Inspection on 27/09/07 for Shannon Court

This inspection was carried out on 27th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 21/03/07

Shannon Court 17/05/06

Shannon Court 13/09/05

Shannon Court 26/05/05

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 Joseph Croft Unannounced Inspection 27th September 2007 10:40 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 Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 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. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shannon Court Address Portsmouth Road Hindhead Surrey GU26 6DA 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) 01428 604833 01428 606422 jelder-ennis@rmbi.org.uk www.rmbi.org.uk Royal Masonic Benevolent Institution Ms Maizie Mears-Owen Care Home 52 Category(ies) of Dementia (12), Dementia - over 65 years of age registration, with number (12), Mental disorder, excluding learning of places disability or dementia (5), Mental Disorder, excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (35) Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Out of the 52 accommodated, 35 may be in the category OP (older persons). Out of the 52 accommodated, up to 5 may fall within the category MD or MD(E) or a combination of both Of the 52 service users, up to 12 can be either DE or DE(E) or a combination of both. 21st March 2007 Date of last inspection Brief Description of the Service: Shannon Court is a care home for older people and provides care for older Freemasons and dependent females of Freemasons. The service is set in its own private grounds. The accommodation for service users is provided on two floors and is separated into five units. Each unit has its own dining room and lounge facilities. Access to the first floor is via passenger lifts. One of the units, Alvernia is on the ground floor and provides accommodation to service users who are elderly and mentally frail. All bedrooms are single rooms and have en-suite facilities. There is a large communal lounge in the main building with a licensed 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 an activities room, a library and a hairdressing salon in the main building, all of which are accessible to the service users. There is ample car parking available to the front of the building. Fees range from £578 - £879 per week. This fee does not include: hairdressing, toiletries, chiropody and newspapers. This information was provided on 27/09/07. Please note: The e-mail address shown on page 4 for the home is incorrect and should read: mmears-owen@rmbi.org.uk Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 27th September 2007 using the ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Mr Joe Croft undertook this visit and the registered manager assisted him throughout. This site visit took place over a period of eight hours, commencing at 10:40 and concluding at 19:00. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, policies and procedures and records of medication. The Inspector had discussions with members of staff on duty, and six residents. Discussions took place with one health care professional and a relative who was present during this site visit. Residents informed the Inspector that they were happy living at the home, and were complimentary about the care they receive from staff, stating that the staff look after them well. Residents informed the Inspector that the food was good, and they are offered a choice of foods. During observations staff and residents were interacting in an appropriate manner, and residents were being addressed by their preferred names. The Annual Quality Assurance Assessment (AQAA) completed by the manager of the care home has been used as a source of evidence in this report. At the time of writing this report the Commission For Social Care Inspection had not received completed surveys from residents, their relatives or other associated professionals. The inspector would like to thank the manager, members of staff and residents for their cooperation during this visit. Feedback was provided to the manager at the end of this site visit. What the service does well: Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 6 Assessment documentation is in place to ensure the individual needs of residents can be met. Residents informed the Inspector that their privacy and dignity is respected at all times by staff. Residents are provided with opportunities to improve their lifestyle, and where possible they are able to maintain contact with family, friends and the local community. People who use the service are offered a balanced diet. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Residents are protected by staff having knowledge, training and an understanding of Safeguarding issues. People who use the service are provided with good communal and individual living space making it a safe and comfortable place to live. What has improved since the last inspection? What they could do better: Care plans must be further developed to include all the information as required to ensure that the health, personal and social care needs of residents is being met. The administration of all medication must be fully recorded on the Medication Administration Record sheet (MARs). All staff must have a Protection Of Vulnerable Adults (POVA) list check undertaken, and must not be left unsupervised until completion. Residents’ monies must be transferred into their own bank/building society accounts where it will earn a reasonable interest. All staff must receive regular one to one supervision. Please contact the provider for advice of actions taken in response to this Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 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 Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: Information provided in the Annual Quality Assurance Assessment (AQAA) informs that two members of the team, one of who is at a senior management level, undertake the pre-admission assessments to determine if Shannon Court can meet the needs of prospective residents. Three care files were sampled as part of the case tracking process. These provided evidence that prospective residents had a pre- admission assessment undertaken prior to admission to the home that included personal, health and social care needs. These assessments were signed and dated. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 10 The manager informed the Inspector that visits to the home are encouraged. This was confirmed during discussions with residents, who stated that they had a visit from two staff of the home who undertook an assessment of their needs, and they did visit the home before moving in. The manager informed the Inspector that care plans are developed from the pre-admission assessments. The home does not offer intermediate care. