Inspection on 26/05/05 for Shannon Court

This inspection was carried out on 26th May 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

Shannon Court 16/11/09

Shannon Court 27/07/09

Shannon Court 27/09/07

Shannon Court 21/03/07

Shannon Court 17/05/06

Shannon Court 13/09/05

Shannon Court 30/11/04

Shannon Court 05/04/04

Similar services:

Springfield House

Springfield House

Sutton Lodge Nursing Home

The Shelley

1 Marten Road

St Helier`s Residential Hotel

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

CARE HOMES FOR OLDER PEOPLE Shannon Court Portsmouth Road Hindhead Surrey GU26 6DA Lead Inspector Catherine Campbell-Ace Unannounced 26 May 2005 10:00 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 H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Shannon Court Address Portsmouth Road, Hindhead, Surrey, GU26 6DA 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) 01428 604833 Royal Masonic Benevolent Institution Mrs Marguerite Holloway CRH Care Home 52 Category(ies) of DE Dementia, 12 registration, with number DE(E) Dementia - Over 65, 12 of places MD Mental Disorder, 5 MD(E) Mental Disorder - Over 65, 5 OP Old Age, 35 Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 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 30 November 2004 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. Alvenia House is ground floor accommodation supporting service users who are elderly, 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 H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted 5 hours. The inspector was assisted by the Administrator, Deputy Manager, service users and staff. The inspector was made to feel very welcome during the inspection. Daily records, care plans, training records and activities of daily living were written clearly and are updated as and when necessary. One service user told the inspector: ‘the staff are A1!’ and another: ‘I cannot fault the place, the staff are so helpful’ Service users live in a spacious, homely environment with large, accessible grounds. What the service does well: The home has a relaxed and friendly atmosphere. It is laid out in 4 units called houses. These houses are very homely, with their own small kitchen, dining room and sitting room. During the inspection it was pleasing to see the service users relaxing together over a cup of coffee. The gardens are well tended and accessible, with a sensory garden planned for the courtyard in the mentally, frail unit. Service users were seen to use the gardens, sitting outside on one of the many benches provided. Safety measures, including railings around the pond, are in place. The home offers activities to suit service users, including shopping trips to the local shops, garden centres and to the seaside. The home has a library supplying videos and audio tapes for the use of service users. The home is at present advertising for an activities organiser who will work 5 days per week. Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 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 H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 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) 1,3,4,5 Service users are well informed, are able to assess the quality, suitability and facilities of the home, and know their needs will be met. EVIDENCE: Pre admission assessments were evidenced to cover personal care and physical well being, dietary needs, including dietary preferences. Weight, sight, hearing and communication, foot care, mobility and history of falls were also covered. Summary of past life, mental state, personal safety and risk assessments were evidenced, and found to be clear and detailed. Care plans were seen and were found to be comprehensive, updated when necessary and signed by either the service user or family member. One of the service users stated that they were assessed in their own home and were able to visit Shannon Court to assess the quality, suitability and facilities within the home. The trial period of one month could be extended if necessary. The manager encourages the family to take part in choosing the home together with the prospective service user to ensure the home meets the service users needs. Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 9 Service users contracts were evidenced and included information regarding fees and period of notice to be given. Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 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 standard(s) 7,8,9 Care plans were evidenced to be clear and detailed, setting out the care needs of service users. All care plans sampled had been updated as required. EVIDENCE: Care plans evidenced were found to be clear, detailed and up to date. They were signed by the service user or family. Care plans included a summary of past life, oral care, pain and discomfort action plan, eating and drinking needs, which included instructions to staff to give one particular service user a soft diet using a lipped plate and a special mug for drinks. Skin condition was monitored regularly, sleep pattern, mobility, washing and dressing, foot care, moods and anxieties and social activities were included. Risk assessments regarding confusion, manual handling and pressure area risk were evidenced and action plans recorded. Activities in this home included watching snooker on T V, manicure, library, which included talking books, shopping trips and trips to the garden centre. The medication policy was evidenced and samples of staff signatures were seen. Medication Administration Records were in order, and all medication Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 11 stored correctly, including Controlled Drugs. Since the last inspection the service users have had medication risk assessments carried out, to include those self- medicating. The general practitioner visits regularly and service users are able to consult with him in their own rooms. Evidence of the doctor’s visits were seen in the care plans. Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 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 standard(s) 13,15 The home offers service users opportunities to choose their lifestyles and encourages visits from relatives. The home offers choice within a well balanced diet. EVIDENCE: Service users stated that they could receive visitors without restriction. The home has its own transport and is planning to purchase another vehicle for the use of service users. It was evidenced that service users went on outings to the shops and garden centres and some service users go out regularly for meals with relatives. A trip to the seaside was planned for later on in the year. Some service users were able to use a computer and used it to email their families. It was evidenced by the monthly menu plan that service users receive a well balanced, nutritious diet. One service user said ’the food is terrific’ There were three choices of food for lunch and baked potatoes or omelette as an alternative. The meals were served in homely dining rooms. Home - made cakes were served for afternoon tea. The administrator stated that in the summer service users could have breakfast served outside, and barbecues were a favourite with service users weather permiting. It was observed during the inspection that service users were enjoying coffee sitting on garden Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 13 furniture in the grounds. Hot or cold drinks were available for service users during the day from the kitchens in each house. Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 14 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) 16,17,18 The home has a satisfactory complaints system with evidence that service users complaints are listened to and acted upon. EVIDENCE: The homes complaints procedure and complaints log was evidenced. The complaints policy was evident in service users rooms and on the notice board in the dining rooms. Service users, when asked, said that they knew to whom they could complain and staff knew of the complaints policy. The inspector noted that during the past month, four complaints had been made against the same member of staff. This person had been rude to service users. The complaints had been investigated and upheld. The staff member apologised to the service users. When the inspector asked the Deputy Manager about these complaints, she said that the staff member concerned had been disciplined. Staff attended Protection of Vulnerable Adults training and knew what constitutes abuse and the policy to follow if abuse occurred. Service users said that they had voted in the general election. They said that they held their own bank accounts and were able to access these readily. Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 15 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) 19,20,23,24,25,26 The standard of the environment is high, providing service users with an attractive homely and safe place to live. EVIDENCE: The home was found to be very comfortable for service users to live in. The dining rooms, and lounges were homely and inviting. It was pleasing to note that one of the safety features in the grounds were railings erected around a pond. The railings were unobtrusive and afforded safety for both service users and visitors. One of the service users said ’the grounds are absolutely beautiful.’ It was observed that service users rooms suited their needs and they could display photographs of family and had brought with them from home some small personal items. Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 16 Communal bathrooms were spacious and homely and it was evidenced that bath temperatures were recorded. Doors to service users rooms were locked on inspection, with service users holding the key. Rooms were centrally heated with radiators covered with guards. The premises were clean, hygienic and free from unpleasant odours. It was evidenced that staff had attended Infection Control training. The house was well decorated with a comfortable, homely atmosphere. When the staff were asked what was good about the home, they said that it was ‘more like your own home’ Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 17 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) 28,29,30 The manager is supported well by senior staff in providing clear leadership throughout the home, with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The training plan was evidenced, which included training in Control of Substances Hazardous to health, Protection of Vulnerable Adults, Food Safety, Health and Safety, Manual handling, Fire Safety, Key working and Whistleblowing. More than 50 of staff had achieved NVQ 2 and 20 staff members were qualified in First Aid. Employment files were found to be robust, and all necessary documentation was in place, including written references, Criminal Record Bureau clearance and work permits. All records sampled included terms and conditions of employment Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 18 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) 35,36,37,38 The manager is supported by a dedicated team, protected by the homes’ policies, procedures and efficient record keeping. EVIDENCE: Care plans, risk assessments, pre admission assessments, supervision records, recruitment records, Statement of Purpose and training plans were evidenced. Care plans were detailed, up to date, and kept securely. Some staff members had not received regular formal supervision. A requirement was made for formal supervision to be carried out on staff not less than 6 times a year. Service users said that they were in charge of their own bank accounts and secure facilities were provided for safe keeping of money and valuables on their behalf. Staff training records showed that they received training on Manual Handling, Fire Safety, Infection Control and Health and Safety. Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 19 It was evidenced that safety checks had been made regularly on Lift Maintenance, Hand Basin Temperatures, Fire Extinguishers, Wheelchairs, Hoists, Fire Alarms, Gas, Legionella and PAT testing. All upstairs windows were fitted with safety restrictors. Accidents injuries and illness were recorded and reported. Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 3 4 STAFFING Standard No Score 27 x 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x x x 3 2 3 3 Shannon Court H58_s17643_Shannon Court_v230550_260505_stage 4.doc Version 1.30 Page 21 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 36 Regulation 18()a Requirement The Registered Person must ensure that Care staff receive formal supervision at least 6 times a year Timescale for action 26/07/05 2. 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. 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