Inspection on 27/09/06 for Shenehom

This inspection was carried out on 27th September 2006.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shenehom 27/11/07

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 09/07/2008.

CARE HOME ADULTS 18-65 Shenehom 31/32 Ranelagh Avenue Barnes London SW13 0BN Lead Inspector Adrian Gordon Unannounced Inspection 27th September 2006 10:00 Shenehom DS0000017393.V313778.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 Shenehom DS0000017393.V313778.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. Shenehom DS0000017393.V313778.R01.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 Mr Stephen Coker Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28th February 2006 Brief Description of the Service: Opened in 1990, 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 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 Barnes high street and public transport networks. Parks and open spaces are within easy reach and the River Thames is nearby. Information about the service is provided in the Statement of Purpose and Service User Guide. There is also a leaflet about the home. Current fees for the service are £685.75 per week. Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and completed over the course of one day. It consisted of examination of records, tour of the premises, observation of practice and discussion with four members of staff and the manager. The inspector also had the opportunity to talk to three residents. Feedback questionnaires were received from six residents and four members of staff. What the service does well: What has improved since the last inspection? What they could do better: Staff feedback was mixed about the support received by management. In order to improve morale and motivation the team needs to make use of psychology support at team meetings to discuss concerns they have. In order to ensure that residents are supported to be independent, risk assessments must be standardised and kept up to date and reviewed. In order to better protect residents all staff must have refresher training in the protection of vulnerable adults and medication records must be maintained accurately. Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 Page 6 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 DS0000017393.V313778.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 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 the following standard(s): 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are given good information about the home which enables them to make an informed choice about living there. EVIDENCE: One resident moved into the home earlier this year. The file of this resident showed that prior to the move an assessment interview took place. This gave the opportunity for the resident to ask questions and the manager to talk about the home and the expectations of people living there. A needs assessment is done before the move and trial visits are arranged in order to make sure the home will be suitable. A resident confirmed that they were able to visit before moving. Shenehom DS0000017393.V313778.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good care planning ensures residents needs are met and they are supported to achieve goals. EVIDENCE: All residents have an individual plan which sets goals for different areas of need, such as personal support, health and independence. The plans examined were up to date and signed by the resident concerned. Feedback from residents confirmed that they are involved in care reviews and are supported by relatives or representatives. Residents also said that they have monthly meetings with their keyworker to review how things were going and to look at what could be done in the future. Cultural needs are addressed in care plans. One resident is able to discuss aspects of their culture with a befriender of the same ethnic background. Residents are supported to make decisions about life in the home. For example every morning the residents meet to decide who will be responsible for Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 Page 10 different daily chores. Formal meetings are also held every two weeks with all residents to keep them informed of developments in the home and enable them to have their say. Risk assessments are in place addressing specific activities by residents. However, they are not all up to date. At the last inspection it was highlighted that risk assessments should be standardised but this has not yet happened. The manager said that the process of risk assessment is to be reviewed shortly and a new format will be implemented afterwards. Shenehom DS0000017393.V313778.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents have the opportunity to take part in appropriate activities of their choosing which allow for personal development. EVIDENCE: All residents have a key to the front door and are able to come and go when they like. Residents are encouraged to participate in activities that encourage personal development, for example attending a day centre at some point in the week. One resident works as a volunteer in a local shop. Residents said that they make use of local community facilities such as banks, shops and public transport. Other activities mentioned by residents include swimming, walking and visiting the library. Residents have recently been asked to fill out a questionnaire regarding the sorts of activities they would like to do, both in the home and outside. Staff hope to encourage residents to participate more in activities of their choice so that days are more stimulating. Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 Page 12 Interactions between staff and residents were seen to be positive. Residents privacy is respected, and their wishes and needs are clearly identified in individual plans. The manager said that sexuality is discussed with residents if it becomes an issue. More thought should go into ensuring that sexual needs are discussed as part of care planning rather than when it becomes a problem. Residents attend a menu planning meeting every fortnight where ideas for meals are put forward and the menu agreed. Feedback from residents was that the food was ‘ok’. Main meals are usually cooked by staff but two days a week are ‘self catering’ days, when residents are responsible for sorting out there own food. One Muslim resident has a care plan which details a need for them to go shopping for Arabic food. Shenehom DS0000017393.V313778.