Inspection on 24/01/08 for Sharea

This inspection was carried out on 24th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sharea 22/12/08

Sharea 12/09/07

Sharea 31/08/06

Sharea 20/12/05

Sharea 07/07/05

Sharea 10/11/04

Sharea 18/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Sutton Lodge Nursing Home

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Sharea Sharea 69 Reigate Road Hookwood Surrey RH6 0HL Lead Inspector Sarah MacLennan Unannounced Inspection 24 January 2008 09:45 th Sharea DS0000013783.V358652.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 Sharea DS0000013783.V358652.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. Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sharea Address Sharea 69 Reigate Road Hookwood Surrey RH6 0HL 01293 776248 F/P 01293 776248 info@avenuestrust.co.uk glebe.house@theavenuestrust.co.uk The Avenues Trust Ltd 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) Post Vacant Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1), Physical disability (6), of places Physical disability over 65 years of age (1), Sensory impairment (6) Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons accommodated will be 18-64 years. 1 (one) person within the category LD(E) or PD(E) may be accomodated over the age of 65 years. Persons may be accommodated who have both a learning disability (LD) and a physical disability (PD). 12th September 2007 Date of last inspection Brief Description of the Service: The home is registered as a care home only within the service user category: Learning disability (LD) and Learning disability over 65 years of age with sensory impairment (SI). The home is registered to accommodate a maximum of six people. Avenues Trust Limited manages the home. It is a large detached bungalow with extensive grounds to the front and rear and is situated on a busy main road, south of Reigate town centre. Fees for the service range from £1095.95 to £1125.25. Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This unannounced visit formed part of a ‘key’ inspection and was carried out by Sarah MacLennan, Regulation Inspector. The acting manager was present as the representative for the establishment. It was a thorough look at how well the service is doing. It took into account detailed information provided by the manager and any information that CSCI has received about the service since the last inspection. A tour of the premises took place. On the day of this visit the inspector met with three people who use the service and some on-duty staff. Some of the comments made to the inspector and made on the survey forms are quoted in this report. The people who use the service were not able to communicate verbally and observations of the interactions between staff and these people were also used to form the judgements reached in this report. The home completed an annual quality assurance assessment (AQAA) prior to the previous visit and care plans of people who use the service, staff recruitment and training records, menus, health and safety check lists, activity records, policies, procedures, medication records and storage were all sampled on the day of this visit. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector would like to thank the people who use the service and staff for their time, assistance and hospitality during this visit. What the service does well: The care plans of people who use the service were person centred, detailed and comprehensive and set out in detail action to be taken by staff with regards to personal care, health needs and the social support of the people who use the service. The service users daily statements evidenced that the care plans were followed and provided details of the people who use the Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 6 services 24hr day. Staff spoken to were aware of the guidance and support required by the people who use the service. The people who use the service were encouraged to be as independent as possible and to make their own choices. The care plans of people who use the service contained individual details of their behaviour and body language and what this meant in relation to their making a choice. The people who use the service were encouraged to be as independent as possible and to make their own choices, such interactions were observed. The home had a daily routine to promote independence and encourage choice. One of the people who use the service was observed to assist with the preparation of dinner during the inspection. Staff were observed to treat the people who use the service with respect and care was provided being in an unobtrusive and dignified manner. What has improved since the last inspection? What they could do better: At the last inspection a requirement was made that the registered provider must ensure that the home is effectively managed at all times. Concerns discussed in the concerns, complaints and protection, environment and the staffing sections of this report and under standard 42 of this outcome group evidence that this requirement has not been fully met. The requirement made at the last inspection that the registered provider must ensure that the home and the grounds are free from potential hazards has not been met. The situation regarding the grounds is unchanged from the previous inspection. A heath and safety audit was conducted on the day prior to this visit it included areas of concern to the external environment, food hygiene (please see environment and lifestyle sections of this report) and the potential risk to the people who use the service due to the lack of radiator covers. The homes periodic electrical wiring safety certificate was due for renewal in November 2007. The audit also identified the water temperature in the upstairs Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 7 bathroom was 57C, in view of the complex needs of the people who use the service this potentially put them at risk. No immediate remedial action had been taken by the staff to reduce this risk to the people who use the service. 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. Sharea DS0000013783.V358652.R01.S.doc Version 5.2 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 Sharea DS0000013783.V358652.R01.S.doc Version 5.2 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. 