Inspection on 17/01/06 for Shandon

This inspection was carried out on 17th January 2006.

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

Shandon 01/05/07

Shandon 08/08/05

Shandon 14/10/04

Shandon 27/05/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOMES FOR OLDER PEOPLE Shandon Shandon White Lane Ash Green Hampshire GU12 6HN Lead Inspector Suzanne Magnier Unannounced Inspection 08:00 17 January 2006 th X10015.doc Version 1.40 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 Shandon DS0000013780.V273468.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 Older People. 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. Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shandon Address Shandon White Lane Ash Green Hampshire GU12 6HN 01252 312801 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) Mrs Pamela Mary Eales Sandra Wheeler Care Home 4 Category(ies) of Learning disability (1), Learning disability over registration, with number 65 years of age (4) of places Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 A named service user with learning disability from age 59 years (LD) Date of last inspection 8th August 2005 Brief Description of the Service: Shandon is registered to Just Homes and is one of several Registered Care Homes administered by the company. The home is registered to accommodate a maximum of four residents over the age of sixty-five years of either gender. All of the residents have learning disabilities. The home is detached and situated in a quiet residential road. Local facilities and amenities are close by. The garden area is attractive and well maintained. The home provides a caring and supportive service and encourages residents to participate in activities and live an independent lifestyle as far practicable within a risk assessed framework. Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Unannounced inspection took place over four hours and was conducted with the Registered Manager and the Deputy Manager. For the purpose of the report the inspector was advised that the people who live in the home are referred to as residents. Part of the focus of the inspection was to review, with the Registered Manager, requirements made under the Care Homes Regulations (as amended) 2001 at the last inspection on the 8th August 2005. A tour of the premises was undertaken, during which the inspector met with all the residents. Files sampled included residents care plans, staff recruitment and training files, the medication procedure and a variety of the homes policies and procedures. The feedback following the inspection was given to the Registered Manager. The inspector also met with the Responsible Individual who arrived at the home for a care plan review appointment. The inspector wishes to thank the residents, staff and Registered Manager for their cooperation during the inspection. What the service does well: The home continues to support four people in a small homely and comfortable environment. The staff on duty during the inspection demonstrated a knowledge and commitment to the support needs of the residents. The care plans sampled during the inspection clearly demonstrated the needs and abilities of each resident and included guidance for staff to support people in their preferred ways. Record evidenced that the Registered Manager and staff in the home undertook regular reviews of peoples care The residents are supported to exercise choice about their daily lives and are supported in a caring and professional manner. Residents are encouraged to take part in local elections and have access to advocacy if they choose to. All staff have undertaken the Protection of Vulnerable Adults training and relevant statutory training. The homes environment offers a relaxed and comfortable atmosphere for the four residents. Specialist equipment is available to residents in order to maximise their comfort and mobility. Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 6 The Registered Manager demonstrated a sound management style, which included a well-supervised staff team. The homes policies and procedures were evidenced as regularly revised in order to ensure the smooth running of the resident’s home. 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. Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5. Prospective residents are free to visit and stay at the home prior to residency. An admission procedure includes a full assessment of the person needs. It has been required that the homes Statement of Purpose be updated in order that prospective residents or their representatives have current information regarding the home. EVIDENCE: The inspector sampled the homes Statement of Purpose and has required that the document contain all the relevant information detailed in Schedule I of the Care Homes Regulations (as amended) 2001. The document did not include the recent changes to the current staff details employed in the home and reference within the document referred to the National Care Standards Commission (NCSC) as opposed to the Commission for Social Care Inspection (CSCI). The Service Users guide was observed in each resident’s bedroom on a selected notice board. The inspector sampled that all residents had a contract of residency from the local Authority. The homes admission procedure indicated that any prospective resident can visit the home prior to residency and trial periods of residency are Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 9 offered which includes day and overnight stays and weekend visits. The home does not currently have any vacancies. The Deputy Manager explained that a full care needs assessment is carried out prior to admission to the home. Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,11. The home continues to provide a high standard of care and support to the residents with the aid of clear and updated plans of care. The medication procedure was observed as efficient. EVIDENCE: The inspector sampled one care plan. The care plan had been recently updated by the Registered Manager and included a full current assessment of the resident’s needs and abilities. Each staff member supporting the resident had signed an agreement stating they had read the guidelines for care. The file contained health care records, which detailed appointments that had been attended, risk assessments including moving and handling, mobility and mealtime guidelines and support needs when the person was out of the home. The inspector evidenced that regular reviews of the residents care plan were held in the home by care staff. It was noted that the Care Manager had not been present at the reviews and it is recommended that the home continue to request attendance at the resident’s reviews. On the day of the inspection a care plan review had been arranged and the inspector met with the Care Manager on their arrival at the home. Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 11 The inspector sampled the homes medication policy and procedure, which was updated and easily understood. The Registered Manager explained that the home had recently changed suppliers of the blister packed medication and that the change had been positive for the home. The inspector noted that the medication cabinets were clean and orderly, medication administration charts were complete and a stock taking procedure had been implemented. The inspector sampled a recently updated policy and procedure in the event of a resident’s death. Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14,15. The residents are supported to exercise choice about their daily lives and are supported in a caring and professional manner. The breakfasts were served individually in the kitchen/dining room to each resident when they wanted their breakfast. EVIDENCE: On arrival at the inspection all the residents were in bed. The inspector noted that the residents were supported up when they wanted to get up and were supported by staff in a professional and caring manner. The inspector noted that the dining table had been attractively presented with cups and saucers, napkins, a flower arrangement centrepiece and that residents had a choice of breakfasts including hot drinks. One resident was having their breakfast of cereal, toast and tea. The main meal of the day was not evidenced on this occasion. The residents sitting at the dining table were relaxed, happy and participated in the banter with staff. The residents care plans document a section regarding choice and independence with each resident having an activity plan. The plans include choices of clothes to wear, weekly choice of menus and other community activities. Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17,18. Residents are encouraged to take part in local elections and have access to advocacy if they chose to. All staff have undertaken the Protection of Vulnerable Adults training. EVIDENCE: The Registered Manager explained that residents are encouraged to take part in the electoral voting and are supported to the local polling station if they choose to. The inspector sampled staff training files, which evidenced that all staff had attended training in the Protection of Vulnerable Adults. The Registered Manager told the inspector that her Deputy and her were going to arrange an update of their Protection of Vulnerable Adults training in the near future. Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,25. The homes environment offers a relaxed and comfortable atmosphere for the four residents. Specialist equipment is available to residents in order to maximise their comfort and mobility. It has been required that one residents bedroom door which was not closely appropriately be repaired with regard to fire safety. EVIDENCE: The inspector observed that some residents used specialised equipment to assist them in moving around their home freely. Easy access to the home via ramp was in place and all areas in the home were accessible to the residents. Grab rails, and other aids including bathroom aids for example bath seats and reclining chairs were also available to maximise residents comfort and mobility. The Registered Manager and staff have made a continued effort to maintain the homely and comfortable clean environment. An immediate requirement was made that one residents bedroom door be repaired in order to close appropriately due to fire safety. Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29,30. The staff on duty during the inspection demonstrated a knowledge and commitment to the support needs of the residents. The staff team have all had the relevant statutory training. Staff recruitment practices were evidenced as appropriate. A requirement has been made that the staff job descriptions the key worker responsibilities are updated in order that staff are fully aware of the duties they are expected to perform. EVIDENCE: The inspector observed that the two staff on duty during the unannounced inspection was calm and supportive to the residents. The staff were observed to wear protective clothing when supporting residents with personal care and were discreet and professional. The home has an updated recruitment and selection policy. The inspector sampled one staff file, which evidenced all recruitment checks in order to ensure the protection and safety of the residents had been attained. The home currently has one and a half staff vacancies, which are covered by the bank staff. The Registered Manager advised the inspector that interest has already been shown regarding recruitment to the posts. The staff training files identified that all staff have received the statutory training. It is recommended that clarification be sought by the Registered Manager regarding the timescales of refresher training related to moving and handling for staff. The inspector sampled a job description, which was dated 1998 and has required that the job description be updated in order that there is clear guidance for staff in the work they are to perform. Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,35,36,37,38. The Registered Manager demonstrated a sound management style, which included a well-supervised staff team. The homes policies and procedures were evidenced as regularly revised in order to ensure the smooth running of the resident’s home. EVIDENCE: During the course of the inspection the Registered Manager demonstrated a sound knowledge of the care needs of the residents. It was evident that staff morale was high and the Manager has she support from a committed and well trained staff team. The residents responded warmly to all staff members on duty and spoke favourably of their care and relationships with staff. The staff files sampled and staff meeting records indicated that the staff are well supported by the Registered Manager who also has an open door policy with regard to staff support and supervision. The inspector sampled a variety of the homes policies and procedures all of which were up to date and in a good order and was easily accessible to the staff. Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 X 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 X X X 3 X X 2 X STAFFING Standard No Score 27 X 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 3 3 Shandon DS0000013780.V273468.R01.S.doc Version 5.0 Page 18 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 OP1 Regulation 4.(1)c Schedule 1 23.(4)c (i)(iv) Requirement The Registered Person must ensure that the Statement of Purpose is updated to include current staff details and relevant details regarding the CSCI. The Registered Person must ensure that one residents bedroom door which was not closely appropriately be repaired with regard to fire safety. The Registered Person must ensure that the support worker job description, which was dated 1998 be updated in order that there is clear guidance for staff in the work they are to perform. Timescale for action 17/02/06 2 OP25 17/01/06 3 OP29 17.(2) 6 (e) 17/02/06 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 Refer to Standard OP7 Good Practice Recommendations It is recommended that the home continue to request attendance by Care Managers at the resident’s reviews. DS0000013780.V273468.R01.S.doc Version 5.0 Page 19 Shandon 2 OP30 It is recommended that clarification be sought by the Registered Manager regarding the timescales of refresher training related to moving and handling for staff. 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