Inspection on 08/08/05 for Shandon

This inspection was carried out on 8th August 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 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 17/01/06

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 White Lane Ash Green Hampshire GU12 6HN Lead Inspector John Chivers Unannounced 8 August 2005 : 2:00pm th 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 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 H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Shandon Address White Lane Ash Green Hampshire GU12 6HN 01252 312802 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) Mrs Pamela Mary Eales Sandra Wheeler CRH - Care Home 4 Category(ies) of LD - Learning Disability (1) registration, with number LD(E) - Learning Disability - over 65 (4) of places Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 - A named service user with Learning Disability (LD) from age 59 years. Date of last inspection 14 October 2004 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 partisipate in activities and live an independent lifestyle as far practicable within a risk assessed framework. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was undertaken on 8th August 05. The duration of the inspection was three hours. As part of the inspection process discussion was held with four residents and one member of staff was formally interviewed. Discussion was also held with the home’s manager. The inspection included examination of the home’s policies, procedures, statutory and none statutory records and residents individual files and personal finances. Staff personnel files could not be accessed for inspection on this occasion. A tour of the premises and garden area was included in the inspection. The findings of the inspection were positive and evidenced good standards of management and care practice. Staff were observed to be working with the residents in a caring and sensitive manner with pro-active engagement and two way communication evident. There was evidence of good humour in staff/resident relationships. Residents stated in discussion that staff do a good job caring for them and that they had no complaints about the service or the way staff treat them. Records were kept to a good standard; however expansion is needed regarding some policies and procedures. Resident’s files were well kept with information easily available. Staff personnel files however could not be accessed on this occasion due to the manager having left the filing cabinet key at home. The manager stated that all staff have been subject to the required recruitment and vetting procedures including checks with the Criminal Records Bureau. The home is active at ensuring staff receive training in the protection of Vulnerable Adults and staff interviewed thought the home/company supportive at enabling staff to attend training courses. The premises are maintained in good order and the garden area is well kept and free from safety hazards. Guards need to be fitted to some of the radiators. There were some shortfalls in the frequency of fire evacuation drills and an updated fire risk assessment needs to be prepared. Staff interviewed were supportive of the home’s management and practices at the home. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 6 What the service does well: 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 H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 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 standard(s) 3 and 6. The home has regard for ensuring written needs assessments are undertaken prior to admission in to the home and are reviewed and updated when necessary. EVIDENCE: Written needs assessments were available in the sample of resident’s files inspected. There was evidence of needs assessments being reviewed and updated as appropriate. The home does not provide intermediate care. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7 and 10. The home has regard for preparing and implementing detailed care plans and ensuring that resident’s are treated with dignity and respect; however one of the resident’s updated care plan needs to be located and held on file. Resident’s health care is monitored and visits by health care professionals are clearly recorded. EVIDENCE: Written care plans were held in the sample of resident’s files inspected. The care plans were comprehensive with evidence of review in all but one of the sample inspected. The manager evidenced via the home’s diary that the review had taken place on 26th June 05; however the updated report was not in the residents file. It is important that the reviewed care plan is located and held on the residents file. A requirement will be made regarding this. The home has a number of policies covering the areas of privacy and dignity. Arrangements regarding the areas of personal and health care are detailed in resident’s care plans and are reviewed as appropriate. There are clear records of visits to the GP and other health care professionals. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 10 Resident’s stated in discussion that staff treat them with dignity and respect and care for them in a proper manner. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12 and 13. The home encourages and enables resident’s to participate in a range of purposeful activities both within and outside the home. The home has regard for resident’s to maintain contact with relatives and significant others. EVIDENCE: The home’s daily routine was observed to be that of an ordinary domestic household. Residents are encouraged to engage in a range of sedentary and active pastimes and a sample of their activity programmes were available. Residents also attend day centres and friendship clubs. Some resident’s were observed to be ‘knitting’ items of clothing and stated that they enjoyed the activity. Another resident was in the garden being attentive to a pet rabbit and budgerigars. Resident’s have excursions to a range of external venues and places of interest and it was evidenced that an annual holiday occurred in Wales on 28th June 05. Visits by family, relatives and friends are recorded in resident’s individual report books and the home’s daily diary. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16 and 18. The home takes complaints seriously and ensures investigation and outcomes. The home has regard for keeping residents safe and is committed to providing staff with training in this area. EVIDENCE: The home has a policy and procedure regarding complaints. The policy is dated November 04. In addition the home has a complaint procedure in pictorial form. It would be important that the pictorial procedure also includes the contact address and telephone number of the CSCI Surrey Local Office. A requirement will be made regarding this. The home’s complaint book was available. The book evidenced that one complaint had been received since the last inspection. The complaint was properly investigated by the home and evidenced an outcome. Resident’s stated in discussion that they had no complaints about the home or the way staff treat them. The home had an internal policy and procedure regarding the Protection of Vulnerable Adults. In addition the home held the Surrey County Council MultiAgency Adult Protection procedures. There was recorded evidence that all of the home’s staff have received training in the Protection of Vulnerable Adults between August 03 and July 05. The manager received the Surrey County Council Multi-Agency Adult Protection training in 2003. A sample of the resident’s personal finances was inspected. The cash held was consistent with the balance in the cash record book. