Inspection on 06/06/05 for Shardeloes

This inspection was carried out on 6th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shardeloes 08/10/08

Shardeloes 19/12/06

Shardeloes 15/11/05

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 Ashstead Woods Road Ashstead Surrey KT21 2EQ Lead Inspector Helen Dickens Announced 06 June 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Shardeloes Address Ashstead Woods Road Ashstead Surrey KT21 2EQ 01372 273228 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) CMG Homes Ltd The Pointe, 89 Hartfield Road, Wimbledon, London, SW19 3TJ Rosaleen Leen Care Home (CRH) 8 Category(ies) of Learning disability (LD) 8 registration, with number Mental disorder, excluding learning disability or of places dementia (MD) 3 S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Of the 8 (eight) adults with learning disabilities (LD) accommodated, up to 3 (three) persons may have a mental disorder (MD). 2 The age/age range of the persons to be accommodated will be: 30-65 YEARS OF AGE Date of last inspection 02 November 2004 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 self-contained 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. S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 6 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Helen Dickens, lead inspector for the service. Rosaleen Leen, Registered Manager, represented the establishment. A tour of the premises took place. Six residents and two staff were spoken to during the inspection. Care plans and other documents were examined. A pre-inspection questionnaire and comment cards were also used in writing this report. This was a positive inspection. The inspector would like to thank the residents, staff and manager for their time, assistance and hospitality during this inspection. What the service does well: The service offers a homely and supportive setting for its residents. The focus is very much on resident’s well-being and quality of life. There are some good examples of best practice such as a resident’s induction programme. This checklist itemises everything a new resident will need to know. It includes an introduction to other residents and to the local area, rules and regulations of the home, and the fire procedure. There is a resident’s forum organised by the company, where residents from across the country meet up for an annual event. Residents can take part in a variety of ways and some give talks and put on exhibitions of their work. Their opinions are sought both with pre-forum questionnaires and on the day. The questionnaires for residents were very well designed and came in pictorial formats. Residents spoke well of the home and it’s staff. Comments such as ‘I think this place is very good’ were typical. Some said it was a better home than where they had been before and one resident told the inspector ‘I am lucky to be in this place.’ Similarly, a complimentary letter from a care manager said their client had received ‘committed and consistent input, especially with communication,’ and had made ‘substantial progress.’ S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2 and 5 The home’s statement of purpose and service user guide provide both existing and prospective residents with sufficient information to help them make an informed choice about admission to the home. The assessment process enables residents to be confident that their needs have been properly recognised. EVIDENCE: The statement of purpose and service user guide have been up-dated and provide a good overview of the home’s facilities. Both documents have sections, which are in accessible formats for residents, including pictures and larger font print. The assessment on a recently admitted resident was thorough and gave a good overview of his needs. It covered social activities as well as health and dietary needs. When speaking to the resident he confirmed he is encouraged to eat ‘healthy’ food, as he needs to lose some weight. The new resident’s agreements have now been given to all but one resident to see and go through. Residents who do not hold their own copy of the agreement should have this documented on their care plans, together with the reason why. S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8 and 9 Residents can be confident that their assessed needs have been recognised and their preferences taken into account. EVIDENCE: The care plans viewed were up to date and had a good overview of health, care and social needs. Strengths and needs, likes and dislikes, and behavioural support were all clearly documented. The key workers had good knowledge of resident’s preferences for food, leisure, travel and any phobias. There was evidence that residents had had some input into their care plans. Residents do not take part in staff meetings or have involvement in the appointment of staff. However, they can take part in the annual resident’s forum and the pre-forum questionnaires go to residents, relatives and care managers. There is a quality assurance folder, which contains policies for activities, complaints, and information on the resident’s forum. There is also a resident’s meetings policy with an example of how the minutes should be taken. Residents are encouraged to take risks and be as independent as possible. The missing persons procedure is part of each resident’s induction. S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 13,14 and 15 Residents at Shardeloes are assisted to be part of the local community and to maintain links with family and friends. EVIDENCE: Shardeloes looks like any other house in the road and those who are able to do so, go into the town themselves or with staff support. Residents told the inspector about the local facilities they used including takeaway fish and chips, outings to Epsom, and bowling. The resident’s induction includes a tour of the area to acquaint themselves with local facilities. Other leisure activities included video nights and weekly barbecues. Support from family and friends is encouraged and residents wishes in this respect were documented on their care plans. S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 18,19,20 and 21 The home provides appropriate personal and health care and residents needs are well met in this respect. Medication is well managed at Shardeloes. EVIDENCE: Personal support required by residents is clearly documented on their assessments and care plans. It is offered in a sensitive way and supports resident’s independence. When the home no longer meets a resident’s needs, they are supported to find alternatives. A medication round was observed during the inspection and good practices were observed. Inspection of the medication administration records showed no omissions, and policies and procedures were in place to safeguard residents. Boots gave advice on the administration, and the care company paid for this on an annual basis. A ‘dying with dignity ’policy together with general policies and procedures on this topic were available for the inspector to view. The resident’s agreement covered a resident’s right to stay in the home. The policies did not however consider ageing and this needs to be added to comply fully with Standard 21. S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 22 The home has a clear and effective complaints procedure EVIDENCE: There have been no complaints at Shardeloes since the last inspection. The complaints procedure is available in a user-friendly format both in the home and in the policies and procedures manual. Copies of this friendly version are also in the statement of purpose and service user guide. The resident’s forum questionnaire also asks residents if they have any complaints. Specifically, it asks when they had their last residents meeting, their last session with their key worker and about numbers of staff on duty. In this way the residents are able to highlight standards of care without formally having to make a complaint. S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 24,26 and 28 The general environment at Shardeloes is good but there are a number of decorative matters which detract from the homely atmosphere, which the staff try hard to create. EVIDENCE: The home is in keeping with the local community and the furnishings and fittings are of reasonable quality. Bedrooms were personalised by residents and those spoken to were happy with their rooms. However, a number of decorative matters are outstanding and the requirement from June 2004 to repair the drive has still not been completed. In addition to the drive, which is uneven and could be dangerous, the following issues were noted on the day of the inspection: a)Kitchen towel dispenser and kitchen floor covering due to be replaced b)The lounge carpet is stained and needs to be replaced c)Not every resident’s room had a chair; the Standard says there should be comfortable seating for two people in each bedroom d)One resident’s carpet was stained with ink and needed replacing; the curtains were hanging off, and the resident also said the room was waiting to be decorated and the seating replaced. The kitchenette adjacent to this room S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 14 needed repair to the walls. e)The stair carpet in the main building had worn patches and looked unsightly. An action plan and timescales for the above should be sent to the inspector at the CSCI Eashing office. S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,35 and 36 Staff morale is good and staff were interacting well with residents in the home. Induction and staff training ensure that residents needs will be met. EVIDENCE: Staff attitudes to residents were good and those staff interviewed were happy in their work. One member of staff interviewed said Shardeloes had a ‘family atmosphere.’ There were regular staff meetings and evidence of formal and informal training and support. Induction training for new staff was well organised and documented and there was evidence of regular staff supervision. S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,40 and 42 Residents benefit from a manager who is competent and provides an open and positive atmosphere within the home. However, the manager must ensure that risks to residents and staff are assessed and dealt with in a timely manner. EVIDENCE: The manager is aware of the few decorative shortfalls in the home and is working to improve them. The manager ensures that the home is correctly run and complies with the Care Standards Act. There is a homely atmosphere and one staff member said the manager was very supportive and the company was a ‘good company to work for.’ Policies and procedures examined were appropriate but not all up to date. The company provides the policies and up-dates them. To comply with Standard 40 all policies, procedures and codes of practice need to be signed by the registered manager and dated, monitored, reviewed and amended. During the inspection the needs of one resident were compromising the health S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 17 and safety of other residents and staff. The risk assessment for this resident required updating and the resident’s needs, having been assessed as being better met elsewhere, should have been addressed urgently. The inspector asked for the risk assessment to be updated and the manager to continue to put pressure on the placing authority to remedy the situation. Since the inspection, the resident has successfully moved to a more appropriate placement. S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 18 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 3 3 x x 2 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 x 3 x x Standard No 11 12 13 14 15 16 17 x x 3 3 3 x x Standard No 31 32 33 34 35 36 Score x 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 S Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x 2 x H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 19 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 YA5 Regulation 5© Requirement Each resident should have a copy of the contract (residents agreement), signed by the resident and the registered manager. Where this is not appropriate, the reasons should be clearly documented. The homes policies should consider the ageing process in order to fully comply with Standard 21. The outstanding decorative works and repairs outlined in the report need to be completed. A plan and timescale for the work should be forwarded to CSCI. The works listed are: Replacement of kitchen towel dispenser and kitchen floor covering; Replacement of lounge carpet; Replacement of residents carpet, damaged curtain, kitchenette wall repairs, and replacement seating; Replacement or repair of worn stair carpet. Residents should have 2 comforatable chairs in their bedrooms. Policies and procedures need to Timescale for action 06.08.2005 2. YA21 17 06.09.05 3. YA24 16©(g) 4(a)(c) 06.08.2005 4. 5. S YA26 YA40 16(2) (c 17(1)(2) 06.08.2005 06.08.2005 Page 20 H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 (3) 6. YA42 14(2)(a) (b) be kept updated and fully comply with Standard YA40. Residents needs must be kept 06.07.2005 under review and risk assessments regularly updated to better promote health and safety within the home. 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 8 Good Practice Recommendations The manager should consider additional ways to get residents input into the running of the home. Involving a resident representative in part of the staff meetings, or in recruiting staff, would be examples of increased resident involvement. S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI S H58 S13782 Shardeloes V219049 060605 Stage 4.doc Version 1.30 Page 22 - 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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