Inspection on 26/09/07 for Shepherds Corner

This inspection was carried out on 26th September 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shepherds Corner 21/08/06

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 26th September 2007 09:00 Shepherds Corner DS0000063517.V350697.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.V350697.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.V350697.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 vacant post Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Shepherds Corner DS0000063517.V350697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2006 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 resident has his or her 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 residents, particularly as its domestic size does not lend itself to wheelchair users. The home is well situated to allow residents 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 residents. The weekly fees start from £700 and are then tailored to meet the individuals’ requirements and needs. Shepherds Corner DS0000063517.V350697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2007/2008. In writing the report consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. This was the home’s first inspection for the year 2007/08. It took place over five hours. Some times were spent looking at records, talking to some residents, staff and manager. A tour of the building was also carried out. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. What the service does well: What has improved since the last inspection? Staff files now contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001. The home recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the National Minimum Standards. The complaints procedure is now also available in picture format. Shepherds Corner DS0000063517.V350697.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. The summary of this inspection report can be made available in other formats on request. Shepherds Corner DS0000063517.V350697.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.V350697.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has its own assessment plan to ensure that any new resident’s needs are fully assessed prior to their admission. EVIDENCE: Residents 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 resident/recognised representative. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Shepherds Corner DS0000063517.V350697.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. 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 using available evidence including a visit to this service. Generally residents’ care plans include detailed information about their needs and personal goals. This helps staff to know the residents’ needs and how to meet them. EVIDENCE: Each individual has a care plan, which includes basic information necessary to deliver the resident’s care. However there was no evidence that the residents were involved in the process. Care plan must be drawn up with the involvement of the resident together with family, friends and/or advocate as appropriate, and relevant agencies/specialists. The plan must also be made available in a language and format the resident can understand (e.g. visual, graphic, simple printed English, deafblind manual, explanation, British Sign Language video), and must be held by the resident unless there are clear (and Shepherds Corner DS0000063517.V350697.R01.S.doc Version 5.2 Page 10 recorded) reasons not to do so. The manager stated that the care plans are being reviewed to make them person-centred. Staff provide residents with the information, assistance and communication support they need to make decisions about their own lives. Residents have meeting on a regular basis. Each care plan includes a comprehensive risk assessment, which is reviewed regularly. Management of risk is positive addressing safety issues whilst aiming for better quality of life. Where limitations are in place, the decisions have been made with the person and are recorded. Shepherds Corner DS0000063517.V350697.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. 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 using available evidence including a visit to this service. Residents 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. EVIDENCE: Generally staff are aware of the need to support residents to develop their skills, including social, emotional, communication, and independent living skills. All residents have an active day activities, some are designed specifically for people with learning disability; others are generic and open to all members of the local communities. Staff support the residents to become part of, and participate in, the local community in accordance with their assessed needs and the individual Plans. Shepherds Corner DS0000063517.V350697.R01.S.doc Version 5.2 Page 12 People who use the service are actively encouraged to maintain links with their families and friends. The acting manager stated that the home has an ‘open’ visitor’s policy. The home tries to be flexible and attempts to provide a service that is as individual as possible using its staff and resources effectively. Residents, who were at home at the time of this inspection, appeared to enjoy some level of independence. Routines can be flexible and are well observed to take into account all the residents’ individual needs. The manager stated that the residents are involved in the planning of the menu. Residents are offered a choice of suitable menus, which meet their dietary needs, and which respect their individual preferences. Care staff is sensitive to the needs of those residents who find it difficult to eat and give assistance with feeding. Shepherds Corner DS0000063517.V350697.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. 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 using available evidence including a visit to this service. Overall the arrangement for health care needs of the residents is good and they receive personal support in the way they prefer. However the system for administration of medications is not always consistent and could potentially place residents at risk. EVIDENCE: The delivery of personal care is individual and flexible. Staff respect the privacy and dignity of the residents and are sensitive to their changing needs. Where needed, guidance and support regarding personal hygiene (e.g. to wash, shave) is provided. Times for getting up/going to bed, baths, meals and other activities are flexible. People who use services have access to health care services both within the home and in the local community. Generally health needs are monitored and appropriate action and intervention taken. Shepherds Corner DS0000063517.V350697.R01.S.doc Version 5.2 Page 14 The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. However it was noted that the administration of antibiotics for one resident was not being administered as prescribed and the medication administration record was not completed accurately. The administration/non-administration of all medication must be recorded accurately at all times for the health and safety of residents. Shepherds Corner DS0000063517.V350697.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well, which should ensure that residents’ and relatives’ concerns are listened to. Generally the home’s policies and procedures help protect residents from abuse and help staff if they need to tell someone about any bad care practice they may observe. EVIDENCE: The home has a complaints procedure that is clearly written and easy to understand. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. Staff working at the service know when incidents need external input and who to refer the incident to. Shepherds Corner DS0000063517.V350697.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: The home is suitable for its stated purpose. It is accessible, meet residents’ individual and collective needs in a comfortable and homely way. Residents’ bedrooms are personalised to reflect their individual needs, and personalities. The bathrooms and toilets are fitted with appropriate aids and adaptations to meet the needs of the people who use the service, and are in sufficient numbers and of good quality. Shepherds Corner DS0000063517.V350697.R01.S.doc Version 5.2 Page 17 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.V350697.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. 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 using available evidence including a visit to this service. Generally staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency and to ensure their safety. EVIDENCE: There are consistently enough staff available to meet the needs of the people using the service. The staffing structure is based around delivering outcomes for the people using the service. The home has a good recruitment procedure that clearly defines the process to be followed. Three staff files were examined at random and found to contain the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. Shepherds Corner DS0000063517.V350697.R01.S.doc Version 5.2 Page 19 The home recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the National Minimum Standards. The acting manager is aware that there are some gaps in the training programme however these are being addressed and further training sessions have been arranged. Although recorded supervision has started, the target of six sessions per year has not yet been achieved. All care staff working in the home must receive formal documented supervision six times a year. Shepherds Corner DS0000063517.V350697.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally the health, safety and welfare of the residents and staff were being promoted and protected. EVIDENCE: The acting manager has the required experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for residents. There is a strong ethos of being open and transparent in all areas of running of the home. The acting manager is currently applying to be the registered manager with the Commission. Shepherds Corner DS0000063517.V350697.R01.S.doc Version 5.2 Page 21 The home has an effective quality assurance and quality monitoring systems, based on seeking the views of service users, to measure success in achieving the aims, objectives and statement of purpose of the home. The home has developed a health and safety policy that generally meets health and safety requirements and legislation. Certificates relating to health and safety were up to date servicing certificates. Shepherds Corner DS0000063517.V350697.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 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 3 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 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 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 Shepherds Corner DS0000063517.V350697.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 YA6 Regulation 15(2) Requirement Residents’ care plans must be drawn up with the involvement of the resident together with family, friends and/or advocate as appropriate, and relevant agencies/specialists. The plan must also be made available in a language and format the resident can understand (e.g. visual, graphic, simple printed English, deafblind manual, explanation, British Sign Language video), and must be held by the resident unless there are clear (and recorded) reasons not to do so. The administration/nonadministration of all medication must be recorded accurately at all times for the health and safety of residents. All care staff working in the home must receive formal documented supervision six times a year. Timescale for action 26/12/07 2. YA6 15(2) 26/12/07 3. YA20 13(2) 26/09/07 4. YA36 18(2) 26/11/07 Shepherds Corner DS0000063517.V350697.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shepherds Corner DS0000063517.V350697.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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