CARE HOME ADULTS 18-65
Shardeloes Shardeloes Ashtead Woods Road Ashtead Surrey KT21 2EQ Lead Inspector
Lisa Johnson Unannounced Inspection 15th November 2005 11:00 Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 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 Shardeloes DS0000013782.V257211.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 Adults 18-65. 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. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Shardeloes Address Shardeloes Ashtead Woods Road Ashtead Surrey KT21 2EQ 01372 273228 01372 273228 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) CMG Homes Ltd Rosaleen Leen Care Home 8 Category(ies) of Learning disability (8), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 30-65 YEARS OF AGE Of the 8 (eight) adults with learning disabilities (LD) accommodated, up to 3 (three) persons may have a mental disorder (MD). 6th June 2005 Date of last inspection Brief Description of the Service: Shardeloes is a care home for 8 adults with learning disabilities. The home is registered to admit both male and female residents, of whom a maximum of three may also have a mental disorder. Shardeloes is situated in a residential area of Ashtead. The building is a large detached house with an adjacent selfcontained flat affording opportunity for semi-independent living for one resident. Accommodation is situated over 2 floors and each resident has a single room. There is a large communal lounge, separate dining room and a well-equipped kitchen on the ground floor. There are also separate utility facilities. The home has off-road parking and a large garden at the front of the premises. There is also a spacious secluded garden to the rear. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection carried out in 2005/2006. One inspector carried out the unannounced inspection over three and half hours. The focus of the inspection was to review the requirements made at the last inspection and to look at other key standards. A tour of the premises took place and care plans, policies and procedures and other documents were sampled. The inspector spoke to three residents who live in the home and to the registered manager and two members of staff. This was a positive inspection. The inspector would like to thank the residents and staff for their hospitality, assistance and cooperation in carrying out this inspection. What the service does well:
The home has completed detailed and comprehensive care plans which are based on assessment. It was pleasing to see that regular reviews of care plans take place and are recorded. Some of the information available in the home is in picture format such as the homes complaints procedure and the home has been carrying out a pilot in respect of introducing health action plans. Residents were supported with a full programme of daily activities including a range of social events including parties, trips to the cinema, shopping, bowling holidays and outings as well as recreational activities held in the home such as video nights and parties. The service provides a homely, welcoming and friendly atmosphere. Good relationships were seen between service users and staff and it was clear that service users were happy and relaxed and were enjoying being in the company of the staff. Residents and staff were seen playing a game of scrabble together and making cards for a Christmas competition. Residents spoken to confirmed that they were happy living in the home. One resident said, “ It’s a nice place to live”. Another resident stated “ Its good here”. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
The replacement flooring and must be completed to ensure that this standard is fully met. This is to ensure that residents have a comfortable and wellmaintained home to live in. In some bedrooms beds were seen to be placed near radiators and a requirement was made that radiator covers must be installed to ensure the health, welfare and safety of residents. One of the driveway entrances was found to be uneven and a requirement was made that a risk assessment is completed and to ensure that it is an adequate state of repair to promote the health and safety of residents, staff and visitors to the home. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 7 Individual training records were placed on individual files. However a recommendation was made that the home should consider completing and updating the training schedule when any staff training takes place. 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. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 Adequate information was available that would assist prospective residents and relatives make an informed choice as to whether the home would be a suitable place to live. Trial visits are accommodated to “test drive” the home. Each resident is provided with a written contract. EVIDENCE: The Statement of Purpose and service user guide is detailed and comprehensive and clearly describes the homes aims and objectives and specialist services it is able to offer The home is able to offer introductory visits with the opportunity to be able to stay for meals with overnight states been available. Opportunity for trial stays is accommodated. This is documented in the homes statement of purpose and service user guide. Since the last inspection the registered manager has supplied a copy of the contract to each resident. Two contracts were sampled and were signed by the registered manager and the individual. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 & 10 The home is able to demonstrate that each resident has an individual plan goal plan, which are regularly reviewed. Risk plans are implemented. Confidential information is handled appropriately. EVIDENCE: Two care plans were sampled which were detailed and structured with clear goal plans in place. Plans were reviewed, updated and recorded. Each plan contained a pen picture, strength and needs list and individual preferences. Risk assessments were detailed and in depth covering health, physical, emotional and life skills. Resident’s records were held in the homes office and all records were maintained to a good standard. A confidentiality policy was available which was reflected in the service user guide. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 16 & 17 The home supports service users to maintain independent living skills. Service users take part in fulfilling activities and participate in the local community. Service users engage in a range of leisure activities. Residents are provided with a well-balanced diet. EVIDENCE: Residents are able to be involved in household activities and support is provided where necessary. One resident said, “ I like to lay the tables and help to clear up”. Another individual has his own living accommodation and kitchen and is supported with shopping and cooking. The home provides a number of recreational and social activities. During the inspection some residents in the house were enjoying a game of scrabble and preparing Christmas card designs for a competition. One resident works in a charity shop and some residents attend a day centre and attend classes at college to undertake courses. There are opportunities to go the cinema, bowling, shopping and the home has video nights. Some residents have been on holiday and/or been on outings, which was confirmed by one resident who said, “ I went to Brighton”. The home is currently in the process of organising Christmas social events.
Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 12 Staff were seen knocking on bedroom doors and bathrooms before entering. Good relationships was seen between residents and staff and it was pleasing to see everybody enjoying recreational activities in the home together and individuals who wished to be alone was also respected. A resident’s charter was in place. Menus were sampled and were varied and the lunchtime meal was seen which was nutritious in content. Menus are based on individual preferences. The mealtime was relaxed and unhurried. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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 inspection. EVIDENCE: For information on these standards please refer to the report on 6th June 2005 Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home is able to demonstrate that there is an accessible complaints procedure. Written policies and procedures were in place to ensure that residents are protected from abuse. EVIDENCE: The homes complaints register was sampled and no complaints have been received since the last inspection. The procedure is available in service userfriendly format and one resident spoken to had a copy available in his bedroom. Two residents spoken confirmed they knew who to approach if they were unhappy of had any concerns. Two residents spoken to confirmed that were happy living in the home and comments received were “ Its nice place to live”. “Its good here”. An updated copy of the local authority protection of vulnerable adults policy and whistle blowing policy was available. The manager has attended the local authority protection of vulnerable adult training and two staff spoken to confirmed that they have received appropriate training and were clear in their responses as to the appropriate actions they would take if they ever witnessed any possible abuse. A recommendation was made that the homes overall training schedule should be kept updated, as there were gaps in recording for staff receiving training in the protection of vulnerable adults. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 29 & 30 The home has made progress in carrying out some redecoration but the furnishing issues must be completed to ensure that residents have a comfortable and well-maintained home to live in. Residents have spacious bedrooms that are comfortable and promote individual tastes and interests, but one issue in respect of chairs must be completed. Adequate toilets and bathrooms were available which provide privacy. The home was able to demonstrate that it was clean and hygienic EVIDENCE: A tour of the premises took place. Some redecoration work has been completed and ordering of new carpets and flooring has taken place for the stairs, sitting room, bedrooms and kitchen. However this work needs to be completed and this has been made a further requirement to ensure that this standard is fully met. There is a large garden to the rear of the house which has a summer house installed. The grounds were adequately maintained, however action needs to be taken in respect of one driveway entrance, which is uneven. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 16 Residents have spacious bedrooms and were personalised with individual’s belongings and range of interests. Chairs for bedrooms have been ordered to ensure that this standard is fully met. Adequate toilets and bathrooms were available and accessible. One resident lives more independently and has his own kitchen and bathroom. Referrals are made to the occupational therapist for assessment if any specialist equipment is required. The home was clean and hygienic. Adequate hand washing facilities were available with soap and disposable towels being provided. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 & 34 The roles and responsibilities of staff are defined. The home is able to demonstrate that residents are protected by the homes recruitment policies and procedures. EVIDENCE: Each member of staff is provided with a clearly defined job description and evidence of these were sampled on personal files. A key worker system is in place It was clear that the staff team have a good knowledge and awareness of the residents individual needs. Two staff personal files were sampled which were well maintained and in good order. All the required information was in place including evidence of police checks. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 39, 41, 42 & 43 The home is run well and managed in an open and inclusive atmosphere. The manager has implemented a quality assurance system based on seeking the views of residents. The registered manager has made progress in updating policies and procedures. The registered manager must ensure that the radiator covers and the driveway are actioned to ensure the health, welfare and safety of residents EVIDENCE: The manager is a qualified nurse and is currently completing the registered managers award. The home was seen to be run in an open and inclusive atmosphere. Staff spoken to confirmed that they felt supported and receive regular supervision, training and attend regular staff meetings. A quality assurance folder was available which was detailed in content and a quality assurance questionnaire has been introduced in the form of resident satisfaction questionnaires, which were detailed with the outcomes being analyzed. A forum is held and the home has monthly residents meetings. The responsible individual visits monthly to carry out quality visits and copies of
Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 19 reports are sent to the Commission for Social Care Inspection and a copy is maintained in the home. A range of policies and procedures were in place and were sampled. Some procedures are currently being updated. The manager records all new policies in the homes communication book and a read and sign system is in place with the manager checking out knowledge with the staff. Record keeping was of a good standard. Accident records, fire documentation, fridge temperature and water temperature records were examined and were maintained adequately and were up-to-date. During a tour of the house some of the beds were placed near radiators and a requirement was made that radiator covers must be supplied to ensure the health, welfare and safety of residents. The entrance to one of the driveways was found to be uneven. A further requirement was made that a risk assessment is completed and to ensure that the entrance is adequately maintained to ensure the health and safety of residents, staff and visitors to the home. The company sets the overall business plan but the manager is able to contribute by submitting proposals for the home. The manager receives a budget, which also includes a budget for training and development. Insurance certificates and were displayed in the office. Shardeloes DS0000013782.V257211.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 Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 2 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X X 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Shardeloes Score X X X X Standard No 37 38 39 40 41 42 43 Score X 3 3 X 3 2 3 DS0000013782.V257211.R01.S.doc Version 5.0 Page 21 Yes 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 YA 24 Regulatio n 23 92)(b) Requirement Timescale for action 01/01/06 2 3. YA 26 YA 42 3. YA 42 The outstanding furnishing replacement outlined in the report must be completed. The works listed are: Replacement of lounge carpet; Replacement of residents carpet, damaged curtain, Replacement or repair of worn stair carpet. This is to ensure that residents have a comfortable and well maintained home to live in. 16 (2) (c) The provision of chairs in resident’s bedrooms is to be completed. 23(2)(b) The registered manager must 13(4)(c) ensure that a risk assessment is (d) completed in respect of the entrance to one driveway and ensure this in an adequate state of repair to ensure the health, welfare and safety of residents and visitors. 13 (4)(c) Radiator covers must be supplied in resident’s bedrooms to ensure the heath, welfare and safety of residents. 01/01/05 29/11/05 16/12/05 Shardeloes DS0000013782.V257211.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 YA 35 Good Practice Recommendations The registered manager should consider ensuring that any staff training, which is completed, should be recorded and kept up-to-date o0n the staff-training schedule. Shardeloes DS0000013782.V257211.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office 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
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