Inspection on 21/08/06 for Shepherds Corner

This inspection was carried out on 21st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shepherds Corner 26/09/07

Shepherds Corner 07/11/05

Shepherds Corner 20/07/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Shepherds Corner Shepherds Corner 132-134 St James Road Croydon Surrey CR0 2UY Lead Inspector Mohammad Peerbux Key Unannounced Inspection 21st August 2006 9:30am Shepherds Corner DS0000063517.V308355.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 Shepherds Corner DS0000063517.V308355.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. Shepherds Corner DS0000063517.V308355.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shepherds Corner Address Shepherds Corner 132-134 St James Road Croydon Surrey CR0 2UY 020 8689 5709 020 8683 2263 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) Glen Care Group Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Shepherds Corner DS0000063517.V308355.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Shepherds Corner is an establishment in the heart of West Croydon and provides accommodation for 13 people with varying degrees of learning disability. Each service user has their own bedroom, situated on either the ground or first floor of the building. As there is no lift, the home is ideally suited to ambulant service users, particularly as its domestic size does not lend itself to wheelchair users. The home is well situated to allow service users to engage within the local community. The transport links are excellent and the main shopping centre of Croydon is within reasonable walking distance. The home provides an in-house daycare programme, which is used by the majority of the current service users. The range of weekly fees is between £658.40 and £2265.97. Shepherds Corner DS0000063517.V308355.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection for the year 2006/07. It was an unannounced inspection and took place over four hours. Some times were spent looking at the policies and procedures, talking to staff, the acting manager and to some of the service users. They are all thanked for their time and assistance. A tour of the building was also carried out. Service users spoken to stated that they were happy with the care being provided. Requirements and recommendations from the previous inspection were also discussed with the acting manager. Overall the inspection confirmed that the home provides a good level of care for the service users who live there. What the service does well: What has improved since the last inspection? There were no requirement or recommendation from the last inspection. Shepherds Corner DS0000063517.V308355.R01.S.doc Version 5.2 Page 6 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. Shepherds Corner DS0000063517.V308355.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 Shepherds Corner DS0000063517.V308355.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): 1 and 2 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The necessary information and opportunity to visit the home is being made available to service users, enabling an informed choice regarding the suitability of the home to be made. The home has its own assessment plan to ensure that any new service user’s needs are fully assessed prior to their admission. EVIDENCE: The home has a comprehensive Statement of Purpose and Service User Guide. The acting manager has recently reviewed both documents. This should ensure that prospective service users have the information they need to make an informed choice about where to live. Service users are only admitted to the home after a full assessment of their needs has been carried out by the home and the Placing Authority for individuals referred through Care Management, involving the prospective service user/recognised representative. The acting manager stated that she is in the process of reviewing the assessment of needs of service users to make it more comprehensive. Shepherds Corner DS0000063517.V308355.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 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Care plans are comprehensive and include detailed information about service users’ needs, personal goals, wishes and risk assessments. Service users are involved in decision making about their lives, they participate and can take some risks so that they live as normal a life as possible. EVIDENCE: Three service users’ care plans were sampled, it was noted that they were well maintained. Overall, the plans demonstrated a thorough needs assessment, which clearly set out how current and anticipated needs would be met. The plans checked established individualised procedures for service users likely to challenge the service, focusing on positive management strategies. The acting manager informed that she is in the process of introducing person centred planning for all the service users. The manager is reminded that the plan must be drawn up with the involvement of the service user together with family, friends and/or advocate as appropriate, and relevant agencies/specialists. Shepherds Corner DS0000063517.V308355.R01.S.doc Version 5.2 Page 10 The rights of service users to make decisions about their own lives is central to the ethos of the home, support and guidance is given in all areas to ensure that service users are making decisions which are in their best interests. Each service user has a skills assessment. These assessments ensure that the staff team are aware of the decision-making ability of each service user, and they could therefore respect, within identified limits, the service user’s right to make their own decisions. There is also service users’ meeting being carried out on a regular basis. A risk assessment is in place for each service user. Potential risks are identified all aspects of their daily living both inside and outside the home. The home is able to demonstrate that this standard is met as individualised care plans were in place for each service user that referred to action required to minimise identified risks and hazards. The acting manager is updating all the risk assessments. Shepherds Corner DS0000063517.V308355.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 and 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are encouraged to explore opportunities to enhance their quality of life as well as maintain and participate with friends and the local community, with the aim of maximum integration. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Two of the service users attend day centres and these are thoroughly enjoyed. The remainder are able to participate in the in-house day care programme. All service users have very active day activities, some are designed specifically for people with learning disability; others are generic and open to all members of the local communities. The acting manager informed that individual daily activities timetable is being implemented. Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual plans. Shepherds Corner DS0000063517.V308355.R01.S.doc Version 5.2 Page 12 Service users are encouraged to be politically active and to vote. The home values and seeks to reflect the racial and cultural diversity of service users and of the community in which it is located. The home has an ‘open’ visitor’s policy and simply recommends that visitors telephone to say they are coming to ensure their loved one will be available. Service users, who were at home at the time of this inspection, appeared to enjoy a high level of independence at the home. They moved about the home freely, helped themselves to facilities and provisions, knew what the house rules and boundaries were, plus the significance of having private space and bedrooms. Service users are offered a choice of suitable menus, which meet their dietary and cultural needs, and which respect their individual preferences. The home had adequate setting where meals are consumed. The acting is presently reviewing the menu with the involvement of the service users. Shepherds Corner DS0000063517.V308355.