Inspection on 28/02/06 for Shenehom

This inspection was carried out on 28th February 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shenehom 27/11/07

Shenehom 27/09/06

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 Simon Smith Unannounced Inspection 28th February 2006 11:30 Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 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.V261261.R01.S.doc Version 5.1 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.V261261.R01.S.doc Version 5.1 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.V261261.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 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 property is owned and maintained by Richmond-upon-Thames Churches Housing Trust. Staff do not provide personal care but if required in the shortterm 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. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 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 visit and involved speaking to residents, the manager and members of staff. A sample of records was examined. The inspector was made welcome and wishes to thanks residents and staff for their help during the inspection. The home met 22 of 23 National Minimum Standards assessed at this visit. One Standard was almost met and one Requirement was made. The home was fully staffed at the time of inspection. One of the strengths of the service is that the manager and a number of staff have worked there for some time. As a result, residents work with staff who are known to them and who know their needs well. There were no resident vacancies at the time of inspection. One resident who had recently moved to the home said that he had been made welcome when he arrived and had been given good support to settle in. Residents gave good feedback about the service during discussion and said that they are consulted about the life of the home. What the service does well: What has improved since the last inspection? What they could do better: Make sure that all written information held about residents is accurate and up to date. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 Page 6 Standardise the documentation used for administration and recording. 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.V261261.R01.S.doc Version 5.1 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.V261261.R01.S.doc Version 5.1 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, 5 Prospective residents are able to visit the home prior to admission and to move in on a trial basis. Residents are issued with tenancy agreements outlining their rights and responsibilities. EVIDENCE: Two residents had moved into the home since the last inspection. Residents’ files demonstrated that admissions to the home are made according to transition plans developed for each resident. People thinking of moving to the home are able to make trial visits before doing so and a formal review is held six weeks after residents move in. Having submitted an application form, residents attend an assessment interview with staff from the home and their social worker. New residents’ files demonstrated that information from previous placements is considered when making an assessment for admission to the home. The inspector was able to speak to one resident who had recently moved into the home. The resident confirmed that he had made a number of trial visits before moving in and that he had been made welcome since his arrival and had good support to settle in. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 Page 9 Residents’ files also contained a tenancy agreement setting out the terms and conditions of their placement. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 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 the following standard(s): 6, 7, 9 Individual plans reflect residents’ needs and aspirations. Residents receive good support to make informed choices about their lives. There are appropriate guidelines for the management of risk but the home should standardise the format used for risk assessment. 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. Personal details held on one resident’s care plan were incorrect. The home must ensure that all written information concerning residents is accurate and up to date. See Requirement 1. Staff have a good knowledge of residents’ needs and a commitment to supporting residents in making informed decisions about their lives. Observation confirmed that residents are able to choose the way in which they spend their time at the home. The service consults significant others, such as family members and care managers, where appropriate regarding the care of residents. All residents have an allocated keyworker. Staff receive training in Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 Page 11 this role prior to keyworking residents. Residents’ keyworkers are changed regularly in order that staff get to know all residents well. The home provides appropriate guidance for staff in the identification and management of risk. Risk assessments are in place addressing specific activities undertaken by residents. The last inspection report made a Requirement that the home assess the risk presented by windows not fitted with restrictors. The manager reported that these risk assessments had now been carried out. Risk assessments on file were recorded using a number of different formats. It is recommended that the home standardise the format used for this purpose to ensure clarity and consistency of information. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 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 the following standard(s): 11, 13, 16, 17 Residents are encouraged to involve themselves in the routines of the home and to develop independent living skills. Residents are encouraged to involve themselves in their local community. The home’s menu is varied, well balanced and takes account of residents’ preferences. 