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good support is in place to meet residents needs but the recording of medication must be improved in order to prevent any maladministration. EVIDENCE: Residents are supported to be as independent as possible and are able to choose what they would like to do, within the agreed expectations of the service. Health needs of residents are identified as part of the assessment process and included in individual plans. All residents are registered with a local GP. Community psychiatric nursing (CPN) is available through the local community health team. Residents confirmed that they have regular contact and visits form their CPN. Medication systems are satisfactory and there are medication profiles in place for each person. However, there were some gaps on Medication Administration Record (MAR) sheets where medication was not recorded as having being Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 Page 14 given. This is bad practice and staff must sign immediately after medication has been given. Shenehom DS0000017393.V313778.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are informed about how to complain but in order to better protect residents, all staff must be trained in the prevention of adult abuse. EVIDENCE: There have been no complaints received at the home since the last inspection. Residents confirmed they have a copy of the complaints procedure and that they would be able to raise concerns with staff if necessary. Two residents stated they have had no reason to complain. The home follows the London Borough of Richmond’s Joint Policy on Suspected Abuse of Vulnerable Adults. Shenehom also has it’s own guidance in recognition, prevention and reporting of abuse. A whistleblowing policy is in place for staff. Staff who are doing NVQ3 are trained in ‘abuse’ but there has been no recent training for all staff in this area. This must be carried out. The majority of resident look after their own money. The finances for one resident are monitored by the home. There are adequate systems in place for ensuring that financial interests are protected. Shenehom DS0000017393.V313778.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is comfortable, well maintained and suitable for the people who live there. EVIDENCE: The home is situated in a quiet residential area with good access to local facilities, open spaces and public transport. The main property has eleven bedrooms and a semi independent unit accommodates two more residents. Communal rooms include two lounge areas, a kitchen/dining room and an activities area with facilities for pool, table tennis and darts. To the rear of the property is a well maintained courtyard area. Communal areas were made homely with pictures and plants. The lounge had a large fish tank which residents said they enjoyed. One resident said that their favourite rooms are their bedroom, the kitchen and the extension. The hallways and stairwells were quite bare and should be redecorated. All parts of the home were well maintained, clean and tidy. Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 Page 17 Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A competent staff team ensures that residents are well supported. EVIDENCE: Staff meetings take place every week and staff have regular meetings with psychologists, one who provides support around team issues, the other who supports with issues to do with residents. Staff were well informed about the needs of residents. Since the last inspection there have been a number of staff changes which has meant an increase in the use of agency staff who are unfamiliar with the home. Staff views about the structure of the team in the home were mixed. Management were more positive than support staff. Two questionnaires raised concerns about issues between management and staff. For example, feeling that internal recruitment was preventing expertise coming in from outside. It would benefit the team if these issues were discussed with the psychologist. Job descriptions and contracts of employment are in place for all posts within the team. Three staff recruitment files were examined. Two of these did not contain a photograph of the staff member or any proof of identity. Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 Page 19 New staff receive appropriate induction and supervision takes place regularly. Appraisals are not all up to date. This was confirmed by one member of staff. A training plan is in place and this identifies individual training needs. All staff commented that training opportunities were suitable for the work they undertake. Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good health and safety systems in the home ensure that the safety of residents is promoted. EVIDENCE: The manager has been in post for 13 years. He demonstrated a good understanding of the needs of residents and areas of improvement for the home. Residents are regularly consulted about the routines of the home. There is a community meeting every two weeks and regular individual meetings with a keyworker. Residents confirmed that these usually happen every month. The manager said annual review is carried out in November. Questionnaires are sent to residents and staff from which an agenda is made for a review meeting which involves everyone at the home as well as the Trustees. An action plan is then drawn up which is reviewed every three months. Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 Page 21 Health and safety is well monitored and all necessary checks are completed and up to date. A member of staff is responsible as the health and safety representative. Weekly fire point tests are carried out and there are regular fire drills. A fire risk assessment was updated in June 2006. Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 3 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 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 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 X 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 3 X 3 X X 3 X Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 Page 23 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 the format for risk assessments are standardised and that they are kept up to date and reviewed. Timescale for action 30/11/06 2. YA20 13(2) 3. YA23 13(6) The registered person must 31/10/06 ensure that staff sign the medication record as soon as it has been administered. The registered person must 30/11/06 ensure that all staff receive up to date training in the protection of vulnerable adults. 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 YA24 Good Practice Recommendations The registered person should ensure that sexual needs are included as part of the care plan system. The registered person should ensure that hallways and stairwells are redecorated. DS0000017393.V313778.R01.S.doc Version 5.2 Page 24 Shenehom 3. 4. YA33 YA36 The registered person should ensure that staff make use of the psychology support at team meetings to talk through any team issues. The registered person should ensure that all staff have a yearly appraisal. Shenehom DS0000017393.V313778.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SW London Area Office 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. 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