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 13 Resident’s stated in discussion that they felt safe in the home and that they had no concerns about the way staff treat them. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 23, 24, 25 and 26. The home has regard for maintaining the environment in very good order and ensuring the residents comfort and safety; however additional guards need to be obtained and fitted to some radiators. EVIDENCE: The premise is situated in a residential road with local facilities and amenities close by. The exterior of the property is maintained in good order. The home’s garden area is attractive and very well maintained. Rabbits and budgerigars are kept in the garden. No safety hazards were evident in the garden area. The interior of the property is decorated and furnished to a very good standard. Communal areas provide adequate space for the residents and are homely and comfortable. The residents bedrooms are decorated and furnished to the same standard and have been personalised by their occupants. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 15 It was noted that not all of the radiators had guards fitted. It would be important that guards are fitted to all radiators in order to prevent burn injuries should a resident fall against them. Bathrooms and toilets were of a very good standard and afforded privacy. Resident’s stated in discussion that they were ‘happy’ with the standard of accommodation provided. The home has a comprehensive ‘infection control’ policy covering many areas. Standards of cleanliness and hygiene were high throughout the home and with the exception of the need for additional radiator guards no further potential safety hazards were identified. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29. The home has regard for ensuring residents are cared for by an experienced and competent staff team; however staff personnel files must be made available for inspection at any reasonable time. EVIDENCE: The home was adequately staffed and the staff duty roster was available. Most of the staff team have substantial experience in caring for older people with learning disabilities and staff on duty were observed to be caring for the residents in a competent and sensitive manner coupled with good humour, which was appreciated by the residents. The home has a recruitment policy and procedure. The policy is dated September 03. The home’s manager had left the key to the staff recruitment filing cabinet at home and therefore it was not possible to access staff personnel files on this occasion. The manager stated that all staff have been subject to the required recruitment and vetting procedures including Criminal Record Bureau checks. In acknowledging the managers statement, it is important that the key be available. A requirement will be made regarding this. Staff interviewed stated that the home had regard for ‘Equal Opportunities’ and that no discriminatory attitudes or practices occurred in the home. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38. The home is active regarding internal quality assurance and seeks the views of others regarding service provision. Whilst only one potential safety hazard regarding the lack of radiator guards was evident, the home must ensure that all safety-associated tests occur, risk assessments prepared and test certificates obtained. EVIDENCE: The home has questionnaires for visiting professionals and residents relatives to complete in order to assist the home with its internal quality assurance monitoring. Questionnaires were evidenced for April 05 and June 05 respectively and opinion regarding the service from either party was very positive. Residents meetings occur monthly where their views and opinions are taken into account. Regulation 26 visits take place unannounced and Regulation visit reports for the previous ten months were available. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 18 The home has a Health & Safety policy statement. The policy is dated May 04. The home’s Health & Safety ‘Law’ poster was prominently displayed. The home had a written fire risk assessment which was due for review on 22nd June 05. At the time of the inspection this had not yet occurred. It is important that this is undertaken. A requirement will be made regarding this. The home could evidence only one fire evacuation drill which occurred on 6th March 05. A requirement that such drills take place on a quarterly basis will be made. Weekly fire alarm tests occur and fire equipment servicing took place on 21st October 04. It was evidenced that all staff received fire awareness training on 1st July 05. The fire officer last visited the home on 19th October 04. Portable electrical appliance testing occurred on 18th May 05 and a current electricity systems test certificate was held. A current gas systems test certificate was also held. Hot water temperatures are taken and recorded on a regular basis. The home did not have a Legionella test certificate or written risk assessment regarding the prevention of Legionella. It is important that this area is addressed. A requirement regarding this will be made. The Environmental Health Department (food Hygiene) inspected the premises on 7th December 04. A small number of requirements were made, which have all been addressed by the home. The home had a current insurance liability certificate. The certificate expires on 16th January 06. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 x 3 3 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x x x x 2 Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 20 No 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. 2. 3. 4. 25.5 29 13, (4) (C ) 19, Schedule 2 23, (4) (c ) (v) 23, (4) (c ) (e) 13, 4 (c ) That radiator guards are obtained for those radiators currently without them That access to the cabinet holding staff personnel files is available to authorised persons at any reasonable time. That the homes fire risk assessment is reviewed and updated. That fire evacuation drills occur quarterly. That the home arrange to have its water systems tested or a risk assessment prepared regarding the prevention of Legionella. 15/9/05 20/8/05 Standard 7.4 Regulation 15 Requirement That the residents revised and updated care plan is located and evidenced on file. Timescale for action 30/8/05 5. 6. 7. 38.6 38.2. (2) 38.3. (5) 30/8/05 30/8/05 30/9/05 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. Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 21 Refer to Standard Good Practice Recommendations Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Shandon H58 H09 S13780 Shandon V243448 080805 Stage 4.doc Version 1.40 Page 23 - 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!