CARE HOMES FOR OLDER PEOPLE
Shannon Court Portsmouth Road Hindhead Surrey GU26 6DA Lead Inspector
Mrs C Campbell-Ace Unannounced Inspection 13 September 2005 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. Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Shannon Court Address Portsmouth Road Hindhead Surrey GU26 6DA 01428 604833 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) Royal Masonic Benevolent Institution Mrs Marguerite Holloway CRH (PC) 52 Category(ies) of Old age, not falling within any other category registration, with number (OP) 35. of places Dementia - over 65 years of age (DE(E)) 12. Mental Disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) 5. 5 Mental disorder, excluding learning disability or dementia (MD) 12. Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Out of the 52 accommodated, 35 may be in the category OP (older persons). 2. Out of the 52 accommodated, up to 5 may fall within the category MD or MD(E) or a combination of both. 3. Of the 52 service users, up to 12 can be either DE or DE(E) or a combination of both. Date of last inspection 23 June 2005 Brief Description of the Service: Shannon Court is a care home for older people. The service is set in its own private grounds. It provides care for older Freemasons and dependent females of Freemasons. The accommodation for service users is provided on two floors. The main building consists of four units known as houses. Alvernia House is ground floor accommodation supporting service users who are elderley, mentally frail. All bedrooms are single rooms with ensuite facilities. There are two passenger lifts accessing the ground floor in the main building. There is a large communal lounge in the main building with a licenced bar at one end and a shop at the other. Service users can purchase goods, for example toiletries, stamps and sweets. The bar and shop are accessible to service users. There is a games room, library and hairdressing salon in the main building all of which are accessible to the service user group. There is ample car parking available. Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection lasted three and a half hours. The manager, service users and staff assisted the inspector who was made very welcome during the inspection. Care plans, Social activities, staffing and management and administration standards were examined and service users, staff and visitors were interviewed. One service user’s relative said that the staff were exceptional, they related to each service user individually and they were part of the family. What the service does well: What has improved since the last inspection?
A sensory garden has been built in the courtyard in the mentally frail unit, which is a calm and peaceful area in which to walk or sit. Another garden area has been built with raised beds for better access for service users to be involved in planting and caring for the plants. This also contains a walkway through wooden archways planted with climbing plants. An activities coordinator has been employed since the last inspection. Staff supervision of staff has been carried out on a regular basis. Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 Page 6 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. Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.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 Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.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) EVIDENCE: Standards 1,3,4,and 5 were assessed at the last inspection. No service users in this home are admitted for intermediate care. (Standard 6) Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.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) 7,8,9,10 There is a clear and consistent care planning system in place that provides staff with the information they need to satisfactorily meet the service users needs. The systems for administering medication are good. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: Care plans were evidenced to be clear, concise and updated as and when necessary. They included falls risk assessments, strategies for challenging behaviour, social activities and personal hygiene needs. Service users choose their own General Practitioner and they receive visits on a regular basis. Eyesight tests were carried out yearly and service users had access to chiropody and dental services. Medication Administration Records were examined and found to be in order. All medication was stored correctly. All service users were risk assessed for self administration of medication, and the risk assessments were updated when necessary. Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 Page 10 The general practitioner visits regularly and service users are able to consult with him in their own rooms. Evidence of doctor’s visits were documented in care plans. Staff were observed to knock on doors before entering. The manager also said that care staff were informed about respecting service user’s privacy during interview and on induction. Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.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) 12,14 Service users were observed to live a full life with opportunities to take part in varied activities. Service users are able to exercise choice and control over their lives. EVIDENCE: Activities in this home were observed to be person centred. Service users were offered activities on an individual basis, for example on the day of inspection, one service user was being showed photographs of famous people from the time when the service user was young, i.e Glenn Miller band and Betty Davies the actress. Others were being read to and some were sitting listening. Activities also included drinks at the bar in the main home, arts and crafts, board games and a sing- a –long. Service users were also offered the opportunity to help with the planting in the garden. There was evidence that this had been carried out. The manager said that service users in the elderly mentally frail unit could join in with activities in the main home. Service users were informed of activities being held by being given a list of activities at the beginning of each week. Activities also included manicures, out for a pub lunch, shopping and trips to the local gallery. Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 Page 12 The manager said that service users managed their own financial affairs if they were able to do so and relatives who had power of attorney managed some service user’s financial affairs for them. Service users were able to keep up to fifty pounds cash each, locked in the home’s safe, for chiropody, outings or hairdressing. Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 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 standard(s) EVIDENCE: Standards 16 and 18 were assessed at the last inspection. Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.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) EVIDENCE: Standards 19 and 26 were assessed at the last inspection Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 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 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) Service users needs are met by the skill mix of staff. EVIDENCE: 27 It was evidenced that a staff rota was kept showing which staff are on duty at any time during the day and night. The duty rotas showed that additional staff were on duty at peak times during the day. No staff providing personal care to service users were under 18 years of age. The manager stated there were difficulties recruiting staff to Shannon Court, and consequently, were using agency staff to fill the vacancies. She said that agency staff were employed from the same agency to provide consistency of care to service users. At present there are 3 care staff vacancies. She said that she was hoping to recruit staff from abroad in the near future. Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 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 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 The home regularly reviews aspects of its performance through a programme of self review and consultations, which include seeking the views of service users and staff. EVIDENCE: Service users meetings were evidenced to have taken place, with service user’s views sought. The manager stated that the home has a development plan based on reflecting the aims and outcomes for service users. Monthly self- monitoring audits were viewed, which involve service users and staff, and action plans identified.
Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 Page 17 Policies and procedures were viewed and were regularly reviewed. Any action identified in past inspections have been progressed within agreed timescales to implement requirements identified in Commission for Social Care Inspection reports. Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 Page 18 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 3 x x x x x Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 Page 19 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. 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. 1. Refer to Standard Good Practice Recommendations Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 Page 20 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 Shannon Court Portsmouth Road, Hindhead, Surrey, GU26 6DA H09 H58 s17643 Shannon Ct v248454 130905 Stage 4 unn.doc Version 1.40 Page 21 - 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!
