Inspection on 12/09/05 for Shottermill House

This inspection was carried out on 12th September 2005.

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 12/06/07

Shottermill House 19/01/06

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 Joseph Croft Unannounced 12 September 2005, 10:00 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 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 H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Shottermill House Address Pilgrim Homes, Liphook Road, Haslemere, Surrey, GU27 1NX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01428 661034 01999 999999 Pilgrim Homes Ms Diane Elizabeth Eldrett Care Home 29 Category(ies) of DE(E) Dementia - over 65, 7 registration, with number OP Old age, 29 of places PD(E) Physical dis - over 65, 13 Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 5 Up to 13 of the older people accommodated may have a physical disability. 6 Up to 7 of the older people accommodated may be in the category DE(E) - older people suffering from dementia 3 The age/age range of the persons to be accommodated will be: 65 YEARS & OVER Date of last inspection 8 September 2004 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. The home is situated on the outskirts of Haslemere and is convenient to the local amenities. Personal care is provided for up to twenty-nine older people who are all accommodated in single bedrooms. Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four hours with one inspector. The inspection included examination of some policies and procedures, samples of residents’ files, staff personnel files, training records and the home’s duty rota. A tour of the premises was undertaken. The home’s registered manager was away on annual leave. In depth discussions took place with the Senior Carer and staff were spoken to individually and during the course of their duties. Discussions took place with four residents. Residents spoken to were complimentary about the staff and the care they received. Residents spoken to stated the home provides them with choices about their daily lives and activities they would like to join in with. Residents stated they were happy living in the home. Bedrooms were appropriately decorated and personalised. Residents were able to have a direct telephone line put into their bedrooms if they wished to. Residents stated that the meals at the home were good, and a choice of food is offered. Family and friends are welcomed and encouraged to visit the home as often as they can. Residents’ files were informative and easily available, however, it was noted that some files sampled had not been reviewed on a monthly basis. Staff training records sampled evidenced mandatory training is in place, and staff receive training in the Protection of Vulnerable Adults. The premises are maintained in good order, and the gardens are well kept and free from hazards. Four requirements have been made during this inspection. What the service does well: The home conducts comprehensive pre-admission assessments, from which individual care plans are written in consultation with the residents and their families. Policies and procedures evidenced were clear and comprehensive. Staff/resident relationships were observed to be positive and respectful. The home has ensured staff receive training in the Protection of Vulnerable Adults. Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 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. Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 6 The home has an appropriate admission procedure in place that includes an individual assessment of prospective residents needs, and offers them an opportunity to visit the home. Intermediate care is not offered. EVIDENCE: The senior carer stated that the home’s manager undertakes pre-admission assessments, and a copy of the care management assessment and care plans are obtained. Residents and their families are invited to visit the home for a day before being admitted. Resident files sampled evidenced that preadmission assessments are undertaken. This included assessments on mobility, personal care, speech and language, health care needs, sociability, personal safety and behaviour. Residents spoken to confirmed that the home’s manager had visited them to undertake an assessment of their needs, and that they had visited the home prior to admission. The senior carer stated the home does not offer intermediate care. Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 10 and 11 The home has regard to preparing and implementing detailed care plans and ensures that residents are treated with dignity and respect. EVIDENCE: Each resident has a comprehensive care plan that is developed from the preadmission assessment. Care plans sampled evidenced that care and health needs are being met. However, not all of the care plans sampled evidenced a monthly review being undertaken. A requirement has been made that all care plans must be reviewed on a monthly basis. Discussions with staff evidenced they were aware of the care plans and the need for them to be reviewed on a monthly basis. Staff stated they maintain daily written records on each resident. These were evidenced. Residents spoken to stated they were aware of their care plan. Arrangements regarding personal and health care are clearly recorded on care plans. GP and other health care appointments are recorded. Residents spoken to stated staff treat them with dignity and respect and care for them in an appropriate manner. Residents stated they can visit the GP at the surgery, or if unable to, then the GP will visit them in their bedrooms. Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 10 Evidence was observed that residents’ wishes in the event of their death are clearly recorded on their care plans. Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14 The home offers opportunities for residents to make choices about their lifestyles, activities and preferences whilst living at the home. Family members and friends are encouraged to visit the home. EVIDENCE: Residents are encouraged to engage in a variety of social activities. A weekly programme of activities is displayed on the resident’s notice board. Activities on offer for the week of the inspection included singing, craft, board games and church services. Residents spoken to stated they could choose whether or not they wish to attend activities. Some residents stated they are able to go shopping to the local supermarket, attend church and go on trips with their family members when they visit. At the time of the inspection, one resident was observed leaving the home to do some shopping at the local supermarket. Residents stated they are able to make choices in regard to activities and food they like. Residents stated that these choices are made during the residents’ meetings, and through talking to the manager. They stated their views are always acted upon. Minutes of the August residents’ meeting were evidenced during the inspection. Residents spoken to stated that their family and friends often visit them, and they are able to meet in private in their bedrooms. Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 12 Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a satisfactory complaints system in place that is used towards ensuring views are listened to and acted upon. The home has regard for keeping residents safe and is committed to providing staff with training in this area. EVIDENCE: The home has a comprehensive Complaints Policy and Procedure that was reviewed in July 2005. A copy of the Complaints policy was displayed on the residents’ notice boards, and is included in the service users guide. The Complaints Policy specifies the time in which complaints will be responded to. The complaints book was viewed and evidenced that no complaints had been received by the home during the last twelve months. Residents spoken to stated they would make a complaint to the manager, and would contact the Commission For Social Care Inspection if they felt the need to. Staff stated they would take complaints to the manager and Pilgrim Homes’ head office. However, staff spoken to stated they were not aware they could contact the Commission For Social Care Inspection Surrey Local Office. A requirement has been made in regard to this. The home has comprehensive Policy and Procedure on the Protection of Vulnerable Adults and Whistle blowing. These documents were reviewed in July 2005. Training files sampled evidenced training in the Protection of Vulnerable Adults had been ongoing since 2003. Evidence was observed that two senior carers had attended the Surrey Multi-Agency Training in Protection of Vulnerable Adults on 21st June 2005. The senior care worker stated that Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 14 another two senior carers would attend this training in October 2005. Staff spoken to gave an accurate account the procedures to be followed if they suspected or witnessed abuse. Residents spoken to stated that they had no concerns about staff. Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The home offers a comfortable well-maintained environment for residents, and is clean, and orderly. Bedrooms are personalised and generally the facilities and equipment meet residents’ needs. EVIDENCE: The home was appropriately decorated and was clean, tidy and free from offensive odours. The requirements from the previous inspection in regard to the air vents in the lavatories had been met. There are 29 bedrooms with ensuite facilities. Bedrooms were appropriately decorated and furnished, and residents had personalised their bedrooms. Residents are able to have landline telephones in their bedrooms. Residents spoken to stated they had chosen the décor for their bedrooms. All radiators in the home had been fitted with suitable covers. There are four bathrooms each containing a shower and toilet, one has a Parker bath, and one has an Oxford Mermaid Hoist. There are sufficient toilets to meet the needs of the residents. Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 16 Communal areas are spacious, bright, free from clutter and furnished well. There is a smaller lounge that is used for certain activities, such as knitting, coffee mornings and for family and friends visiting residents. Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The home has a robust Recruitment Policy and Procedure that is intended to support and protect residents. The home endeavours to ensure a sufficient and competent staff team cares for residents. EVIDENCE: The home was adequately staffed at the time of the inspection. The duty rota was viewed and evidenced that five members of staff plus the manager are on duty during the morning shift, three members of staff plus a senior care officer are on duty during the evenings, and two waking night staff are on duty throughout the night. Four staff files were sampled, and provided evidence that all mandatory training is undertaken, and training in the Protection of Vulnerable Adults has been regularly provided for staff. The senior carer stated that six members of staff currently hold the NVQ level 2, and the Registered Manager has recently competed the Registered Managers Award. Recruitment files were sampled and provided evidence of an application form, two written references, proof of identity and a photograph. Three of the files sampled provided evidence that Criminal Records Bureau clearance had been undertaken. However, one of the recruitment files sampled was that of the most recent member of staff to join the team. This did not provide evidence that a Criminal Records Bureau application had been sent. An immediate Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 18 requirement has been made that this member of staff does not work without supervision until a satisfactory Criminal Records Bureau clearance has been obtained. Pilgrim Homes operates a six-week induction for new staff joining the team at Shottermill House. However, it became evident that one member of staff has yet to fully complete her six week induction. A requirement has been made in regard to this. Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These Standards were not assessed during this inspection. Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x x x x x x x x Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 21 Are there any outstanding requirements from the last inspection? 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. 2. Standard 7 16 Regulation 15 (2) (b) Requirement Timescale for action 19/9/05 4/10/05 3. 29 4. 30 Residents care plans must be reviewed every month. 21 (7) (b) The manager must ensure all staff are aware they can contact the Commissioin For Social Care Inspection at any time in regard to a complaint. 19 (4) (b) The member of staff identified (i) must not work unsupervised until a satisfactory Criminal Record Bureau clearance has been obtained. 18 (1) (c ) The manager must ensure all (i) new staff complete the homes six-week induction. 12/9/05 Immediate 12/10/05 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 Good Practice Recommendations Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shottermill House H09-H58 s13788 Shottermill House v248358 120905 Stage 4 UN.doc Version 1.40 Page 23 - 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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