Inspection on 23/06/05 for Shenehom

This inspection was carried out on 23rd June 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 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

Shenehom 27/11/07

Shenehom 27/09/06

Shenehom 28/02/06

Shenehom 02/11/04

Shenehom 18/05/04

Shenehom 01/09/03

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

CARE HOME ADULTS 18-65 Shenehom 31/32 Ranelagh Avenue Barnes London SW13 0BN Lead Inspector Simon Smith Unannounced 23 June 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. Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Shenehom Address 31/32 Ranelagh Avenue Barnes London SW13 0BN 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) 020 8876 2199 020 8876 6336 RCHT/Shenehom Housing Association Mr Stephen Coker Care Home 13 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia (MD) of places Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2.11.04 Brief Description of the Service: Shenhom provides accommodation and support for a maximum of thirteen service users who experience severe and enduring mental health issues. Staff do not provide personal care but if required in the short-term this can be provided by an external agency. The property is owned and maintained by Richmond-upon-Thames Churches Housing Trust. The Home’s Statement of Purpose states, “Shenehom Housing Association is a voluntary organisation in partnership with Richmond-uponThames Churches Housing Trust who are the registered social landlord, Shenehom being the managing agent”. Shenhom opened in 1990 and increased the number of places available to service users through the addition of a two-bedded semi-independent unit in 1993. The Home is situated in a pleasant residential area, close to Barnes high street and public transport networks. Parks and open spaces are within easy reach and the River Thames is nearby. Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over the course of a single afternoon and involved discussion with residents, the manager, staff and a visiting healthcare professional. A sample of records and staff files was examined and a tour of the premises made. The inspector was made welcome throughout the visit and wishes to acknowledge the time and consideration that residents, the manager and staff provided during the course of the inspection. The home met 23 of 26 National Minimum Standards assessed at this visit. Three Standards were almost met. Areas identified for improvement included placement reviews and risk assessments. A Requirement was also made concerning resolution of a complaint, which was ongoing at the time of inspection. The main property houses eleven residents whilst the semi-independent unit houses two further residents. The home provides a number of lounges, a kitchen/dining room and an activities area. Residents are given keys to the front door, their bedrooms and lockable space in their rooms. Residents are encouraged to personalise their bedrooms and are able to bring personal items with them when they move in. All residents spoken to by the inspector said they were happy with their bedrooms. The inspector spoke to five residents during the inspection. One resident said that he attends a resource centre twice each week and goes to church every Sunday. Another resident said, ”I’ve got no complaints – I’m well looked after”. The inspector also spoke to a visiting health professional, who gave positive feedback about the home. No admissions or discharges had been made since the last inspection. The home still had one vacancy, although a prospective new resident had made a number of introductory visits and was planning to move in on a trial basis. Residents are expected to attend some form of day service during their stay, usually one whole day or two half days each week. Residents are also expected to manage their own laundry and help with meal preparation. Household jobs are allocated at morning meetings. Most residents have regular contact with their families and some stay with relatives for at least one night each week. Residents are supported to participate in social activities and an annual holiday of their choice. Residents are supported to access community healthcare resources when necessary and community psychiatric nursing is available through the local mental health team. Staff do not provide personal care, although verbal Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 6 support is given where necessary. Should a resident require personal care in the short-term, this can be arranged through a domiciliary care agency. The staff team at the home is stable. Staff are recruited according to a clear recruitment process including application form, informal visit and interview. Residents are able to meet applicants before they are appointed. New staff receive a thorough induction to the home. All staff have good opportunities for training and development and receive regular supervision and appraisal. What the service does well: 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. Shenehom G54-G04 S17393 Shenehom V234822 280605 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 Shenehom G54-G04 S17393 Shenehom V234822 280605 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, 3, 4, 5 Residents have access to information about the home and the services it provides. Prospective residents have the opportunity to visit the home prior to admission and to move in on a trial basis. Residents are issued with contracts outlining their rights and responsibilities. EVIDENCE: The home makes available clear information about the facilities and services it provides. Residents of the home are tenants of Richmond-upon-Thames Churches Housing Trust. Three residents’ files were examined. All contained evidence of an appropriate tenancy agreement and, where applicable, placement agreement with the placing authority. No admissions or discharges had been made since the last inspection. Prospective residents are invited to visit the home and to meet informally with residents and staff before making a decision to move in. Prospective residents are then invited to meet more formally with senior staff to discuss their needs and wishes for the placement. Applications are discussed at staff and residents meetings and are considered by the ‘Staff and Residents’ sub-committee prior to final approval. Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 9 Residents move into the home on a trial basis, which is usually six weeks but can be extended if necessary. During this time, a temporary keyworker will be allocated and the resident will be encouraged to participate in all aspects of life at the home, such as attending outings and doing household jobs. A review is held at the end of the trial period to assess the suitability of the placement. One prospective new resident has made a number of introductory visits to the home. The deputy manager has liaised with the prospective new resident and her care manager regarding a programme of trial visits and has negotiated additional staffing to meet the resident’ assessed needs. Three overnight stays were planned for the week following inspection. Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 8, 9, 10 Residents’ strengths, needs and preferences are identified effectively through the care planning process. Individual plans must be reviewed more regularly. Residents have opportunities to contribute to the life of the home. Risk assessments must be performed wherever there is an identifiable element of risk. Risk assessments must be completed fully and reviewed more regularly. Confidential information is stored appropriately within the home. EVIDENCE: An individual plan of care is in place for each resident. Care plans record residents’ strengths, needs and goals in areas including personal, emotional and social support, healthcare, religion/cultural issues, finance and independent living. Three residents’ files were examined. All had been signed by residents and contained evidence of regular keyworking sessions. However Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 11 none of the files examined contained evidence of review in the last twelve months. It is acknowledged that the home is addressing this area (reviews for two residents were planned for the day of inspection), although improvements must continue in order to ensure that residents’ changing needs and personal goals are reflected in their individual plans. See Requirement 1. The issue of placement reviews was discussed with the manager, who reported that, in some cases, residents found the review process challenging. The manager advised that the home aims to make future reviews more personcentred and to encourage residents to set the agenda for their reviews. The home has an appropriate format for risk assessment and management but risk assessments on file required review in some cases. It was also noted that some sections on the pro forma (such as ‘risk minimisation’, ‘crisis responses’ and ‘long term management’) were not completed on a number of assessments. Risk assessments must also be performed to assess the risk presented by windows not fitted with restrictors. See Requirement 2. The home’s Statement of Purpose advises, “Involvement and consultation [of residents] is encouraged and supported at an individual level through care planning, evaluation, reviews and in regular meetings with the individual’s keyworker. Communally, the weekly community meeting and the annual review day provide an opportunity for resident involvement and consultation”. Residents are involved in menu planning, which is discussed at bi-weekly meetings. Community meetings in intervening weeks are used to discuss other issues regarding the service raised by residents. A short community meeting is also held each morning, at which daily household jobs are allocated. Meetings are chaired by residents and supported by staff. Residents have regular access to an advocate, who visits to seek their views and feeds this information back to the service manager. Staff work within written guidelines concerning the storage, access, handling and usage of confidential information. All sensitive information was stored appropriately within the Home. Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 14, 15 Residents are encouraged to involve themselves in the routines of the home and to develop independent living skills. Residents are involved in their local community. Residents participate in a range of activities appropriate to their needs and wishes. Residents are supported to develop and maintain relationships with their families and friends. EVIDENCE: There is an expectation that residents will attend some form of formal day service or during their stay at the home. The minimum commitment is usually one whole day or two half days per week. There is also an expectation that residents will manage their own laundry and contribute to communal meal preparation. Residents are encouraged to participate in the routines of the home, such as food shopping, and staff provide support in developing independent living skills, such as cooking and money management, if required. Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 13 The home is able to support residents aiming to move on to more independent living through the provision of a two-bedded semi-independent unit. Residents access local drop-in centres at the Level Crossing Centre in Mortlake and the Richmond Royal Hospital. Mereway Day Centre in Twickenham offers a range of activities and offers assistance with transport if needed. One resident reported that he enjoyed visiting the Level Crossing Centre to maintain contact with his friends. Most residents have regular contact with their families and several residents stay with their families at least one night each week. Six residents travelled with staff to Lyme Regis for their annual holiday in the week prior to inspection. One resident chose to go on a short break with two members of staff, as he prefers small group activities. Three residents were planning to take their holiday later in the year. One resident was on holiday with his family at the time of inspection. Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 Residents are supported to access community and specialist healthcare resources where necessary. Staff liaise effectively with healthcare professionals regarding the care of residents. EVIDENCE: All residents are registered with a local general practitioner and are supported to access other community healthcare resources as required. Community psychiatric nursing is available through the local community mental health team. The inspector spoke to a visiting community psychiatric nurse, who advised that she visits the home every two to three weeks. The community psychiatric nurse reported that staff liaise effectively with her when she visits and that, in her opinion, the home meets residents’ needs well. Care plans identified residents’ individual support needs and contained guidance for staff delivering support. The home’s Statement of Purpose clarifies that staff do not provide personal care, although prompts and verbal support are given where necessary. Should a resident require personal care in the short-term, this can be arranged through a domiciliary care agency. Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 A formal Complaints procedure is available to stakeholders. One complaint has yet to be resolved. EVIDENCE: The home has a formal Complaints procedure, a copy of which is included in the Residents’ Handbook. One complaint was ongoing at the time of inspection. This was discussed with the manager and staff during the visit. The manager outlined a number of proposals regarding the complaint and advised that these would be presented to the complainants at a forthcoming meeting to discuss the issues involved. The complaint involves a number of complex issues and has proved challenging to resolve. However for the long-term benefit of the resident involved, the home must demonstrate that all necessary steps continue to be taken until resolution is achieved. See Requirement 3. residents and other Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 28, 30 The home is comfortable, safe and well maintained. Communal and private rooms are homely and reflect residents’ preferences. The home is clean and hygienic. EVIDENCE: The manager reported that the cost of internal decoration is usually met by Shenehom, whilst Richmond Churches Housing Trust is responsible for essential maintenance and external decoration. The manager reported that the Trust responds well to maintenance requests and that Shenehom is able to give feedback on the service provided. The main property accommodates eleven residents whilst the semiindependent unit houses two further residents. The home provides a smoking and non-smoking lounge, a kitchen/dining room, a quiet room, and an activities area with facilities for pool, table tennis and darts. All communal areas were clean, welcoming and hygienic and were appropriately furnished. A Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 17 payphone is located on the ground floor. The building has a dedicated laundry area. The home has a courtyard garden. Residents are issued with keys to the front door, their bedroom and lockable space in their rooms. All bedrooms are for single occupancy and are equipped with washbasins. Residents are encouraged to personalise their bedrooms and are able to bring personal items with them on admission. All residents spoken to by the inspector indicated their satisfaction with their bedrooms. Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 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 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, 36 Staff have an awareness of their own and one another’s roles. Staff have experience and qualifications relevant to their roles. Staff are appointed following an appropriate recruitment and selection procedure. Staff receive effective induction, supervision and appraisal. EVIDENCE: The home has a clear staffing and management structure and benefits from a stable staff team. The most recent addition to the team was appointed in November 2004, taking the staff complement to eight. The inspector spoke to the recently appointed member of staff, who confirmed that her appointment followed a recruitment process including application form, initial informal visit and formal interview with senior staff. The member of staff confirmed that she had undertaken a comprehensive two-week induction to the home and its working practices. The induction also includes elements of mandatory training such as fire, first aid and food hygiene. Job descriptions are in place for all posts within the service. All staff spoken to on the day of inspection demonstrated an awareness of their own role and the Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 19 aims and objectives of the home. The home provides staff with good opportunities for continuing professional development. Staff meetings take place twice each week and staff completing their shift give handovers to those beginning work. Staff confirmed that they receive individual supervision on a regular basis. Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 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 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) 38, 42 Systems of recording and administration within the home are clear and well organised. The health and safety of residents and staff within the home is maintained. EVIDENCE: Systems of recording and administration within the home are clear and well organised. A number of management responsibilities are delegated to members of the staff team, which provides opportunities for staff to develop skills and experience in a range of areas. The home has an appropriate fire detection system. Staff conduct fire alarm tests on a regular basis. Clear instructions for staff and residents in the event of a fire were prominently displayed. The kitchen is equipped with a fire blanket and extinguisher. A health and safety check is carried out on a monthly basis. The home was clean, hygienic and free of obvious health and safety hazards on the day of inspection. The home maintains an Accident book. Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 21 Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 x 3 3 x x Standard No 31 32 33 34 35 36 Score 3 3 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shenehom Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 3 x G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 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. 1. 2. Standard 6 9 Regulation 15(2) 13(4) Requirement Ensure that all placements are reviewed a minimum of twice each year. Risk assessment formats must be completed fully. Risk assessments must be reviewed on a regular basis or when there is a change in need. Risk assessments must be performed to assess the risk presented by windows not fitted with restrictors. Demonstrate that all necessary steps continue to be taken until the outstanding complaint is resolved. Timescale for action 30.08.05 30.08.05 3. 22 12 22 30.08.05 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 Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Shenehom G54-G04 S17393 Shenehom V234822 280605 Stage 4.doc Version 1.30 Page 25 - 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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