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 the people who use the service are fully assessed prior to their admission. EVIDENCE: All of the people who currently use the service have been at the home for a number of years, there has not been a new admission since 2000. The acting manager stated that a full and comprehensive pre-admission needs assessment would be carried out prior to any new admissions; this assessment would take in to account the existing group of people who use the service. The organisation has an appropriate set of policies and procedures in place regarding the pre-admission processes. Sharea DS0000013783.V358652.R01.S.doc Version 5.2 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. 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. Comprehensive care plans, procedures and practices were in place to ensure the people who use the services health care needs are met. Care was seen to be provided in a respectful and sensitive manner. EVIDENCE: The care plans and files of the people who use the service were randomly sampled; one persons care plan and daily statements were looked at in detail. The plan was person centred, detailed and comprehensive, it set out in detail action to be taken by staff with regards to personal care, health needs and the social support of the people who use the service. The daily statements evidenced that the care plans were followed and provided details of the service users 24hr day. Staff spoken to were aware of the guidance and support required by the people who use the service. Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 11 Following conversation with staff and examination of records it is evident that people who use the service were encouraged to be as independent as possible and to make their own choices. The care plans of the people who use the service contained individual details of their behaviour and body language and what this meant in relation to them making a choice. Samples of individual risk assessments were comprehensive information regarding personal behavioural guidelines. seen. These included care, road safety and Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provision of activities and food are suitable for the needs of the people who use the service. EVIDENCE: From examination of records and discussion with staff it was apparent that the people who use the service were encouraged and enabled to live a full life and participated in age related activities such as music therapy, reflexology, trampolining, music and cookery. The home had its own transport, the records showed the people who use the service to be accessing a variety of social and leisure resources in the community such as library visits, meals out in local restaurants and pubs, horse and carriage rides, farm visits, charity walks, visiting National Trust gardens and properties and garden centre visits. The people who use the service were supported by staff to shop for clothes and toiletries in the local Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 13 community; they were encouraged and practically supported to attend day centres. The home has links with various religious establishments in the local community. Due to the needs of the people who currently use the service these links are not pursued. Contact with family was encouraged. The majority of the people who use the service had regular contact with their families. The inspector was informed that the people who use the services rights would be respected if they did not wish to have any visitors. The home does not currently use any advocacy services, but the acting manager is hoping to introduce this in the future. Conversation with staff evidenced that the people who use the service were encouraged to be as independent as possible and to make their own choices, such interactions were observed. The home had a daily routine to promote independence and encourage choice. One of the people who use the service was observed to assist with the preparation of dinner during the inspection. Staff were observed to treat the people who use the service with respect and care was provided being in an unobtrusive and dignified manner. The inspector was informed that there was a great deal of flexibility with regards to the meal planning. The people who use the services preferences were clearly documented, and their behaviour was observed closely to ascertain their likes and dislikes. A sample menu was examined and evidenced that balanced and nutritious diet was provided. No cultural diets were provided, but could be upon request. An external heath and safety audit was conducted on the day prior to this visit it included food hygiene as an area of concern, specifically, out of date ham and marmalade in the fridge, butter & spreads not dated and meal temperature were not recorded. The acting manager stated that action had been taken regarding these issues. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural groups. Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service health needs are met and they receive the support they require. EVIDENCE: Staff spoken to were aware of the guidance and support required by the people who use the service. The people who use the service received additional specialist support including dentist, GP, physiotherapist, chiropodist, occupational therapist, optician and psychiatrist. Daily statements are made on each of the people who use the service, samples of which were seen at inspection. These statements were comprehensive in nature and related to the care plans. The homes storage and recording of medication were seen and found to be in order. The requirements made at the previous inspection had been met. The home had a suitable policy for the administration of medication. The acting manager stated that all staff responsible for the administration of medication were suitably trained, samples of training files were seen. Written guidelines Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 15 were in place that clearly stated the reasons for the administration of the majority of the ‘as required’ medication. The inspector was informed that the acting manager was reviewing and updating these guidelines. Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service have been put at risk by insufficient staffing numbers. EVIDENCE: The home had a simple and accessible complaints procedure. This procedure was available in audio and pictoral formats. There had been no complaints since the last inspection. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. All appropriate safeguarding adults policies and procedures were in place and readily available to staff. All staff spoken to were aware of these policies and procedures and their whistle blowing responsibilities. All staff had had training in the protection of vulnerable adults. Two safeguarding referrals had been made since the previous inspection. One of these referrals was as a direct result of the home having insufficient staff on one occasion. Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The external environment is potentially hazardous to the people who use the service. EVIDENCE: The inspector toured areas of the home. It was seen to be clean, tidy and free from offensive odours. The people who use the service were able to access all areas of the home and grounds. The home was suitable for the needs of the people who use the service. Their bedrooms reflected their individual styles and contained their own possessions. The décor was domestic in nature and general standards of internal maintenance were satisfactory. The issues regarding the external environment raised at the previous inspection remain. The terraced area in the rear garden contains weeds and moss and presents a trip hazard to the visually impaired service users. The Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 18 portion of the rear garden furthest from the house has an area overgrown with brambles and nettles and there is an unused summerhouse with a broken windowpane. An external heath and safety audit was conducted on the day prior to this visit that included the areas of concern to the external environment. The inspector was informed that these areas would be attended to when the weather improved, probably in the spring. It is required that an action plan stating when and how these issues will be dealt with in order to provide a safe environment for the people who use the service is forwarded to the commission. Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff receive adequate training and recruitment policy and practices protect the people who use the service. EVIDENCE: Following the requirement made at he previous inspection staffing numbers had been reviewed, the home usually maintains staffing numbers of three during the day and one a night. However on one recent occasion the home had only one evening staff member. A safeguarding referral was made as a direct result of the home having insufficient staff on this occasion. (Please refer to the conduct and management section of this report). Examination of the staff rota evidenced that this shortfall was not the norm. The homes area manager was conducting an investigation into how this shortfall occurred. The staff files contained a staff information sheet. These sheets were signed by the human resources department and evidenced the information that was stored on the main staff files at the company’s head office. Five staff files were seen and evidenced that the required information and documents specified in paragraphs 1 – 9 of Schedule 2 of The Care Homes Regulations Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 20 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) had been obtained. Samples of the staff’s training files were seen. This evidenced that training of staff is given high priority. Staff spoken to felt that they received adequate training. Staff had received training in health and safety, first aid, infection control, medication, manual handling, safeguarding vulnerable adults and food hygiene as well as training specific to the people who use the service including epilepsy, visual impairment and challenging behaviour. Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and safety and management of the home do not adequately safeguard the welfare of the people who use the service. EVIDENCE: At the last inspection a requirement was made that the registered provider must ensure that the home is effectively managed at all times. Concerns discussed in the concerns, complaints and protection, environment and the staffing sections of this report and under standard 42 of this outcome group evidence that this requirement has not been fully met. In the absence of a registered manager The Avenues Trust LTD has given the responsibility to manager the home to the acting manager. The acting manager has worked for the company for six years and up until taking up this Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 22 post was the registered manager for another of its services. She has been in post since October 2007 and has not yet submitted an application to the commission to become the registered manager. The requirement made at the last inspection that the registered provider must ensure that the home and the grounds are free from potential hazards has not been met. The situation regarding the grounds is unchanged from the previous inspection. A heath and safety audit was conducted on the day prior to this visit it included areas of concern to the external environment, food hygiene (please see environment and lifestyle sections of this report) and the potential risk to the people who use the service due to the lack of radiator covers. The homes periodic electrical wiring safety certificate was due for renewal in November 2007. The audit also identified the water temperature in the upstairs bathroom was 57C, in view of the complex needs of the people who use the service this potentially put them at risk. No immediate remedial action had been taken by the staff to reduce this risk to the people who use the service. Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 23 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 3 3 X 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 2 ENVIRONMENT Standard No Score 24 1 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 2 3 X X 1 X Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 24 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 YA42 Regulation 13(3&4) Requirement The registered provider must ensure that the home and the grounds are free from potential hazards. (Previous timescales of 30/10/07 not met) The registered person must ensure that the hazards identified in the external audit 23/01/2008 are appropriately risk assessed and systems are in place to safeguard the service users – specifically: water temperatures of 57C in the bathroom; lack of radiator covers; slip / trip hazard in the rear garden; and out of date food in the fridge. Timescale for action 24/03/08 2 YA42 13 (4) 24/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Sharea DS0000013783.V358652.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!