Inspection on 27/11/07 for Shenehom

This inspection was carried out on 27th November 2007.

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

Shenehom 27/09/06

Shenehom 28/02/06

Shenehom 23/06/05

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 09/02/2009.

CARE HOME ADULTS 18-65 Shenehom 31/32 Ranelagh Avenue Barnes London SW13 0BN Lead Inspector Louise Phillips Unannounced Inspection 27th November 2007 10:30a Shenehom DS0000017393.V354504.R02.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 Shenehom DS0000017393.V354504.R02.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. Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shenehom Address 31/32 Ranelagh Avenue Barnes London SW13 0BN 020 8876 2199 020 8876 6336 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) RCHT/ Shenehom Housing Association Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2006 Brief Description of the Service: Shenehom provides accommodation and support for a maximum of thirteen residents who experience enduring mental health issues. The service is provided by Richmond Upon Thames Churches Housing Trust (RUTCHT) who lease the property from the London Borough of Richmond. Staff do not provide personal care but if required in the short-term this can be provided by an external agency. The home is situated in a pleasant residential area, close to local shops and public transport networks. Parks and open spaces are within easy reach and the River Thames is nearby. The current fees for the service are £685.75 per week. Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day and included a visit to the service by a Regulation Inspector. When we visited we spoke to the people who live and work at the home and the manager. We also looked at records, observed what was going on and looked at the environment. As well as the visit we asked the manager to complete a quality selfassessment. 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. The summary of this inspection report can be made available in other formats on request. Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 6 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 Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 7 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): 2, 3, 4 and 5 Quality in this outcome area is excellent. Potential residents are provided with good information about the service. The assessment process is thorough to ensure that the service is the right place for new residents to move to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a comprehensive policy and procedure for the admission of new residents. Potential residents are provided with an application pack and information about the service. Social workers are required to complete Shenehom’s own referral form when making a referral to the service. Since the last inspection one new resident has moved to the home. Their care file contains information about the referral and assessment prior to their moving to the home, with details about their mental health, important relationships, etc. In addition there is information about any areas of risks that need to be planned for. As part of the assessment process up-to-date reports are gained from the social worker, psychiatrist and occupational therapist, where necessary. An assessment interview is held, involving the manager, social worker and Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 8 potential resident, where the referral information is looked through and the resident can discuss their mental health needs, goals and aspirations. During the interview, the resident is informed of the aim of Shenehom and the expectations of residents moving to the service. Following the meeting the manager takes the information to the team meeting where it is discussed how Shenehom can meet the needs of the potential resident, and a formal offer of accommodation is then made. Admissions to the service are planned, taking place through day visits and overnight stays. A care plan is developed for this process and is reviewed after each visit, where the new resident is assessed and their mental state monitored, particularly when interacting with existing residents at the home. Good records are kept of each visit to the home, including what the resident has done, who they have spent time with, meals eaten, whether they were anxious or settled, etc. New residents are offered a trial period to ‘test drive’ the home, with this reviewed after a period. If this is successful the resident is then given a contract and licence agreement with RUTCHT, and they can also choose the colour that they wish their new bedroom to be decorated in. Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. The needs of service users are met by through appropriate care planning and support. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The support planned for residents is documented in individualised care plans, with the resident involved in identifying their needs and how these can be supported. Two files were looked at during the inspection. The care plans are individualised and identify relevant issues from the assessment process, along with a lot of information about areas particular to the resident, such as medication, independent living and engagement with outside activities. Any specific cultural needs are identified in care plans. An example of this is where a resident has particular religious needs, and a care plan has been Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 10 developed to ensure they are supported with this, and the purchase of specific foods. Residents are involved in choosing their care plans and also their keyworker, where they meet with them regularly to review their care plans and ensure they are relevant to their needs. Residents are involved in making decisions about living at the home. Every morning the residents meet to decide who will be responsible for different daily chores and there is also a community meeting every fortnight with staff and residents to inform of developments in the home and enable residents to have a say in any proposed changes. Where there are more specific risks or as a result of an incident, a risk assessment and management plan details the current safety needs of the resident. These include risks such as being support when outside of the home, or vulnerability in certain situations. In one case a risk assessment had been completed but areas identified had not been developed into a risk management plan. A requirement has been made to address this. Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 and 17 Quality in this outcome area is good. Residents have the opportunity to be involved in activities that are planned around their needs, interests and community living. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of inspection the residents were pursuing their own interests and activities. The care files contain information about the different activities that residents pursue such as attending a college course, or going to work as a volunteer or spending time at a day centre or ‘drop-in’ service. One resident was observed going out to stay overnight at one of their relatives’ house. The manager stated that there are in-house activities for the use of residents, such as art groups, quizzes, walks, bingo and outings, and that a ‘dog walking’ Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 12 group has recently been introduced. There is also a pool table, table tennis table and keyboard for use. All residents have been on a holiday within the past year. The manager spoke about how the ethos of the working day is to ensure a lot of focus on working with residents, with staff spending time with each resident, promoting their independence and the meeting of their needs. She also spoke about how the service has made steps to promote equality, with the introduction of more culturally diverse meals and discussion with residents around equality issues. The menu offered by the home is planned by residents at the fortnightly community meeting. The shopping for this is done via the internet in addition to regular local shopping for fresh vegetables, fruit and milk. The fridge and freezer contain a good stock and variety of foods for preparing and for residents to help themselves to. Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. The service is responsive to the healthcare needs of the residents. Improvements need to be made to the medication system. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents are independent when attending to their personal care needs. A record is maintained of all healthcare appointments that residents attend. Records indicate that there are regular reviews of each residents care, with their involvement, and that healthcare issues are dealt with promptly. The medication for two residents was looked at and the information on the Medication Administration Record (MAR) corresponded correctly with that on the medicine chart. There was one discrepancy where for one resident a box of Fluoxetine medication was found in the medicine cabinet but not listed on their MAR chart. This was pointed out to the manager at the time of inspection. Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 14 It is required that a weekly audit of medication administration, and checking of MAR charts is commenced to ensure that any discrepancies and errors are identified and managed appropriately. During the inspection a resident was getting ready to stay out overnight at a relatives house. Staff were observed giving the resident medication for them to take whilst they were out. The staff was then seen signing the MAR chart. This practice should not be encouraged as the MAR chart should be used to record medication observed being taken by the resident. It is recommended that a separate recording format is developed for when medication is given to residents to take whilst they are away from the service. Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made as there are systems are in place to reduce risks to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a satisfactory complaints procedure and format for the logging of complaints. However, some amendments are needed to update the complaints procedure, to include the current chairperson and the CSCI. Residents spoken to said that if they had any concerns they would talk to their keyworker or the manager. The training records for staff indicate that they have received recent training in the Protection of Vulnerable Adults (POVA). There are also policies and procedures in place regarding abuse awareness and what to do in the event of this. Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. The environment is welcoming and homely, with some improvements needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has taken steps to address previous cleanliness and hygiene issues at the home, with residents and staff involved in maintaining the environment, with the support of a cleaner five hours a week. Improvements have been made since the last inspection, with some hallways having been redecorated and new flooring in the kitchen. The manager is aware of further improvements needed and stated that plans were in progress to re-furbish the showers and bathrooms. Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made as staff receive relevant training for their role. Some improvements are needed to recruitment checks to minimise the risks to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff have been working at the service for varying periods of time, and feedback regarding each person’s recruitment to the service was positive, with all stating that they had been interviewed and had received an induction to their role. Staff files demonstrate that some relevant checks and references are sought prior to new staff commencing at the home. A record is also maintained of the interviews of potential staff, including questions asked and the responses of the applicant. Three staff files were looked at and seen to contain varying amounts of information. One staff file contains all relevant information to demonstrate Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 18 that thorough recruitment checks were carried out, eg. two references, Criminal Records Bureau (CRB) check and copies of proof of identification. However, for two other files there was either no CRB, or one relating to a previous employer, and no proof of a POVA First check having been carried out. The service must demonstrate that relevant recruitment checks have been carried out to ensure the safety of the residents. All staff spoken to said about the good training budget for the service, and this is reflected in the qualifications of the staff employed at the service. All staff are either working towards the National Vocational Qualification (NVQ) level 3 in Care, or the NVQ level 4 in Management. The current training and development plan for 2007-2008 details that staff have done, or are shortly due to do training in first aid, medication awareness, basic food hygiene, fire safety, protection of vulnerable adults and dealing with violence and aggression. In addition the plan states personal development needs of staff, with training needs identified in motivating teams, sexuality awareness and dual diagnosis. Staff spoke about feeling well supported by the manager, and that they have regular supervision and staff meetings to discuss any issues. Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made as the manager is competent and understands the responsibilities of their role. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feedback from staff is that they feel there is good management at the home and that they are able to be involved in the development and progression of the service. One staff member stating that: “…the service is well managed…”. The manager has been in an ‘acting-up’ position for a period of time and has just been confirmed as the new manager for the service. She has a good understanding of the areas of improvement needed for the home, and is Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 20 proactive in addressing these. The manager must submit an application to be registered to the Commission. The CSCI was notified that the Responsible Person for the organisation resigned earlier this year. The organisation needs to provide formal notification to the CSCI as to who will be taking on the role of Responsible Person. On the day of inspection the service was in the process of carrying out its quality assurance assessment. Previously the resident had been surveyed for feedback regarding the home and the service provided, where on this day the staff were involved in going through the feedback with the residents and Trustees, and developing an action plan to progress the service. In addition, there are fortnightly community meetings for residents to be involved in the service. Appropriate health and safety checks are carried out around the home, with records to demonstrate that up-to-date checks had been done on the electrical installation, gas safety, fire systems and water temperatures. The service needs to ensure that regular Portable Appliances Tests (PAT) are carried out on all electrical objects around the home. Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 21 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 4 3 4 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X X 2 X Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 YA9 Regulation 13(4) Requirement The Registered Person must ensure that risk management plans are developed for any areas of risk identified. Timescale for action 31/01/08 2. YA20 13(2) The Registered Persons must 31/01/08 introduce a weekly audit of medication administration, and checking of MAR charts to ensure that any discrepancies and errors are identified and managed appropriately. The Registered Persons must 31/01/08 ensure that the complaints policy and procedure contains up-todate information regarding the Commission and Registered Person. The Registered Persons must ensure that relevant recruitment checks have been carried out on all staff to ensure the safety of the residents. The manager must submit an application to be registered with the Commission. 31/01/08 3. YA22 22 4. YA34 19, Schedule 2 5. YA37 8 31/01/08 Shenehom DS0000017393.V354504.R02.S.doc Version 5.2 Page 23 6. YA37 7 The organisation must formally notify the Commission of who is the Responsible Person. The Registered Persons must ensure that regular PAT testing is carried out. 31/01/08 7. YA42 23(2)(c) 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA15 YA20 Good Practice Recommendations The Registered Persons should ensure that sexual needs are included as part of the care plan system. The Registered Persons should ensure that a separate recording format is developed for when medication is given to residents to take whilst they are away from the service. 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