Inspection on 12/06/07 for Shottermill House

This inspection was carried out on 12th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Shottermill House 19/01/06

Shottermill House 12/09/05

Shottermill House 08/09/04

Shottermill House 20/04/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Shottermill House Pilgrim Homes Liphook Road Haslemere Surrey GU27 1NX Lead Inspector Helen Dickens Unannounced Inspection 12th June 2007 10:30 X10015.doc Version 1.40 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 Shottermill House DS0000013788.V339491.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 Older People. 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. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shottermill House Address Pilgrim Homes Liphook Road Haslemere Surrey GU27 1NX 01428 661034 01428 645233 shottermill@pilgrimhomes.org.uk www.pilgrimhomes.org.uk Pilgrim Homes 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) Paul Mason Care Home 31 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0), of places Physical disability over 65 years of age (0) Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - (OP) Dementia, over 65 years of age - (DE(E)) Physical disability, over 65 years of age - (PD(E)) 2. The maximum number of service users to be accommodated is 31. 19th January 2006 Date of last inspection Brief Description of the Service: Shottermill House is a purpose built care home. It was opened in 1990 and is owned and operated by a Christian charity called Pilgrim Homes. The service provides care for elderly Protestant Christians who subscribe to the Doctrinal Basis of faith. The home is situated on the outskirts of Haslemere and is convenient to the local amenities. Personal care is provided for up to thirtyone older people in the above categories who are all accommodated in single bedrooms. Weekly charges vary from £514 to £616 and some local authority funded residents are accepted. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over 7.5 hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The Registered Manager, Paul Mason, represented the establishment. A partial tour of the premises took place. The inspector spoke to five residents on a one-to-one basis and talked briefly with most of the remaining residents during lunch. Fourteen ‘comment cards’ returned to CSCI, and a number of questionnaires on file at the home, were also used in writing this report. Three resident’s care plans and a number of other documents and files, including two staff files, as well as risk assessments and maintenance records, were examined during the day. The Commission for Social Care Inspection would like to thank the residents, relatives, manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: Shottermill House offers a very homely environment for elderly Christians who have chosen this home for its emphasis on a Christian way of life and for access to services relating to their faith and spirituality. One visitor wrote on their comment card that the home is ‘always very sensitive towards resident’s spiritual needs.’ The premises are well looked after and the home was very clean and pleasant throughout. Resident’s rooms came in for plenty of praise, with one describing her room as her ‘castle’. One resident who said she hadn’t been there very long described it as ‘….a very good place.’ Communal areas were domestic in appearance with good quality furnishings and fittings. The kitchen had just been inspected by the Environmental Health Department and no remedial actions were needed. Residents commented positively on the help they received from staff, one lady saying the staff were ‘very attentive.’ Another resident, describing a particular care worker, said she was ‘Lovely. You couldn’t wish for a better carer or more understanding one.’ There were a number of comments received about the meals and residents were mainly complimentary, one gentleman telling the inspector: ‘You couldn’t better the food…it is beyond expression. And so is everything else. ’Another resident said ‘We get lovely dinners.’ Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents only move into the home following a comprehensive assessment of their needs and being assured they will be met. There is a high level of involvement from the resident and their family in this process. EVIDENCE: The home has an admissions policy in place and all residents have an assessment carried out by the manager. In addition, those residents admitted through the local authority also have a care manager’s assessment and care plan. Residents can come for the day or overnight to try out the facilities and care at the home. There is an emphasis on the spiritual needs of residents as this is a Christian home and both assessments and care plans set out resident’s preferences in this regard. The assessment of the latest resident to be admitted was checked and the correct documentation was in place. Three resident’s files were checked during the day and all demonstrated a high level of involvement from either the resident or their next of kin. Residents are Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 9 asked to provide a testimony regarding their spiritual background and requirements, and in most cases this was hand written by the resident. Resident’s contracts with the home were also on their files, as was a copy of a letter from them asking their medical practitioner to pass on their medical history to the home. Those residents with a diagnosis of dementia have an extra assessment template on file to ensure their mental impairments are recognised and documented. