Inspection on 19/01/06 for Shottermill House

This inspection was carried out on 19th January 2006.

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

The inspector 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 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 Mary Williamson Unannounced Inspection 10:00 19 January 2006 th 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.V257457.R01.S.doc Version 5.0 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.V257457.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shottermill House Address Pilgrim Homes Liphook Road Haslemere Surrey GU27 1NX 01428 661034 01999 999999 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) Pilgrim Homes Ms Diane Elizabeth Eldrett Care Home 29 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (29), of places Physical disability over 65 years of age (13) Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to 13 of the older people accommodated may have a physical disability. Up to 7 of the older people accommodated may be in the category DE(E) - older people suffering from dementia The age/age range of the persons to be accommodated will be: 65 YEARS & OVER 12th September 2005 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. 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 DS0000013788.V257457.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and the second in The Commission for Social Care Inspection programme year 2005/2006. Mary Williamson who is a Regulation Inspector undertook the inspection. The Registered Manager Mrs. Diane Eldrett was present for the duration of the inspection. A tour of the premises was undertaken and records relating to the care of the service users and the management of the home were examined. There was a regular weekly coffee morning taking place in the small lounge organised by volunteers of the home and attended by service users and neighbours. Both service users and friends stated that this is a popular social event. The inspector had the opportunity to talk with several service users who all had positive comments regarding the standard of care they receive and were also very complimentary about the carers providing this. Several of the staff were spoken to who all had a good understanding of service users needs. They also confirmed some of the training they had undertaken, and were familiar with the complaints procedure and the abuse awareness policy. Accommodation is offered in single en-suite rooms all of which are well decorated and have been personalised. Service users are encouraged to bring personal items of furniture with them into the home. The standard of record keeping is good and care plans are comprehensive, informative and reviewed on a regular basis. Staff have a good rapport with service users and were observed to interact in a positive and respectful manner with them. The premises are well maintained. The home is based on a Christian ethos with worship taking place each morning from the lounge. There is a sound system to all bedrooms to enable service users to worship in private if they wish. The inspector would like to thank the service users, staff, and manager for their hospitality and positive input to the inspection process. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There are no requirements as an outcome of this inspection. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 7 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 DS0000013788.V257457.R01.S.doc Version 5.0 Page 8 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.V257457.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 1, 2, 3, and 5. Prospective service users have the information necessary to help them make an informed choice regarding the home. Need assessments and contracts are in place. EVIDENCE: The home has a statement of purpose and service users guide in place providing service users and their relatives with the information necessary to help them make an informed decision regarding the choice of home. The manager stated that she undertakes a pre admission needs assessment on all prospective service users entering the home. These assessments were sampled as part of individual care plans. The basic criteria for admission, is all service users are Christians. Individual contracts of terms and conditions of occupancy are in place, and all service users of their designated representative have a copy of this. Trial visits are encouraged either for a meal or coffee. There are occasions when relatives will choose the home on behalf of a service user. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 10 Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 7, 8, 9, and 10. Individual care plans outline how health and personal needs are met in a dignified manner. The service users are safeguarded by the homes administration of medication procedures. EVIDENCE: Individual care plans are in place. The care plans are written on information gathered from the pre admission needs assessment, and input from the service user and their families. These are well maintained, comprehensive, and outline all the relevant care to be given. Regular reviews are undertaken. The care staff maintain daily records on all service users. Appropriate arrangements are in place to meet the personal and health care needs of service users. They are all registered with a local GP and are seen regularly. There is also access to district nurses, chiropody treatment, dental care, and an optician service. Specialist services can be accessed through the GP for example Physiotherapy and occupational therapy. One service user was being nursed in bed. She looked well cared for comfortable and had a “care chart” in her room which was well maintained. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 12 There is a procedure in place for the administration of medication. All staff that administer medication have the appropriate training. The medication recording charts were seen and are well maintained. All medication is supplied by Lloyds Pharmacy in the Nomad System. There is an audit trail in place for the ordering and disposal of medication. The medication recording charts were seen and are well maintained. Service users are treated with dignity and their privacy is respected at all times. Accommodation is offered in single rooms. Locks are fitted to bedroom and bathroom doors, and staff were observed to knock on service users bedroom doors prior to entering. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 12, 13, 14, and 15. The activities programme in place meets the service users individual and collective needs. Family links are maintained and nutritional needs are met. EVIDENCE: There is a leisure activities programme in place, which includes individual and group activities, for example singing, craft, board games, and trips out. On the day of the inspection the service users were enjoying their weekly coffee morning taking place in the small lounge. This is organised by volunteers of the home and some of the local neighbours were also attending this. The ethos of the home revolves around Christian worship, which takes place every morning in the main lounge. Various clergy and volunteers arrange this. There is a sound system link to all bedrooms, which provides service users the option of private worship. Family links are maintained and relatives and friends are welcome in the home at any reasonable time. Several visitors made comment to the inspector regarding the good standard of care and support provided by the home and staff team. There is a small kitchen on the first floor where service users can make their visitors a cup of tea when required. There is also individual cupboard space to store their own crockery and refreshments. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 14 Two service users stated that they are able to make choices regarding all aspects of their daily life. They can choose their food and the activities they participate in. Service users meetings are held six- monthly and minutes kept. The catering arrangements in the home are satisfactory. The kitchen was visited during the inspection, which was clean and orderly. There was an agency cook on duty as the permanent cook was on holiday. She was able to demonstrate that the menus are planned on a four- week basis with input from the service users. The menus are well balanced, varied and nutritious. Lunch was observed during the inspection and consisted of beef casserole and dumplings, potatoes, and a selection of fresh vegetables. This was followed with pears and chocolate sauce. All the relevant records relating to fridge and freezer temperatures and cleaning of equipment were in place. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users are confident that their complaints would be taken seriously and acted upon. EVIDENCE: The home has a complaints procedure in place. This is available to all service users and their relatives on admission to the home and is also included in the welcome pack. There is a copy of the complaints procedure also displayed on the notice board. Two service users stated that they would be able to discuss any concerns with the manager if such circumstances were to arise. There have been no complaints since the last inspection. Several letters of thank you and compliments were seen. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 19, 20, 21, 22, 24, and 26. The service users live in a clean, comfortable, well-maintained home, which meets their individual collective, and mobility needs. EVIDENCE: The home was clean tidy and free from offensive odour. The lounge areas are comfortable, well decorated and furnished. The dining room is spacious bright and airy and offers a relaxed and comfortable atmosphere during meal times. There are ample toile and bathing facilities situated throughout the home. The mobility needs of the service users are addressed, and some bathrooms have been adapted with assisted baths, and showers, there are raised toilet seats, and hoists also available. There is a lift in place to access the first floor and there is ramp access to the garden. There is input from a physiotherapist and an occupational therapist when required. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 17 Most of the service users bedrooms are of single en-suite occupancy. These are well decorated, comfortably furnished and personalised to reflect individual personalities and hobbies. Service users are encouraged to bring items of furniture and personal possessions with them on admission to the home. The home has an infection control policy in place and staff have training in this procedure during induction training. The laundry is well equipped and the lady working in the launder was aware of the infection control policy and was using the “RED” bag system for soiled linen. Arrangements are in place for the collection of clinical waste. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30 The number and skill mix of staff on duty was adequate to meet the assessed needs of the service users. EVIDENCE: The duty rota was seen during the inspection. Both senior carers were attending a study day and the manager was the “hands on” senior carer on duty. There were four carers, three housekeepers, one laundry assistant, one cook, one administration assistant, and two maintenance persons on duty. The skill mix of staff was adequate to meet the assessed needs of the current service users in the home. The staff training files were sampled. All staff undertake induction training and this is signed in individual files. Certificate of attendance are also in place for first aid, fire safety, manual handling, food hygiene, and COSHH. The manager stated that four staff have NVQ Level 2 and two staff have NVQ Level 3 and this training is ongoing. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36, and 38. The service users live in a well managed home and their health and welfare is promoted and protected. EVIDENCE: The home is well managed by a manager who has been in post for seven years. She has considerable experience in the provision of care to older people. She also holds her RMA award (Registered Managers Award). The manager demonstrates an open and inclusive style of leadership, and staff and service users confirmed that they feel happy and confident to approach her at any time. All the staff receive regular formal supervision. This is undertaken by the senior care staff and recorded. The manager undertakes yearly appraisal with all staff. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 20 The home has a wide range of Health and Safety policies and procedures in place some of which were viewed during the inspection. All staff undertake training in Health and Safety and are aware of COSHH procedures. Risk assessments are in place for safe working practice. Fire records were seen. These are well maintained and records show that fire alarms are tested weekly and fire drill take place every three months. There is a contract in place for the regular maintenance of fire fighting equipment. The accident records are also well maintained. Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 21 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 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 X 3 Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 22 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. Standard Regulation Requirement Timescale for action 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 Shottermill House DS0000013788.V257457.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office 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 DS0000013788.V257457.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!