block on site. The inspector has personally reviewed the arrangements for staff recruitment on several occasions. It was accepted that the robust procedures are firmly embedded within the organisation and therefore individual staff records for this home were not seen. Shelanu DS0000033981.V330913.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, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users benefit from a well managed home where their views influence the development of the service. The excellent health and safety arrangements protect service users and staff. EVIDENCE: Evidence was provided from discussion with the manager and staff, from a range of records and from the results of surveys. The manager is experienced and competent. She has achieved the Registered Managers Award and Level 4 NVQ. She is currently undertaking a degree in Learning Disabilities with Winchester University. Shelanu DS0000033981.V330913.R01.S.doc Version 5.2 Page 21 Staff spoken to described the manager as efficient, fair, approachable and supportive. One member of staff described her as the “best boss I have ever had”. One general practitioner described staff as professional and the home as well run. Discussions with the manager provided sound evidence that she has the service users’ needs at the centre of all planning and development and she demonstrated a sound and detailed understanding of promoting the rights of service users. There are robust systems for monitoring the outcomes for service users. The results of service user reviews are used to influence the service and directly feed into the annual development plan. Of the four care plans seen, the service could demonstrate clear development for each service user. The manager reviewed the systems operating in the home on a regular basis and used this information to address issues and update procedures. The health and safety systems are robust and regular checks are undertaken and recorded in a range of health and safety areas. Information provided by the service prior to the visit confirmed that all external servicing and inspections of equipment are undertaken to the required frequency. Records seen confirmed that this was the case with up to date servicing certificates contained within relevant files. Risk assessments were comprehensive and up to date with reviews being undertaken on a regular basis. One staff member is designated as the health and safety representative for the home and is expected to attend quarterly health and safety meetings held by the organisation. It was seen that monthly checks of all rooms are undertaken to ensure early identification of any hazards. An audit of all accidents is undertaken within the home to a level which exceeds that required by the organisation. In addition, an assessment of the potential for slips, trips and falls has been undertaken and necessary action in response was recorded. The manager was advised to record the time of fire drills to ensure that different times of the day are covered. Shelanu DS0000033981.V330913.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 X 5 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X 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 X 12 4 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 3 X X 4 X Shelanu DS0000033981.V330913.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. Refer to Standard Good Practice Recommendations Shelanu DS0000033981.V330913.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Shelanu DS0000033981.V330913.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. 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!