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements for meeting resident’s health and social care needs, and for the administration of medication are good at this home. Resident’s privacy and dignity are protected by the policies of this home though more work needs to be done to meet Standard 10 in full. EVIDENCE: Three care plans were sampled and found to be completed in full, including information on 14 areas identified as activities of daily living for example personal hygiene, mobility and mental abilities. Two of the plans had been reviewed monthly, and the newest resident’s plan was not yet due for review as she had been at the home for less than one month. There were long and short-term goals under each heading and plenty of evidence of resident involvement. One resident who is aged over 100 spoke highly of the home and the staff and it was evident from his care plan that he had been involved in the monthly reviews, with each one being signed off by him. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 11 There were some concerns about whether adequate risk assessments are in place regarding some potential environmental hazards, particularly for those people with dementia and this is dealt with under Standard 19 on premises. Arrangements for healthcare are well documented on care plans including the past medical history of each resident, any ongoing treatments and appointments, and visits to the home by the community optician and the chiropodist. One resident who was diabetic had this clearly documented on file and a record of blood sugar tests was kept. Resident’s files also had nutritional risk assessments and weight charts. Mobility risk assessments and moving and handling guidelines were also on file. There were some favourable comments returned on comment cards to CSCI prior to the inspection regarding health matters. A community nurse wrote about the home; ‘If they have any medical problems…..they always contact us promptly to seek advice…’ and ‘They have been very caring towards terminally ill patients.’ A GP noted that ‘I have always found the staff very helpful and well informed. A very well run home.’ The administration of medicines at the home is overseen by one senior member of staff and was found to be well organised with good record keeping practices. They have recently changed the community pharmacy they were using and the new pharmacist has been in to train staff and check that the new arrangements are working well. One medication administration period was observed during lunchtime and medicines were kept secure throughout. Three medicine administration records were checked and there were no unexplained gaps. The senior member of staff checks these herself and said it is also the responsibility of the next person giving medication to double check that the last dose was correctly documented. On a fourth record it was noted that for ‘as required’ medication, where a resident can choose if they wish to have for example a painkiller, some staff write ‘N’ when not required whilst others leave this blank. It was recommended that staff are encouraged to be consistent in how they complete records for ‘as required’ medication. The manager was also asked to chase up the local NHS body regarding an annual pharmacy inspection by a community or NHS pharmacist. A community nurse wrote on the comment card to CSCI that respecting the confidentiality and privacy of clients was something the home did well. During the inspection there were no instances of staff being disrespectful to residents and one resident commented that staff always ask before taking anyone to her room. Staff were observed to knock on doors. Two issues reported to the inspector and then passed on to the manager would have had an impact on the dignity of residents and this is now being dealt with through the proper procedures. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Activities are arranged for residents but more work needs to be done to review the way residents with and without dementia are being integrated, and on specialist training regarding activities for people with dementia. Family contact is encouraged and residents are given some opportunities to make choices. More work is being done on menus and the majority of residents reported enjoying their meals most of the time. EVIDENCE: The home has an activities plan in place and there is much emphasis on spiritual aspects of the home with morning and evening prayers and The Grace which is said before meals. There is at least one other activity on a daily basis and on the afternoon of the inspection there was Christian music playing in the lounge area for residents to join in. One resident said there were activities if you wanted to take part – she had taken part in a quiz the day before adding that you can’t please everybody. There is a keyboard in the lounge and that was also being played on the day of the inspection. There were no negative comments about activity provision from residents. However there were no special activities for people with dementia though some evidence that Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 13 residents are being supported by staff to join existing activities. No staff were trained specifically for activities for people with dementia and this will be a Requirement. There were a number of negative comments both on comment cards and during resident interviews about the perceived increase of people with dementia moving into the home, and some were going into others bedrooms, including at night. This means that not all residents are experiencing the lifestyle