Inspection on 07/07/05 for Sharea

This inspection was carried out on 7th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sharea 22/12/08

Sharea 24/01/08

Sharea 12/09/07

Sharea 31/08/06

Sharea 20/12/05

Sharea 10/11/04

Sharea 18/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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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 69 Reigate Road Hookwood Surrey RH6 0HL Lead Inspector Mr P Benthom Announced Inspection 07 July 2005 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. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sharea Address 69 Reigate Road Hookwood Surrey RH6 0HL 01293 776248 01293 776248 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) The Avenues Trust Ltd Mr William Smith CRH (PC) 6 Category(ies) of Physical Disability (PD) 6. registration, with number of places Physical Disability over 65 years of age (PD(E)) 1. Learning Disability (LD) 1. Learning Disability over 65 years of age (LD(E)) 1. Sensory Impairment (SI) 6. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be 18-64 years. 2. 1 (one) person within the category LD(E) or PD(E) may be accommodated over the age of 65 years. 3. Persons may be accommodated who have both a learning disability (LD) and a physical disability (PD). Date of last inspection 10 November 2004 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 Service Users. Avenues Trust Limited manages the home. It is a large detached bungalow with extensive grounds to the front and rear and is situated on as busy main road, south of Reigate town centre. Sharea aims to provide a safe and homely environment that enables Service Users to develop to their maximum potential and where they are treated with dignity and respect. Service Users are very much an integral part of the homes operation despite their profound disabilities. The home provides a good standard of accommodation to its four male and two female Service Users. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is of the first inspection of the Home by the Commission for Social Care Inspection within the regulatory framework of the Care Standards Act 2000 for the year 2005/6. The Home’s performance was measured against the National Minimum Standards for Care Homes for Older People. A tour of the premises took place and care, training and Health and Safety records were inspected. What the service does well: What has improved since the last inspection? What they could do better: The physical condition of the premises is poor and in need of much needed general refurbishment. Work has commenced on some areas, but has not been completed and as a result the home looks shabby and run down in places. The kitchen is in need of urgent refurbishment and the communal lighting in all Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 Page 6 areas of the home is very poor and unsuitable for this service user group all of whom have visual disabilities. Please see requirements on Page 20. 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. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 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 Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 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 ,3 4 and 5 Service users are admitted only following a full assessment undertaken by people trained to do so. The registered person was able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: All potential service users are assessed prior to admission. It was reported that the service only admits new service users based on an assessment of needs, and appropriateness of placement The initial assessment was used to form the basis of the care and the support plan, which identified the actions that carers should follow to assist an individual living at the home. All current service users in this home have been living there from its early days of operation. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 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, 9 and 10 The systems for Service User consultation are good with a variety of evidence that indicates Service Users views are both sought and acted upon. EVIDENCE: Extensive care plans have been drawn up, with the help of the service user wherever possible and relatives/representatives. Care plans were well documented and highlighted all areas of care needs for each service user. All care plans showed evidence of regular reviews. Risk assessments were in place where appropriate. Care plans included personal goals for each individual to achieve; goals are reviewed and can be amended at any given time. Service users participate in the day-to-day running of the home e.g. helping with food shopping, assisting with meal preparation. This is carried out in a very limited way on account of the profound physical and visual disabilities of the service users. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 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) 11, 12, 13, 14, 15,16 and 17 A good daily activity programme for each Service User was seen as part of the inspection process. EVIDENCE: Service users make use of the local facilities and go out to pubs and restaurants. Supported by members of staff they go shopping for their toiletries, clothing and footwear. All outings are subject to risk-assessments. This freedom is sometimes restricted though on account of the location of the service that is in a rural setting, but on a very busy main road to Gatwick Airport. It is difficult to access any facility locally without the use of the home’s vehicle and as a consequence all newly recruited staff have to be able to drive. It would be unsafe to take service users for a walk for exampl as the road is too dangerous to cross for service users with limited mobility. A copy of the menu was seen as part of the inspection process and personal preferences were taken into account. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 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 and 20 The healthcare needs of Service Users are well met with evidence of good consultation with other professionals taking place on a regular basis. EVIDENCE: All service users are registered with the local GP and have access to all NHS healthcare facilities as required. Service users will receive support from members of staff e.g. offering support to and from appointments. Health records were seen as part of the inspection process. There is a good medication policy in place. Avenues Trust Limited have a policy governing all administration of medication and the medication is stored securely in a locked cabinet in the office. No Service Users currently administer their own medication. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 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 and 23 Service Users are well protected by the companies training policies and procedures with regard to the protection of vulnerable adults. EVIDENCE: The complaint procedure was compliant with statutory requirements. Complaint forms were available for recording complaints. Records demonstrated there had been no formal complaint received by the home or the regulator within the last twelve months. Service Users are well protected by the companies training policies and procedures with regard to the protection of vulnerable adults. Up to date training in the Protection of Vulnerable Adults is in place and is part of the company’s ongoing commitment to staff training. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 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, 25, 26, 27, 28, 29 and 30 The standard of décor and equipment in this home is of a very poor standard with no satisfactory evidence of improvement through maintenance and refurbishment. EVIDENCE: The interior standards of decoration and furnishings in this home are of an unacceptably poor standard. • • • Interior redecoration has been carried out in a haphazard fashion and as such is of poor quality and is institutional in appearance. The kitchen is worn, unsightly and hazardous with broken and unsafe doors and worktops on the units The upstairs bathroom sanitary ware does not match. The bath and hand basin are green and the toilet is white. The toilet fitting is unsightly with a wooden casing surrounding the soil pipe which is stained and difficult to clean The downstairs toilet has been replaced with a white unit that does not match the existing sanitary ware. The installation of the toilet unit has not been completed and the area surrounding the toilet bowl is unsightly and unhygienic H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 Page 14 • Sharea • • The communal lighting in the home is unsatisfactory and does not provide sufficient adequate lighting for people with visual disability. Interior redecoration has been carried out in a haphazard fashion and as such is of poor quality and is institutional in appearance. Staff must be commended for providing a service in surroundings that are not favourable in terms of comfort and quality. Please see requirements on Page 20. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 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) 31, 32, 33, 34, 35 and 36 The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: Staff spoken to at the day of the inspection had a good understanding of their job descriptions and their responsibilities and they were able to identify the roles of other members of staff in the hierarchy. Communication between staff was good. At the day of the inspection personnel files were seen and considered to be accurate. All documents required by Schedule 2 of the Care Homes Regulations 2001 were available in individual files. Staff meetings are in place and are organised monthly. The manager gave evidence of a professional and comprehensive induction period for new members of staff. Staff confirmed that they receive training on a regular basis. Records were examined and evidence was found of a very full and varied training programme. All members of staff receive supervision on a regular basis. 50 of staff have completed or are undertaking NVQ training. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 Page 16 However recruiting staff to permanent posts is difficult in this service on account of the location of the home, which is in a rural setting, and new staff must be able to drive in order to offer service users a full range of activities out side the service. Gaps in the rota are covered by staff working extra shifts and the use of agency staff. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 Page 17 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) The manager is supported by senior staff in providing clear and consistent leadership in the home with staff on duty demonstrating an awareness of their roles and responsibilities. EVIDENCE: The registered manager is completing his Registered Managers Award and his NVQ Level 4. He has considerable experience in the provision of residential care to people with learning disabilities. The manager operates an open and inclusive style of management approach in the home. Records required for the protection of service users and sampled on the day of the inspection were well maintained, accurate, and up to date. The staff-training programme includes training in first aid, manual handling, infection control, fire safety, health and safety and basic food hygiene. Systems were in place to safeguard the health and safety and welfare of the service users. Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 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 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 1 1 1 1 1 1 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sharea Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 Page 19 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 YA24.1 Regulation 16 (1)(g) Requirement It is required that the kitchen is refurbished as soon as possible. Please provide an action plan for refurbishment Timescale for action 31/8/05 2. YA24 23 (2)(b)(c) (d)(p) 23 (2)(b)(c) (d)(p) 3. YA24 4. YA24 23 (2)(b)(c) (d)(p) It is required that the kitchen is refurbished as a matter of urgency and the broken, unsightly and unhygenic units are replaced. It is required that the upstairs bathroom sanitary ware is replaced, as the current equipment does not match. The bath and hand basin are green and the toilet is white. The toilet fitting is unsightly with a wooden casing surrounding the soil pipe which is stained and impossible to clean. It is required that the installation of the toilet unit is completed and the area surrounding the toilet bowl that is unsightly and unhygenic is made good. Also that the hand basin in the 31/08/05 31/08/05 31/08/05 Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 Page 20 5. YA24 23 (2)(b)(c) (d)(p) downstairs toilet is replaced with one that matches the current toilet bowl. It is required that the communal lighting in the home that is unsatisfactory and does not provide sufficient adequate lighting for people with visual disability, be replaced as soon as possible. 31/08/05 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 Good Practice Recommendations Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 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 Sharea H58 H09 s13783 Sharea v216546 070705 Stage 4 ann.doc Version 1.40 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. 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. 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