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans require further development to ensure all aspects of health, personal and social care needs are being met. The standard of medication administration must be improved to safeguard residents. EVIDENCE: Three care plans that were sampled as part of the case tracking process during the site visit. These included goals/aims and risk assessments for daily living, including falls, moving and handling, bathing and Waterlow scores. Risk assessments were being reviewed on a monthly basis. Requirements made at the previous inspection in regard to care planning have been met, however, care plans must be further developed to include all the information as required; for example medication, communication, hearing, eating/drinking, behaviour and personal safety. One care plan had no information in regard to nutrition, and one care plan informed that a resident must have their weight recorded on a weekly basis but this had not taken place. The manager stated Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 12 all this information had been included in the care plans, and she would undertake a full audit of care plans on the 29th and 30th September 2007. The manager informed the Inspector that staff have had one to one training from herself and deputy managers in regard to care planning, and it is now part of the induction training. Care plans had been reviewed on a monthly basis, and had been signed by residents. The manager was advised that notes in regard to the monthly reviews of care plans should include more detail as opposed to a single sentence. A good practice recommendation has been made in regard to this. Residents had copies of their care plan in their bedrooms, although during discussions, some residents stated they could not remember the contents. A requirement has been made that care plans must be further developed to include all the information as required to ensure that the health, personal and social care needs of residents are being met. Staff informed the Inspector that they use a key worker system, and were responsible for the reviewing and updating of care plans on a monthly basis. One relative informed the Inspector they were aware of the care plans, and that the staff are knowledgeable of the contents. From discussions with staff and residents, and from viewing records, it was clear that health care professionals including a General Practitioner, District Nurse, Dentist and Chiropodist are available to support residents. The District Nurse maintains their own notes that are kept in the residents’ bedrooms. Residents informed the Inspector that the General Practioner will visit them in the privacy of their bedrooms, that they have access to all NHS facilities, and that they always receive their medication on time. The home follows the organisation’s Policies and Procedures in regard to medication. The home uses the blister packs that are provided by the local pharmacy, and Medication Administration Record sheets (MARs) for the recording of medicines. The MAR sheets were viewed during this site visit. It was not clear if residents had received their medications as prescribed as there were a number of gaps on the Medication Administration Record sheets (MARs) for September 2007. An immediate requirement has been made in regard to this. The manager informed the Inspector that she would undertake a full audit of the medication. At the time of writing this report the manager had forwarded written information of how this had been addressed. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 13 Medication was appropriately stored in secure metal medicine cabinets in each of the units. Controlled Drugs were appropriately stored and two members of staff sign these records. Two medication rounds were observed during this site visit; staff were administering medication appropriately. The home maintains a record of medication that has been returned to the Pharmacist. During discussions staff informed the Inspector that only staff who have received training administer medication. Evidence of this training was not viewed during this site visit. Staff informed the Inspector that they treat residents with respect, they always knock on their bedroom doors and call them by their preferred names. Personal care is undertaken in the privacy of bedrooms and bathrooms. This was confirmed during discussions with residents. Information provided in the AQAA informs that Equality and Diversity is met through following the organisation’s Policies and Procedures in regard to Equality and Diversity. Residents are supported to follow their religious beliefs, and the home has rooms at the home that are designate multi - faith quiet rooms. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with opportunities to improve their lifestyle, and where possible they are able to maintain contact with family, friends and the local community. People who use the service are offered a balanced diet. EVIDENCE: The home currently employs one activity co-ordinator who works thirty hours per week at the home. A monthly activity list is displayed on the notice boards in each of the four units, and residents are provided with their individual copies. During discussions the activity co-ordinator informed the Inspector that activities offered include quiz, exercises to music, craft club, discussion groups and shopping trips. The activity co-ordinator is to further develop the activities to include trips outside of the home, but this is dependant on the delivery of the new mini-bus that has been ordered. The home has visits from external entertainers that include theatre groups and a visiting pianist. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 15 During discussions, some residents informed the Inspector that activities are organised by the home, but they do not always wish to take part in them. Other residents stated they like to join in with activities. Residents and staff informed the Inspector there are no restrictions on visitors to the home. Visitors were present at the home during this site visit. Residents stated that they make every day choices about their lives, and that they like their bedrooms and the staff. All residents living at the home are white British, and hold Christian beliefs. Staff and residents informed the Inspector that a local church leader attends the home on a monthly basis to provide a religious service, and residents are able to attend the local church if they choose to. The home uses an external catering company for the provision of meals, and uses a four-week rolling menu. Menus were viewed and found to offer fresh meat, fish, fresh vegetables and fruit. During discussions, the assistant chef informed the Inspector that special diets are catered for. A record of all residents who require a special diet is maintained in the kitchen. The assistant chef showed the Inspector a sample of the daily surveys that are completed by residents after lunch and supper. Any issues raised are addressed immediately. Residents informed the Inspector that the food is good at the home, you always get a choice, and you can ask for something different from the menu. Some residents stated they could have their breakfast in bed, and have all their meals in their bedrooms if they wished to. Each unit has its’ own dining room and a small kitchen. Dining room tables accommodate four residents and a copy of the day’s menu was placed on each table. Meal times were observed to be relaxed occasions with staff available to offer support as and when required. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Residents are protected by staff having knowledge, training and an understanding of Safeguarding issues; however, recruitment practices are placing residents at risk of possible abuse. EVIDENCE: The Commission For Social Care Inspection had received one complaint in regard to the home. This was passed to the manager who stated that written information in regard to the outcome would be forwarded to the Commission For Social Care Inspection. The home follows the organisation’s Complaints Policy and Procedure. This document includes the timescales for responding to complainants and the contact details for the Commission For Social Care Inspection. A copy of the Complaints procedure was displayed in each of the units, and is included in the Statement of Purpose that each resident has in their bedrooms. The home has dealt with two complaints since the previous inspection and they are recorded in the complaints record maintained by the home. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 17 During discussions residents stated they would talk to the manager if they had any complaints, however, they had not had the need to make any complaints. There are no current ongoing issues in regard to the Protection of Vulnerable Adults. The home follows the organisation’s Policy and Procedure in regard to the Protection of Vulnerable Adults, and has a copy of the recent Surrey Multi – Agency Procedures that is available to staff. Training in regard to Safeguarding Adults is included in the induction training for new staff. The training matrix provided to the Inspector on the day of the site visit evidenced that staff had received training in regard to Safeguarding Adults. During discussions staff were able to give an account of the procedures to be followed in regard abuse, and stated they would not hesitate to follow the organisation’s procedure in regard to Whistle Blowing. The recruitment procedure does not fully safeguard residents living at the home. Concerns relating to the recruitment have been addressed under the Staffing section of this report. Evidence found during the site visit in regard to staff training and Policies and Procedures supported the information provided in the Annual Quality Assurance Assessment (AQAA). Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with good communal and individual living space making it a safe and comfortable place to live. EVIDENCE: A tour of the premises was undertaken. The accommodation for residents is provided on two floors and is separated into five units, however, one unit is currently closed due to being refurbished. Each unit has its own dining room and lounge facilities. Access to the first floor is via passenger lifts. All bedrooms are single rooms and have en-suite facilities. The manager informed the Inspector that one unit is dedicated to residents who suffer with Dementia, and is to be appropriately refurbished throughout. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 19 There is a large communal lounge in the main building with a licensed bar at one end and a shop at the other. Residents can purchase goods, for example toiletries, stamps and sweets. There is an activities room, a library and a hairdressing salon in the main building, all of which are accessible to the residents. Communal areas are accessible to all residents, and handrails are in place on the walls. Bathrooms and toilets had paper towels and liquid soap. It was noted that the waste bins in some bathrooms/showers and toilets had no lids and/or were broken. This was discussed with the manager, and arrangements were made for their immediate replacement. Freestanding fans were observed in the communal areas that required risk assessments. The manager produced these during this site visit. On the day of the site visit the home was very clean, tidy and free from offensive odours. Residents informed the Inspector that the home is always clean and tidy, and they have unrestricted access to the communal areas of the home. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory, ensuring staff have the qualities and training to meet the needs of residents. The home has a recruitment policy and procedure in place; however, this has not always been followed when recruiting staff, therefore not fully protecting the residents. EVIDENCE: The home is currently operating four residential units, one of which is designated to the care of residents who suffer with Dementia. The manager informed the Inspector that staffing for this unit is three care staff and two waking night staff. The other three units each have two members of staff and one waking night staff on duty. This was verified on the duty rota maintained by the home. The manager and two deputy managers are supernumerary to the duty rota, but do attend to the units. This was confirmed during discussions with residents and staff who stated that it was nice to see the managers in the residential units. The requirement made at the previous inspection in regard to the reviewing of staff levels had been undertaken by the home. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 21 The manager informed the Inspector that there is currently a recruitment drive to employ more permanent staff, which will decrease the use of agency staff. The manager stated that staff employed at the home are not under the age of twenty-one. Information provided to the Inspector during the site visit informs that the staff are attending training in regard to NVQ levels two and three, and upon completion the home would exceed the National Minimum Standard in regard to 50 of the care staff holding the minimum of NVQ level 2 or above. The home follows the organisation’s Recruitment Policies and Procedures. Four staff files were sampled at random. These included an application form, two written references and proof of identification. It was observed in one staff file that a date was missing in regard to when this person ceased a particular job. The manager informed the Inspector that she would follow this up immediately. During the sampling of Criminal Record Bureau certificates, it was noted that the Protection Of Vulnerable Adults (POVA) list had not been requested on the certificates for six members of staff. Each had a current Criminal Record Bureau certificate. An immediate requirement was made in regard to this, and staff must not work unsupervised until these checks have been completed. The requirement made at the last inspection in regard to recording the reasons for gaps in employment had been complied with. The manager stated that she is included in the process of recruitment of staff, and had undertaken training in Recruitment and Selection with her previous employer. The home had written confirmation from the Agency who provides temporary staff that they had obtained all the information and documents as specified in Schedule 2 of The Care Home Regulations 2001, as amended. This was a requirement made at the last inspection that has been complied with. Staff attend Induction training that is in line with the Skills For Care council. Information provided to the Inspector informed that three staff had completed their induction, another two new staff were in the process of completing the induction. The AQAA informs that the organisation is continuing to actively recruit permanent staff throughout the local area, universities and hospitals Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was evidence of areas of good management and practice within the home, however, issues in regard to care plans, medication and staff recruitment must be addressed to ensure the health, safety and welfare of the residents is maintained. EVIDENCE: The home has a new registered manager who will offer stability within the management team. The manager commenced her post in March 2007, and successfully registered with the Commission For Social Care Inspection in August 2007. The manager is a registered nurse (RMN) and qualified in 1992. Since that time she has Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 23 worked in older care and with people with dementia, also qualifying as a drama therapist. She has been in managerial positions for the past six years, and is currently undertaking the NVQ level 4. During discussions staff informed the Inspector that the management of the home is more accessible, and the manager has an open door policy. The manager must address the issues raised in this report in regard to care plans, medication and staff recruitment. Evidence was seen that the home conducts meetings for residents. The minutes of the 5th September 2007 were viewed during the site visit. It was recorded in these minutes that residents would prefer the meetings to be on a three monthly basis. The organisation had commissioned an external company to undertake an annual quality assurance survey of residents and their relatives. A summary of the findings were held at the home and seen by the Inspector. The manager informed the Inspector that residents and their relatives are responsible for their finances, but the home does hold small amounts of money for residents that are pooled in one bank account that does not pay interest. This was discussed with the manager who informed the Inspector this had been ongoing before she commenced her post. The manager stated that the organisation had this agreed with the Commission For Social Care Inspection in 2003. Copies of correspondence received from the organisation confirmed this. The Inspector is following this up with the Commission For Social Care Inspection, however, a good practice recommendation has been made that the home should review the arrangements in regard to holding residents’ monies in a pooled bank account, as all monies should be able to accrue interest for the resident concerned. Evidence was viewed that some staff are receiving supervision and an annual appraisal, however, one member of staff last received formal one to one supervision on the 24th October 2006. A requirement has been made that all staff must receive the minimum of six formal supervision sessions per year. A training matrix for all staff was provided on the day of the site visit. Random selection of six staff provided evidence that they had attended mandatory and refresher training as required. Information provided in the AQAA informed that the annual maintenance and safety checks of equipment had been undertaken. The Inspector was not able to view these certificates as the person responsible had left the premises for the day; however, the gas certificate and Employers Liability Insurance were seen. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 24 The manager informed the Inspector that the home is to have an inspection from the Surrey Fire and Rescue service on the day after this site visit, 28th September 2007. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 25 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15 (1) Requirement Care plans must be further developed to include all the information as required to ensure that the health, personal and social care needs of residents is being met. The administration of all medication must be fully recorded on the Medication Administration Record sheet (MARs). Timescale for action 27/11/07 2. OP9 13 (2) 27/09/07 3. OP29 19 (4) (b) (i) This will ensure that people who use the service are protected by the home’s policy, procedure and practices. All staff must have a Protection 27/09/07 Of Vulnerable Adults (POVA) list check undertaken, and must not be left unsupervised until completion. This will ensure that people who use the service are not being placed at the risk of harm or abuse. Residents’ monies must be DS0000017643.V344909.R01.S.doc 4. OP35 20 (1) 27/10/07 Page 27 Shannon Court Version 5.2 5. OP36 18 (2) transferred into their own bank/building society accounts where it will earn a reasonable interest. All staff must receive the minimum of six formal supervision sessions per year. This will ensure that people who use the service benefit from staff having their performance appraised. 31/12/07 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. 2. Refer to Standard OP7 OP35 Good Practice Recommendations It is recommended that the care plan monthly reviews should be more detailed to reflect the changes in care objectives. The home should review the arrangements in regard to holding residents’ monies in a pooled bank account, as all monies should be able to accrue interest for individual residents. Shannon Court DS0000017643.V344909.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000017643.V344909.R01.S.doc Version 5.2 Page 29 - 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. 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