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. During discussion, residents confirmed that they are involved in the routines of the home and that they have input into the home’s menu, holidays, outings and activities. Residents said that household jobs are allocated at morning meetings and that menu planning done alternate weeks. Residents were Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 Page 13 involved in communal tasks, such as meal preparation and cleaning, on the day of inspection. Residents also said that they make use of local community facilities such as banks, shops, parks and public transport networks. The manager said that the home may employ a cleaner for two hours a day, four times a week. It is hoped that this will free up residents from some household tasks and enable them to concentrate on group work, supported by a project worker. The manager advised that residents will be consulted about which groups they would like to see and that potential groups include cookery and gardening. Responsibility for shopping and cooking is shared amongst staff and residents. The home’s menu indicated that residents receive a varied and well-balanced diet. Snacks and drinks are available to residents at any time. Residents said that they enjoy the food provided at the home. Interactions between staff and residents was positive during the inspection. Residents have unrestricted access to all communal areas of the home and are able to have privacy when they want it. Residents’ wishes and needs are clearly identified in their individual plans. Staff used appropriate forms of address when speaking to residents. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 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 the following standard(s): 19 Residents are supported to access community and specialist healthcare resources where necessary. EVIDENCE: The inspection provided evidence that residents are supported to get medical advice and treatment when they need it. All residents are registered with local general practitioners and referrals are made to specialist services where necessary. The manager reported that a psychologist visits the home once a month to work with residents and to provide guidance to the staff team. Community psychiatric nursing is available through the local community mental health team. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 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): 23 There is appropriate guidance for staff in the recognition, prevention and reporting of abuse. Residents feel that any concerns they raise would receive an appropriate response. EVIDENCE: The home works within the framework of the local authority‘s ‘Joint Policy on Suspected Abuse of Vulnerable Adults’. Guidance is provided for staff in the recognition, prevention and reporting of abuse. The home also has a Whistleblowing procedure, which provides a mechanism for staff to raise any concerns they may have about the service. Residents spoken to during the inspection said that they would feel comfortable raising concerns with staff. Residents also felt that any concerns raised by them would be taken seriously by staff and would receive an appropriate response. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 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 The home is comfortable, safe and well maintained. The home is clean and hygienic. Maintenance issues are addressed effectively. EVIDENCE: The home is situated in a pleasant residential area and has good access to local community facilities, open spaces and public transport networks. A good standard of decoration has been achieved throughout the home and the property has a courtyard garden. The main property accommodates eleven residents whilst the semiindependent unit houses two further residents. Communal rooms include two lounge areas, a kitchen/dining room, a quiet room and an activities area with facilities for pool, table tennis and darts. All communal areas were clean and hygienic at the time of inspection. Residents said that they liked their bedrooms and that they enjoy the facilities provided by the home. Residents also said that any maintenance issues that arise are usually dealt with promptly. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 Page 17 Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 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): 31, 33, 34, 35, 36 There is a stable staff and management team who know residents and their needs well. Staff have experience and qualifications relevant to their roles. New staff are appointed according to an appropriate recruitment procedure. Staff receive a good induction when they start work and have access to regular supervision and support. EVIDENCE: There were no staff vacancies at the time of inspection. The manager and a number of staff have worked at the home for some time. As a result, residents work with staff who are known to them and who know their needs well. The manager said that the home is planning to recruit some bank staff to cover vacant shifts if needed. The home has a clear staffing and management structure. Job descriptions and contracts of employment are in place for all posts within the staff team. Regular staff meetings ensure that staff are well briefed on current issues within the home. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 Page 19 New staff are recruited according to an appropriate recruitment procedure and must comply with pre-employment checks before they take up their post. New starters undertake a programme of induction when they begin work and staff are encouraged to attend training relevant to their roles. Staff receive individual supervision and good support to do their jobs. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 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, 43 The home aims to seek and respond to residents’ views. The home is managed effectively. EVIDENCE: The manager has a number of years experience in post and has achieved qualifications relevant to the role. The manager demonstrated a positive approach to the inspection process and said that he has access to appropriate supervision and support. The home aims to seek residents’ views through regular meetings, which are supported by staff. Residents are encouraged to involve themselves in the routines of the home and are consulted about decisions that affect them. The home’s management committee performs regular monitoring visits and submits subsequent reports to the CSCI. The committee is proactive in identifying opportunities for improvement and development. For example the Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 Page 21 committee commissioned an independent management review in 2005, which examined all aspects of the business. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X 3 X 3 X X X 3 Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 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 YA6 Regulation 15(2) Timescale for action The Registered Person must 30/04/06 ensure that all written information held about residents is accurate and up to date. Requirement 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 YA9 Good Practice Recommendations The home should standardise the format used for risk assessment. Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Shenehom DS0000017393.V261261.R01.S.doc Version 5.1 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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