Inspection on 19/12/06 for Shardeloes

This inspection was carried out on 19th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Shardeloes 08/10/08

Shardeloes 15/11/05

Shardeloes 06/06/05

Shardeloes 02/11/04

Shardeloes 04/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

Dovedale Court

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

CARE HOME ADULTS 18-65 Shardeloes Shardeloes Ashtead Woods Road Ashtead Surrey KT21 2EQ Lead Inspector Lisa Johnson Unannounced Inspection 19th December 2006 09:10 Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 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.V324066.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 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.V324066.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shardeloes Address Shardeloes Ashtead Woods Road Ashtead Surrey KT21 2EQ 01372 273228 01372 270711 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) www.caremanagementgroup.com Care Management Group Ltd (trading as 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.V324066.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 8 (eight) adults with learning disabilities (LD) accommodated, up to 3 (three) persons may have a mental disorder (MD). The age/age range of the persons to be accommodated will be: 30-65 YEARS OF AGE 15th November 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. Weekly charges range from £1,078- £1,350. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. This visit was unannounced and took place over seven and half hours and was carried out by Mrs. L Johnson Regulation Inspector and Mrs.R Leen Registered Manager represented the establishment. The inspector spoke to five service users to gain their views on the care provided. Six service user comment cards have been received and these comments are reflected in this report. A full tour of the premises took place. Staff training records, staff files and policies and procedures were sampled. The inspector spoke to two members of staff. The inspector would like to thank the staff and service users for their time, assistance and hospitality during this inspection. What the service does well: The home provides a welcoming and friendly atmosphere. During discussion with service users it was clear that service users are supported to access a range of activities and social events. One Individual said, “ I go to the pub for a drink”. Another service user said, “I go shopping with staff “. Service users spoke positively about the care they receive. Comments included, “Its nice here”. “ I can talk to staff about what I want to do”. Service users spoken to during this visit thought that the food in the home was good. One individual said, “My favourite is fish and chips”. During this visit the inspector had the opportunity to speak to relative who said that the home is very welcoming and was happy with the care provided. Care plans and health action plans were completed for all service users. These were detailed and informative and gave a good overview of the care and support needs of individuals. The strengths and needs, likes and dislikes and individual preferences of service users were clearly recorded. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 7 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.V324066.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of service users are assessed prior to admission to the home. EVIDENCE: There have been no admissions to the home since the previous visit. Evidence sampled concluded that pre admission assessments are completed prior to any individual moving into the home. The company has an assessment and referral team with the registered manager having the opportunity to visit prospective service users. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are provided with an individual care plan, which records their individual needs and goals. Service users are supported to make decisions about their lives with assistance. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: The inspector sampled care plans for three service users. Each service user has a completed care plan which were person centred in approach and based on full needs assessment including personal care, health and emotional needs, communication, safety and social skills. Individual plans were of a good standard detailed and structured with clear priorities, objectives and goals recorded. A life picture and pen portrait was completed and a “where am I going section”. Clear support plans were in place for routines and strengths and need lists clearly defining individual preferences for example favourite Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 10 community and leisure activities, favourite diet and favourite tasks. It was evident that plans were regularly reviewed with annual, six monthly and monthly reviews recorded. There is a key worker system in place and two members of staff spoken to were aware of the care plans and their involvement in the review processes. Plans were agreed and signed by service users and where this was not possible this was recorded in their plan. Service users are invited to their reviews and six service user comment cards received indicate that staff listen to their views and act upon them. The inspector sampled one plan where a clear support plan was in place for one individual to manage his finances. Some service users have their own keys to their bedrooms. However it was recommended where individuals choose not to use their keys this should be recorded in their individual plan. A wide range of comprehensive risk plans were completed including personal care such a bathing, health, self help skills including the use of the kitchen. Some individuals have emotional difficulties, which could lead to possible aggression to other with clear plans and management guidelines in place. Risk plans are bought to the attention of staff and are signed by them with regular reviews completed. However it was recommended that one risk plan be updated. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a range of appropriate activities and engage in a range of leisure activities. Service uses are supported to take part in the local community. The rights and responsibilities of service users is respected. The home is able to demonstrate that service users are provided with a wellbalanced and nutritious diet. EVIDENCE: The home provides a range of recreational and leisure activities for service users to attend. It was clear that activities were tailored to suit individual needs and preferences. An activity plan was available for each individual and three plans were sampled which included for example attending Cheam day Centre, arts and crafts, music sessions, shopping trips, bowling, pub visits and one individual is supported to attend church on Sundays. The inspector spoke to two service users who said that they go shopping with staff and one individual said, “ The staff take me out to buy clothes”. Service users are Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 12 supported to assist in household activities. One individual stated, “I like laying the tables”. Another individual said, “I like mopping the floors”. Annual holidays have been completed and two service users told the inspector that they went to Butlins. Service users maintain links with their family and friends and during this visit one individual was being visited by his relative. A telephone is available for service users to maintain contact with their family and friends. During this visit one individual was being visited by his relative. The manager provided copies of the homes menus, which were varied and well balanced with service users being given the opportunity to make choices about their meals, and this is discussed as an agenda item at service users meetings. Service users spoke positively about the meals provided with three individuals stating, “My favourite is fish and chips”. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users receive personal support in the way they prefer. Service users physical and health needs are met. Service users are protected by the homes medication administration procedures. EVIDENCE: The preferences, likes and dislikes of service users were clearly recorded in their care plans such as favourite meals and activities and which was also demonstrated in the individuals support plan for example morning routine. The health care needs and objectives of service users are documented in their care plans and the home has completed health action plans. Three health care plans were sampled which contained detailed information of the health care needs of individuals including records of health appointments and screening checks. One individual had a support plan in place for epilepsy and is supported by a specialist epilepsy nurse. Service users are supported to access a range of health care professionals for example a local general practitioner, community psychiatric nurse, district nurse and chiropodist. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 14 The homes Medication administration practices were examined. Procedures were in place including a copy of the Royal Society Pharmaceutical Guidelines. Protocols were in place for service users receiving “As required” medication. Three medication administration cards were examined. Photographs of service users were available with their records and a list was available for all staff that are trained and authorized to administer medication. All medication administered was signed for. The home appropriately maintains records for all medication received and disposed of. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that the views of service users are listened to and acted upon. Service users are protected from abuse. EVIDENCE: The Commission for Social Care Inspection received which the manager appropriately investigated. A complaints procedure is available and is accessible to residents and is printed in service user-friendly format. Written comments received from residents indicate that they are aware of whom they can approach if they were unhappy and feel supported by the staff. Two service users spoken to during this visit said, “The home is nice”. There is a clearly written safeguarding adults procedure and a copy of the local authority safeguarding adults from abuse policy was available. The contact details for the local authority Social Care Team was also displayed. The manager has attended the local authority protection of vulnerable adult training and staff records sampled indicate that staff have been attending training. One member of staff spoken with confirmed her attendance at training and was clear in her responses to indicate that she was aware of the policies and procedures. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a well-maintained, comfortable, homely and safe environment. The home is able to demonstrate that service users bedrooms promote their independence. The home is clean and hygienic ensuring that service users have a pleasant home to live in. EVIDENCE: The home has made progress since the previous visit in improving the internal décor. New carpets been obtained in the corridors and in a number of rooms. New flooring has been laid in the kitchen and chairs have been made available in service users bedrooms. The home is spacious and one room is converted into a sensory area. During a tour of the home some minor maintenance issues were identified that need some attention including repainting to window ledges in the bathrooms and a seal needs replacing around one bath. The manager informed the inspector that the company’s maintenance department is currently completing work in the home to address these issues. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 17 Bedrooms were viewed as comfortable with service users having a varied range of possessions, which meets their interests and preferences. There is a large accessible garden to the rear of the house, which has a sunroom. During this visit it was observed that maintenance is being undertaken to repair and resurface the driveway. It was recommended that consideration be given to repainting some of the exterior window frames to the rear of the house to enhance the appearance. The home was clean ad hygienic with adequate hand washing facilities being available. The inspector spoke to one individual who said “The staff keep the home clean and fresh”. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Competent and qualified staff support service users. Service users are protected by the homes recruitment policy and appropriately trained staff meets practices and their needs. EVIDENCE: The manager provided copies of duty rotas to the inspector, which indicated that adequate staffing levels are maintained in the service. During the inspection the manager was working supernummary with three other members of staff on duty. A number of staff have completed National Vocational Qualifications (level 2) or above with some staff completing the programme. Three members of staff records were sampled. Each member of staff has their own training record in place and it was evident that staff have received mandatory training in safeguarding adults, fire, food handling, food hygiene manual handling, health and safety, first aid and managing medication. The inspector was informed that staff receive training in epilepsy and other examples of training completed was continence promotion and rights and responsibilities. The inspector observed that some mandatory training needed to be updated. The manager provided evidence of a programme of training dates for staff to attend updated training to include Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 19 infection control. It was recommended that this matter be completed including updating the individual staff training schedules to verify when training has been completed. New staff receive induction training based on Skills For Care standards. Copies of induction records were maintained in staff files Three staff personal files were sampled which were maintained in good order and contained the required information. POVA first checks are carried out and enhanced police checks are completed. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is able to demonstrate that service users benefit from a home, which is well run, and in the best interests of service users. The health safety and welfare of service uses is protected. EVIDENCE: The registered manager is a qualified nurse and is currently completing the Registered Managers Award. The manager informed the inspector that she is due to undertake further management training and development, which is being conducted by the company. The home holds regular staff meetings which was confirmed by staff spoken to and from records sampled Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 21 Service user Quality assurance questionnaires have been updated which were available for viewing. The company has also updated feedback questionnaires to include relatives and other stakeholders. The company holds an annual service users forum where there is an opportunity for service users to discuss their views and opinions in relation to subjects chosen by service users and issues raised by the feedback questionnaires. Comment cards received from service users indicate that staff listen to them and act on what they say. The Responsible Individual carries out monthly monitoring visits and the home holds service user meetings. The inspector received pre- inspection information, which indicates that the company provides a range of policies, and procedures, which have been updated with the manger bringing this information to staff attention during staff meetings. Substances hazardous to health (COSHH) were stored securely and appropriately. Health and safety checks are completed and recorded regularly which were sampled including fire prevention records, fridge and water temperatures. The manager provided information to indicate that records and certificates and identified systems are in place for routine service and maintenance arrangements for the environment. Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 22 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 Standard No Score 1 X 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X X 3 X Shardeloes DS0000013782.V324066.R01.S.doc Version 5.2 Page 23 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. 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 2 3 Refer to Standard YA7 YA24 YA35 Good Practice Recommendations It is recommended that where service users who choose not to use their bedroom door keys this be documented in their individual plan. Consideration should be given to repainting the exterior window frames to the rear of the house. It is recommended that all staff attend mandatory training updates and this is recorded in their training schedule. 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