Inspection on 30/01/06 for Shandon House

This inspection was carried out on 30th January 2006.

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 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 House 15/01/07

Shandon House 11/05/05

Shandon House 09/11/04

Shandon House 04/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Shandon House 3 Mill Road Eastbourne East Sussex BN21 2LY Lead Inspector Nigel Thompson Announced Inspection 30th January 2006 09:30 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 House DS0000021211.V261198.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 House DS0000021211.V261198.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shandon House Address 3 Mill Road Eastbourne East Sussex BN21 2LY 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) 01323 723333 01323 410129 Mrs Lindsey Bree Mrs S Bree Nicola Louise Moss Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That a maximum number of service users to be accommodated must not exceed (25) twenty-five. That service users must be aged (65) sixty-five years or over on admission. That only older people, not falling into any other category be accommodated. 11th May 2005 Date of last inspection Brief Description of the Service: Shandon House is registered to provide care and accommodation for up to 25 residents. The home is a large detached three-storey house in the Ocklynge area of Eastbourne. A lift is available to facilitate access to all floors. Twelve of the twenty five rooms have en-suite facilities. Residents are encouraged to bring in personal possessions in order to personalise their rooms. Mealtimes are flexible and alternatives are offered at each meal. The home aims to provide a safe, homely environment in which residents are able to lead satisfying lives, retaining dignity, privacy and the freedom to exercise choice. Regular social activities within the home and outings are arranged. The home has a well maintained rear garden and ample parking to the front of the house. Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over six hours in January 2006. It found that all of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users and relatives spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. On the day of the inspection there were twenty service users living at the home. The inspection involved a tour of the premises, examination of the home’s records and discussion with the Registered Manager. Two members of staff, seven service users and two relatives were also spoken with. The focus of the inspection was on the quality of life for people who live at the home. In order that a balanced and thorough view of the home is obtained, this report should be read in conjunction with previous inspection reports. What the service does well: Service users at Shandon House clearly benefit from having an experienced Manager and dedicated staff team who are committed to providing consistent and high quality care. Staff work closely with service users and have developed a sound understanding of their individual care and support needs. The relaxed, homely and welcoming environment has evolved over several years and reflects the stability and commitment within the staff team and the open and inclusive management style. Service users are encouraged and supported to make decisions about their lives. They are involved and regularly consulted on many aspects of life in the home, including menu planning and activities. Communication and consultation with service users’ family members is also effective and ongoing. Relatives have the opportunity to partake in individual assessment, care planning and reviewing processes. Staff receive effective induction and foundation training, regular supervision and are clearly valued and supported by the management team. Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: To minimise the potential risk for service users, it is required that the remaining unguarded radiators be fitted with covers. The Statement of Purpose is to be reviewed and updated, as required. The format of the Service User Guide is to be improved and a copy is to be made available to all existing and prospective service users. It is recommended that the pre-admission assessment be restructured, allowing space for more detailed information and additional comments and that the revised format contains information regarding an individual’s social and recreational interests. To further improve the quality of daily life for service users within the home, it is hoped that the post of Activities Co-ordinator could be reinstated. It is recommended that individual care plans and review reports be signed by the service user and/or a relative, to confirm their involvement in the development and reviewing process and agreement with the content and any changes to the plan. Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 7 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 House DS0000021211.V261198.R01.S.doc Version 5.0 Page 8 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 House DS0000021211.V261198.R01.S.doc Version 5.0 Page 9 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, 3, 5 & 6 Documentation, including a concise information leaflet, statement of purpose and service users’ guide ensures that prospective service users and their relatives have sufficient information about the home and the services provided. However details in certain documents need to be reviewed and updated. The thorough admission policy and procedures ensure that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. EVIDENCE: Following an enquiry to the home, information is made available to prospective service users and their relatives in the form of a concise, illustrated leaflet, containing details of the aims, objectives and philosophy of the home and services provided. Although there is a statement of purpose in place, on a table in the entrance hall, it is evident that it has not been recently updated and, as discussed with the Manager, it is required that it be reviewed and amended, in accordance with Schedule 1. Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 10 As with the statement of purpose, the current service user’s guide is presented as a series of information sheets in a hard backed ring binder file, in the entrance hall. Following discussion with the Manager, it is recommended that the format be reviewed and improved, with the possible addition of photographs, to be more ‘user friendly’ and readily accessible. It is required that a copy of the service user’s guide be provided to each current and prospective service user. The current pre-admission assessment format is comprehensive but would benefit from being restructured, allowing space for more detailed information and additional comments. It is also recommended that the revised format contain information regarding an individual’s social and recreational interests as well as specific details, as discussed, including the service user’s name, the identity of the assessor and the date of the assessment. The Manager confirmed that intermediate care is not currently provided at Shandon House and emergency or unplanned admissions are avoided. Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 11 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 Service users’ care plans are developed from a comprehensive assessment of an individual’s needs and enable staff to meet such needs in a structured and consistent manner. Policies and procedures for the control and administration of medication are effective with clear and comprehensive systems being in place to ensure service users’ medication needs are met. EVIDENCE: Individual care plans have been developed for each service user and are clearly and directly linked to their assessed needs. Plans that were inspected were found to be accurate, generally well maintained, and up to date. Structure and consistency in the care and support provided across the staff team is promoted by the development of ‘Care action’ sheets, contained in service users’ individual plans, which clearly set out details of the action to be taken by staff. Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 12 Care plans are regularly reviewed and routinely involve the service user and, where appropriate, a family member. It was noted however that no record of this involvement is maintained and it is recommended that care plans and subsequent reviews be signed by the service user and/or a relative. All service users are registered with local GPs and have access to other health care professionals, including district nurses, via the surgery. Nutritional screening forms part of the initial assessment process. Following risk assessments, there are currently four service users who maintain responsibility for the control of their medication. Although the Manager confirmed that the situation is closely monitored, there is little documentary evidence to support this. It is therefore recommended that a written disclaimer be produced and signed by all relevant parties, confirming understanding and agreement with the arrangement. The Manager is clearly keen to promote individuality and independence, within a risk management framework. In each case the service user has a lockable drawer or cabinet in their room, in which to store the medicines. Satisfactory policies and procedures are in place for the control, storage, safe administering and recording of medication. Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 13 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): 12, 13, 14 & 15 Social activities and meals are both generally well managed, creative and provide daily variety and interest for people living in the home. Family involvement and links with the community are generally good and support and enrich service users’ social opportunities. EVIDENCE: The home provides a range of in-house activities such as bingo, quizzes and musical entertainment. A weekly programme of organised activities, outings and events has been developed and is displayed in the hallway. A member of staff, spoken with during the inspection, was aware of and clearly very enthusiastic and motivated about the importance of meeting service users’ social care needs. As previously documented, service users’ recreational interests are to be identified and recorded, as part of the assessment process. In line with these observations and developments, it is recommended that consideration now be given to reinstating the post of ‘Activities co-ordinator’. Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 14 Independence continues to be promoted and encouraged within the home and wherever possible, service users are enabled and supported to make choices and take decisions affecting their life and daily routines. Effective systems are in place for regular consultation with service users and their relatives. A quarterly ‘Residents’ Forum’ is held and twice a year there is a popular ‘Residents and Relatives Meeting’, both of which give the opportunity for people to discuss service related issues or raise any concerns that they may have. Visiting is unrestricted at Shandon House with service users able to choose whom they see, where and when and friends and relatives made welcome at any time. This was confirmed by a service user’s relative, spoken with during the inspection: ‘Everyone here is so kind and helpful. We are made to feel so welcome whenever we visit’. Varied, balanced and nutritious meals are provided, reflecting service users’ choice and preferences. The experienced cook, who has recently completed the NVQ level 2 in catering, confirmed that service users are consulted and directly involved in compiling the four-week rolling menu. Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 15 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): 18 Service users are safeguarded from abuse through robust policies, procedures and relevant staff training. EVIDENCE: The home has an updated policy and procedure for the protection of vulnerable adults, (POVA), including a whistle blowing policy. This forms one of the ‘key policies and procedures’ that staff are now expected to sign to confirm that they have read, discussed and understand. The manager confirmed that staff are made aware of these and other key policies and procedures as part of their induction and foundation training and they are also reinforced during regular supervision and staff meetings. Specific POVA training is provided for all staff, although from training records that were examined, it was evident that some members of staff have yet to attend the sessions. It was noted that the home also has obtained a copy of the East Sussex multi agency guidance notes on the Protection of Vulnerable Adults. Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 16 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): 19, 20, 21, 22, 23, 24, 25 & 26 The service is accessible, safe and clean and remains clearly suitable for it’s stated purpose. Service users benefit from pleasant, homely accommodation that is comfortable, well maintained and decorated to a satisfactory standard. A potential risk for service users remains as several radiators have yet to be fitted with covers. EVIDENCE: Standards relating to the physical environment remain largely unchanged. As previously documented, independence and individuality is promoted within the home and this is evident from the personalising of service users’ individual rooms, which clearly reflects individual tastes and interests. It was noted that several radiators throughout the home, including service users’ bedrooms, still have not been fitted with covers. The Manager confirmed Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 17 that the programme for this is ongoing, however to ensure the safety of service users, it is required that this issue be addressed as a priority. The light and spacious lounge provides a comfortable focus for many of the daily recreational and leisure activities in the home and clearly meets the individual and collective needs of the service users. A pleasant dining area provides a relaxed, homely and sociable setting for meal times. A programme of routine maintenance, renewal and redecoration is in place. However it was noted that the bathroom on the second floor is rarely used, as service users are currently unable to safely get in or out. This was discussed with the Manager and it is recommended that consideration be given to installing an overhead hoist in this room. Infection control procedures are in place and clearly adhered to and levels of cleanliness remain high throughout. Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 18 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 There are sufficient trained and competent staff on duty at all times to meet the assessed, medium to low dependency needs of the service users. Thorough recruitment procedures help to ensure the safety and protection of service users. EVIDENCE: The stable and dedicated staff team is clearly able to meet the assessed, individual and collective needs of service users within the home. Staff files that were examined were found to be well maintained, containing all necessary information, including two written references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. Following discussion with the Manager, it is recommended that reference request letters be reviewed and amended to include specific details of the proposed referee. A comprehensive portfolio of staff training has been developed and includes details of specific training undertaken as well as qualifications and certificates. All new staff are provided with and sign a written contract, including a statement of terms and conditions. Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 19 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): These standards were not assessed on this occasion. All key standards were assessed during the previous inspection carried out on 11 May 2005. EVIDENCE: Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 20 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 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 3 3 2 3 3 3 3 STAFFING Standard No Score 27 X 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X x Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 21 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. Standard OP1 Regulation 4 (1) © Schedule 1 5 (2) Requirement It is required that the statement of purpose be reviewed and amended, in accordance with Schedule 1. It is required that a copy of the service user’s guide be provided to each current and prospective service user. It is required that radiators throughout the home be covered to ensure a safe environment for service users. Timescale for action 31/03/06 2. OP1 31/03/06 3. OP19 23 (1) (a) 30/06/06 Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 22 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 OP1 Good Practice Recommendations It is recommended that the format of the service user’s guide be reviewed and improved, with the possible addition of photographs, to be more ‘user friendly’ and readily accessible. It is recommended that the pre-admission assessment be restructured, allowing space for more detailed information and additional comments. And that the revised format contains information regarding an individual’s social and recreational interests and other details, as discussed. It is recommended that individual care plans and subsequent reviews be signed by the service user and/or a relative, to confirm their involvement and agreement. It is recommended that a written disclaimer be produced and signed by all relevant parties, confirming understanding and agreement with the arrangements regarding self-medication. It is recommended that the post of ‘Activities co-ordinator’ be reinstated. It is recommended that consideration be given to installing an overhead hoist in the, currently unused, second floor bathroom. It is recommended that current reference request letter be reviewed and amended to include specific details of the proposed referee. 2. OP3 3. 4. OP7 OP9 5. 6. 7. OP12 OP21 OP29 Shandon House DS0000021211.V261198.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 House DS0000021211.V261198.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. 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