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 and 20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users’ personal, physical and emotional health needs are being appropriately met and reviewed. This ensures that the service users’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Service users’ medication is also well managed to ensure maximised good health. EVIDENCE: Staff provide sensitive and flexible personal support to maximise service users’ privacy, dignity, independence and control over their lives. The acting manager stated that where needed, guidance and support is provided. Times for getting up/going to bed, baths, meals and other activities are flexible. Service users have the technical aids and equipment they need for maximum independence. The service users are all registered with a local General Practitioner. Records checked indicate that GP’s and other community based medical/health care professionals are contacted on an as needed basis. It was evident that records of all medical/health appointment/visits were being maintained. Shepherds Corner DS0000063517.V308355.R01.S.doc Version 5.2 Page 14 In general, medication records, including medicines received, administered and returned were all being appropriately maintained. Medication profiles in respect of each service user were also available. Shepherds Corner DS0000063517.V308355.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 and 23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. Generally the home’s policies and procedures help protect service users from abuse and help staff if they need to tell someone about any bad care practice they may observe. EVIDENCE: The current complaints procedure is a good and gives clear step-by-step guide of how to make a complaint. There have been no complaints since the last inspection. It is recommended that the home provide the complaints procedure in an appropriate format where needed. The home has a copy of London Borough of Croydon adult protection procedures. The acting manager informed that most of the staff have attended the Abuse Awareness Training and that she would be attending “ Training the Trainer” course herself. The home also has its own protection of vulnerable adults policy in place. There has been one adult protection concern raised since the last inspection and following an investigation, this was not substantiated. Shepherds Corner DS0000063517.V308355.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 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally hygienic, clean, homely and comfortable however fire safety issue need to be addressed as this potentially places service users and staff at risk. EVIDENCE: The home is suitable for its stated purpose. It is accessible, meet service users’ individual and collective needs in a comfortable and homely way. Service users’ bedrooms are personalised to reflect their individual needs, and personalities. However the registered provider is required to replace the chest of drawers and radiator cover in H.J’s room. It was also noted that two doors were wedged open for which a requirement has been made under standard 42. The home is kept very clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Shepherds Corner DS0000063517.V308355.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs and ensure their safety. One concern was identified in regard to recruitment checks not being completed satisfactorily, which impinge on the safety and protection of service users being ensured. EVIDENCE: The home arranges for a least four members of staff to be on duty in the morning, three in the afternoon and one awake plus one sleep-in at night. Current staffing levels are consistent with minimum standards. As part of the inspection process staff records were sampled for references, criminal record checks, application forms and copies of identification. Not all relevant documents were in place. Prior to the inspection it was also noted that one staff member was working with a CRB disclosure that was issued for another organisation. The registered provider is required to ensure that staff have all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001. Shepherds Corner DS0000063517.V308355.R01.S.doc Version 5.2 Page 18 From the staff training records, it was noted that they were not always up to date and there are gaps in mandatory training. It was very difficult to ascertain if the staff were up to date with their training. The registered manager must ensure that all staff are up to date with their mandatory training. Shepherds Corner DS0000063517.V308355.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally managed well however the health, safety and welfare of service users and staff are not being promoted/protected and this potentially places them at risk. EVIDENCE: The registered manager resigned in June 2006. An acting manager is now in post and is in the process of applying to be the registered manager. She stated that she would be starting her NVQ Level 4 in September of this year. The acting manager undertakes periodic training to maintain and update her knowledge, skills and competence while managing the home. The acting manager informed that there are regular service user’s meeting where the service users have an opportunity to discuss about the service they are being provided. There is also an annual quality assurance audit that is carried out to measure the home success in achieving its aims and objectives. Shepherds Corner DS0000063517.V308355.R01.S.doc Version 5.2 Page 20 However it was noted that no “Regulation 26”visits had been carried out by the registered provider for the month of June and July 2006. The registered provider must visit the home at least once a month and this should be unannounced as part of the quality assurance system. During the inspection it was noted that two doors were wedged open. The registered manager must ensure that fire doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. Certificates relating to health and safety were up to date servicing certificates. These included gas safety, fire safety and legionella. Shepherds Corner DS0000063517.V308355.R01.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 X 2 X 2 X X 2 X Shepherds Corner DS0000063517.V308355.R01.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 YA24 Regulation 13(4)(a) Requirement The registered provider is required to replace the chest of drawers and radiator cover in H.J’s room. The registered provider must ensure that staff files contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001. The registered manager must ensure that all staff are up to date with their mandatory training. The registered provider must visit the home at least once a month and this should be unannounced as part of the quality assurance system. The registered manager must ensure that fire doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. Timescale for action 30/09/06 2. YA34 19 20/09/06 3. YA35 18(1)(c ) 30/11/06 4. YA39 26 21/08/06 5. YA42 13(4) 30/09/06 Shepherds Corner DS0000063517.V308355.R01.S.doc Version 5.2 Page 23 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 YA22 Good Practice Recommendations It is recommended that the home provide the complaints procedure in an appropriate format where needed. Shepherds Corner DS0000063517.V308355.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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