they prefer. The manager has tried hard to integrate residents with dementia within the home which is commendable, but more work needs to be done. A review is needed whereby better communication with existing residents (and relatives) and specialist advice about the layout of the premises should be considered. Community contact is good with a regular coffee morning which one resident said gave people from outside the opportunity to come in; she used to attend herself when she lived at home before she moved in as a resident. Visitors are welcomed and there is an additional small lounge where residents could see their visitors if they chose. Residents can invite guests for meals and these are charged at a reasonable rate. There was good evidence of involvement from family and advocates on care plans and assessments. Some very favourable comments were received from relatives including ‘Always staff in evidence…they speak kindly to residents, and meals are good.’ This person’s relative had been in other homes and wrote ‘Shottermill House is the best choice.’ In response to the question ‘What does the care home do well?’ another relative wrote ‘just about everything.’ However, there were a few negative comments from relatives including one who said the home was sometimes short of staff, and two who commented on the admission of people with dementia and the negative effect they perceived it was having on the home and existing residents. These issues were discussed with the manager, though there was no evidence on the day of the inspection that there was a shortage of staff. Residents have some opportunities to make choices including whether they attend the religious services, and whether they wish to take part in activities. The manager has recently sent around a satisfaction questionnaire to residents regarding the food and residents were heard to be offered choices by staff. Resident’s care plans clearly document choices which have been discussed and made with residents on various aspects of their personal and social care. There are also resident’s meetings which give residents another opportunity to take part in decision making. One resident said; ‘staff are nice…no-one says you must do this or that…and staff ask if for example they want to bring someone up to your room.’ Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 14 However, there are more opportunities which should be made available to residents. None of the residents spoken to in the dining room knew what was on the menu for lunch. There is a menu on the board in the hallway. It is recommended that the manager looks at other ways of making the menus accessible to all residents. Also, there is only one main course option each day unless a resident has previously made it known they do not like something – in which case they are given an acceptable alternative. It was recommended that the home have a menu on each table, as the cook said she already does for special occasions. If there is to remain only one main course option per day, the home might consider other regular options (e.g. white fish, or baked potato and salad, or omelettes) which could be noted at the bottom of each menu card as available any day if ordered by a certain time. The precise choices would need to be decided by the cook in consultation with residents. The manager is about to change the menus but said the current ones are based on resident’s known likes and dislikes. Noted in admission records, care plans, and kept as a record in the kitchen. Food is also discussed at resident’s meetings. The manager said he would like to introduce menu cards where residents can choose for the week. The menu for the week was on the notice board. Satisfaction surveys have gone out to residents on current food arrangements and giving the opportunity for them to make suggestions. The dining room is very pleasant with cotton tablecloths and napkins, and each resident having a named placemat. The Grace was said before the meal and it was noticeable how the manager waited until every resident had arrived and was seated before The Grace was started to make sure everyone was included. Most residents commented favourably on the food though a significant number also said it varied from day to day. Positive comments included: ‘…Couldn’t better the food….it is beyond expression’; ‘Very good food. We get lovely dinners’; and ‘food excellent.’ The inspector tasted one teaspoon of each item on the main course menu on the day of the inspection and found the chicken pie to be well cooked with tender chicken, tasty sauce and light pastry. The mashed potato was creamy and the carrots and beans neither under nor over cooked. Everyone spoken to on the day of the inspection (and the inspector visited almost every table during lunch) was enjoying their meal that day. The Manager said he is aware of the sometimes mixed reception regarding food and is taking action. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a clear and accessible complaints procedure and residents knew who they could complain to. Procedures are in place to protect vulnerable adults but more work needs to be done on staff training to ensure all staff are aware of their responsibilities. EVIDENCE: There is a complaints procedure in place at this home and residents, both on their returned comment cards and in person during the inspection, said they would know how to make a complaint. The complaints book was seen and four complaints documented – these had all been dealt with, including one where someone from Pilgrim Home’s head office had dealt with the issue. No complaints have been made to CSCI since the last inspection. There is a protection of vulnerable adults policy in place and staff cover this subject as part of their induction. As there was no central training record available on the day of the inspection, (the manager is currently working on this), it was difficult to ascertain, without looking through every staff training file, how many staff had had safeguarding adults training. The manager collated this information and forwarded it to the inspector by e-mail the next day confirming that 18 of the 22 care staff had had this training. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 16 Two issues were raised with the inspector on the day of the visit to the home which had not been dealt with by the home either under their complaints procedure, or under their protection of vulnerable adults policy. The home manager was unaware of either. This was discussed with the manager and reported by him under the relevant procedures. As a result, two Recommendations will be made. One is to review the Pilgrim Homes policy which instructs the manager to fill out an investigation form – this is contrary to the Surrey–wide Safeguarding Adults Protocol whereby all such matters must be referred to the local authority in the first instance; the Local Authority will then decide who will carry out any necessary investigation. The second is to arrange refresher training for all staff to ensure absolute clarity about reporting complaints and issues relating to vulnerable adults. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Shottermill House provides a homely environment which is clean and pleasant throughout. EVIDENCE: Shottermill House provides a very homely environment for residents. All those spoken to liked their rooms, one describing it as ‘My castle’. Five residents’ bedrooms were visited and all found to be nicely decorated, and very bright and cheerful. All had brought some of their own belongings and rooms were personalised with photographs and ornaments. There is a programme of routine maintenance and a maintenance officer was employed to carry out minor works and do the regular checks, for example on water temperatures and boilers. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 18 The communal areas were well furnished and the bathrooms were all clean and tidy. The lounge had the majority of chairs in ‘rows’ but the manager said these were moved around when the various activities were taking place, and the rows facilitated some of the communal activities such as morning prayers when everyone would be facing towards the centre of the room. There is also a smaller lounge available to residents. The home is registered to take residents with dementia and the environment may need further modification to ensure that these residents are being cared for in the safest environment. The manager was asked to take specialist advice on this matter and to ensure sufficient risk assessments were in place, particularly with regard to the stairs. The manager was also asked to review arrangements for fire doors as not all had automatic closers and some residents like to have their doors open when they are in their rooms. This home is kept clean and fresh and visitors to the home made written comments about its cleanliness on their returned comment cards. There were no unpleasant odours in any part of the home and there are sufficient domestic and catering staff employed. The laundry was visited and found to be clean and tidy. There are two commercial washing machines with sluicing facilities, and two tumble driers. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s needs are being met by the numbers and skill mix of staff though more work needs to be done on staff training. Residents are protected by the home’s recruitment policies and practices. EVIDENCE: On the day of the inspection resident’s needs were being met by the numbers of staff on duty. A written rota is in place and there are extra staff on duty during busy periods. However, more work needs to be done on staff training and qualifications and this is discussed below. The current manager has made improvements regarding training including beginning to increase the number of staff who have NVQ qualifications. Currently 7 of the 22 care staff have NVQ Level 2 or above, and 3 other staff have been put forward. Standard 28 requires that at least 50 of staff should be qualified to at least this level. Two staff recruitment files were sampled and found to be kept in good order with CRB, protection of vulnerable adults list checks, and references being taken up prior to employment. The application form asks staff for their employment history and an explanation of any gaps, as required in the Regulations. One staff member interviewed was asked about equal Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 20 opportunities in relation to recruitment, and in particular whether the home insisted that all staff were of the same religious faith. This staff member was not of the same religious faith and said that the home had not discriminated in any way, and they did take staff from a variety of faith backgrounds. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home and their financial interests are safeguarded. Health and safety matters are promoted within the home. EVIDENCE: The registered manager has been at Shottermill House since September 2006 and registered with The Commission since March 2007. He has worked in the care sector since 1994 and this includes being in management positions since 1997. He was required at his registration to begin the Registered Manager’s Award and he has now started the course and expects to complete it by the end of 2007. He is responsible for the day to day management of the home and it was observed that there are clear lines of accountability between Pilgrim Homes, the manager, and staff within the home. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 22 This home uses the Quality Management System for Pilgrim Homes and this was examined during the inspection. The system includes a self-assessment checklist and covers care, development of the service, quality improvement, and organisational fitness. The latest quality assurance audit identified a number of issues and the actions required to correct each issue. Target dates were set and there are quality management review meetings held. As part of their ongoing measurement of the quality of their service, the organisation carries out Regulation 26 visits, as well as satisfaction level questionnaires for residents and staff. There are also resident’s meetings which give a regular opportunity for residents to have their views taken into account. The home also carries out ad hoc surveys, for example the recent one covering food and arrangements for meals. A commitment is made to equal opportunities and this is set out in the policies and procedures of the home, as well as in their practices, for example employing staff from diverse backgrounds within the home. Residents are encouraged to be independent and the service is arranged to facilitate this, for example providing a kitchenette for resident’s use, and including residents in every review of their care plan. The home offers an option for residents to keep some money in the safe for their day to day expenses for example the hairdresser or chiropodist, or for a newspaper. This money is kept separately for each resident with a cash book recording all transactions. One resident’s cash box was sampled and the amount of cash matched the amount recorded in the cash book. All receipts are kept and these monies are audited randomly during the monthly Regulation 26 visits. There are systems in place to promote health and safety within the home. The manager has overall responsibility and carries out regular monthly checks on all parts of the home, including resident’s bedrooms. The maintenance officer carries out a number of additional checks, for example on the water systems, and twice yearly legionella checks are carried out. There are risk assessments on file for areas identified as potentially hazardous including fire safety, gas, water, hot surfaces, and pathways. The environmental health officer visited the home recently and made no recommendations. This certificate, together with their insurance and CSCI certificates, are displayed on the wall. A Requirement is being made regarding reviewing current risk assessments to ensure specific dangers relating to people with dementia are being identified, for example the stairways in the home. The home must also take specialist advice on the environment in relation to caring with people with dementia now that they could potentially take more residents with this condition. And though nearly half of the staff have received health and safety training, the remainder will need to do so in order for this home to meet this Standard in full. Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 24 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 OP12 Regulation 18(1)(a) Requirement A review of current activities must be carried out to ensure there are suitable activities for residents who have dementia, and that at least one member of staff has specialist training in this regard. A review must be carried out regarding the integration of different client groups within the home. This should include better communication with residents and their families, and specialist advice on whether the current layout of the home and the general environment are the most suitable. A review of current risk assessments must be made to ensure they are sufficient to cover all identified risks, for example with regard to the stairs. A review of arrangements for fire doors must be carried out as not all had automatic closers and some residents like to have their doors open when they are in their rooms. DS0000013788.V339491.R01.S.doc Timescale for action 12/08/07 2. OP12 12(2)(3) 23(1)(a) 2(a) 12/09/07 3. OP19 13(4)(a)( b)(c) 12/07/07 Shottermill House Version 5.2 Page 25 4. OP30 18(1)(a) Staff training needs to be reviewed to ensure all staff have completed at least the mandatory courses for example safeguarding adults, first aid, health and safety etc. to ensure that staff have the training and skills to carry out the work they are asked to perform. The shortfall on numbers of staff with NVQs must be included in this review. 12/08/07 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 OP15 OP18 Good Practice Recommendations It is recommended that other ways are found to make the home’s menus more accessible to all residents. The Pilgrim Homes safeguarding adults policy should be reviewed to ensure it is in keeping with the Surrey–wide Safeguarding Adults Protocol, i.e. the local authority determines when an investigation is carried out, and who will do this. Refresher training on staff responsibilities in relation to reporting Safeguarding Adults matters should be arranged as discussed in the report and with the manager. 3. OP18 Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI Shottermill House DS0000013788.V339491.R01.S.doc Version 5.2 Page 27 - 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. 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