Inspection on 10/01/06 for Stiperstones

This inspection was carried out on 10th 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stiperstones 10/07/09

Stiperstones 15/04/09

Stiperstones 05/01/09

Stiperstones 23/10/08

Stiperstones 21/04/08

Stiperstones 22/05/07

Stiperstones 11/08/04

Stiperstones 26/04/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Stiperstone Stiperstone Clappers Lane Chobham Surrey GU24 8DD Lead Inspector Deavanand Ramdas Announced Inspection 10:00 10 January 2006 th Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 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 Stiperstone DS0000013802.V256447.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 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. Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stiperstone Address Stiperstone Clappers Lane Chobham Surrey GU24 8DD 01276 858440 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) Welmede Housing Association Ltd Mr Alistair Ian Ogilvy Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the category `LD` (learning disabilities), 1 (one) service user may be within the category `LD` and `PD` (learning disabilities/physical disability) The age/age range of the persons to be accommodated will be: 35-64 YEARS 25th July 2005 Date of last inspection Brief Description of the Service: Stiperstones is a care home for eight people with learning disabilities and provides personal care only. The property is located in Clappers Lane, Chobham, Surrey and accommodation is provided on two floors accessed by stairs. The home has eight single bedrooms and facilities include a kitchen, lounge, dining area, office, laundry, bathrooms and toilets. The property has a private drive and a large garden which is secure and easily accessible. Private parking is available. Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection by one inspector carried out over a period of five hours. A full tour of the premises took place, staff and service users were spoken to, documents and care records were examined. The inspector noted service users had communication difficulties and judgements were made about them based on their mood and behaviour. The inspector would like to thank the manager, staff and service users for their contributions to the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure care plans reflect the wishes of service users concerning ageing, illness and death and offer training opportunities to staff on bereavement counselling to ensure they have the appropriate skills to support service users. The training of staff needs to improve to ensure the home meet the targets set for National Vocational Qualification Training (NVQ) which equips staff with the knowledge and skills to support service users. The home Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 6 must ensure service certificates for equipment and appliances are available to promote the health and safety of staff and service users. 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. Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 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 Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3. The homes statement of purpose and service user guide are good providing service users and prospective service users with details of the services the home provides enabling an informed choice to be made about admission to the home. The arrangements for meeting service users needs are satisfactory ensuring the aspirations of prospective service users will be met on admission to the home. EVIDENCE: The home had a statement of purpose and service user guide which contained information about the aims, objectives and philosophy of the home. The information was well-presented, written in plain English and described the services and facilities the home offered using pictorial references. The manager stated prospective service users admitted to home would be offered specialist input to meet their needs. The inspector noted the home had contact with a psychiatrist from the primary care trust, input from a behavioural specialist and a practice nurse carried out annual health checks on service users. One service user admitted to the home had assistance from an advocate throughout the process of choosing the home. The inspector noted the service user had unrestricted access to the home and was happy and smiling which indicated his satisfaction with the home based on the information given by staff. Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8. The systems for decision making are satisfactory ensuring service users are supported to make decisions about their lives with assistance as needed. The arrangements for participation are adequate ensuring service users are offered opportunities to participate in the day to day running of the home. EVIDENCE: The manager stated the home supported service users to make decisions about their lives which are recorded in the service users care plans. The inspector noted service users went to the Isle of Man which was their preferred destination for a holiday and observations confirmed staff supported service users to make decisions by providing service users with information and communication support. The manager stated the activities schedule is being developed using pictorial references to make the information understandable to service users and has plans to introduce meetings for service users to consult them on, and support them to participate in decision making in the home. Observations confirmed service users were involved in activities of daily living such as clearing the tables after lunch, using the dishwasher and hovering and cleaning bedrooms which indicated participation in domestic life in the home. Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12&13. The arrangements for occupation are satisfactory ensuring service users are supported to take part in appropriate activities. The systems in place at the home supports service users to become part of the local community. EVIDENCE: The manager stated service users were able to take part in valued activities and commented one service user admitted to the home continued to attend the local adult education centre. Staff stated service users would not be able to find and keep employment or participate in further education due to the level of their learning disability and functioning. The manager stated the home supported service users to be part of the local community and remarked the home provided a “house vehicle” to enable service users to access the local shops, pubs and cinema. The home had good relationships with neighbours, and a vicar and a volunteer from the local parish visited the home. The manager has been offered a stall at the local village fete and stated staff and service users will attend the event to meet with the local people and to raise money for charity. Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20&21. The systems for managing medications are good promoting the health of service users. The arrangements for managing ageing, illness and death of a service user need to improve to ensure it is handled as the individual would wish. EVIDENCE: The home had a policy on medications dated May 2005 and a service level agreement with a local chemist. Medications were supplied to the home every four weeks and stored securely in a locked metal cabinet. The inspector sampled medication record sheets and noted they had a recent photograph of service users and were dated and signed by staff with no discrepancies. Staff were trained in medications in February 2005 and a list of staff names with specimen signatures was available for information. The home had a record of medications returned to the pharmacy and a homely remedies list approved by the GP. The home had a policy on care of the dying and bereavement and the manager stated service users are able to receive treatment, care and to die in their own room. The inspector noted staff had no training in bereavement counselling and care plans did not reflect the ageing, illness and death of service users and a requirement has been made in this area to ensure the illness and death of a service user is handled as the individual would wish. Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The complaint process at the home is satisfactory with complaints information available to staff, service users and relatives. EVIDENCE: The home had a complaint policy and the manager stated the home had received no complaints since the last inspection. The inspector noted the complaint policy was available in the office for information and during discussions staff stated they were aware of complaints policy. Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27&30. The systems for managing the premises are satisfactory ensuring service users live in a homely, comfortable and safe environment. The furniture and fittings are adequate ensuring service users’ bedrooms promote their independence. Toilets and bathrooms are adequate and provide sufficient privacy to meet service users needs. The arrangements for hygiene are satisfactory ensuring the home is clean and hygienic for service users. EVIDENCE: On the day of the inspection the home was airy, clean and free from offensive odours, furnishings and fittings were of good quality and the standard of décor was good. The inspector noted furniture in the dining area had been rearranged to create more space for service users and new dining chairs had been purchased. Bedrooms were well presented and personalised with family photographs, plants, ornaments, television, CD player, video and other items of personal interest. The inspector noted bedrooms had wash hand basins, chairs, chest of drawers, wardrobes and two bedrooms had new flooring to make it nice and comfortable for service users. The home had adequate toilets and bathrooms which were lockable, accessible and offered privacy. Policies Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 14 and procedures were in place for infection control and observations confirmed staff washed their hands regularly using anti-bacterial hand-wash. The home had industrial washing machines and dryers and the floor finish in the laundry was impermeable. Hand washing facilities were sited in the laundry and kitchen and anti-bacterial hand-wash widely available in the home. Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34&35. Staff have job descriptions ensuring service users benefit from the clarity of staff roles and responsibilities. The arrangements for National Vocational Qualification (NVQ) training needs to improve to ensure care staff hold a care qualification. The recruitment and vetting practices at the home are satisfactory ensuring service users are protected from harm. The training and development of staff is satisfactory ensuring service users needs are met. EVIDENCE: The home had a management structure and an on-call system to provide staff with advice and support. The manager delegated responsibilities to staff who had job descriptions describing their role. During discussions staff stated they had responsibilities for menu planning, health and safety, key working and were issued with the General Social Care Council (GSCC) code of conduct. The manager stated staff have the qualities and competencies to support service users and observations confirmed staff were good listeners and comfortable with service users. The inspector noted the target set for National Vocational Qualification (NVQ) had not been achieved and a requirement was made in this area to ensure service users are supported by competent staff. The home had a policy on recruitment and the inspector sampled personnel files which included a recent photograph of the employee, a completed application form, references, statement of terms and conditions, job descriptions and a Criminal Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 16 Record Bureau (CRB) disclosure information. The manager stated the home had an induction programme for staff and each staff had a personal development plan which was linked to the homes’ aims and service users’ needs. The inspector sampled staff training files and noted the deputy manager had completed a training course in epilepsy to meet the needs of a service user with the condition and the manager was involved in staff induction training. Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,40,41,42 The arrangements for quality assurance are satisfactory. Policies and procedures at the home are adequate safeguarding the rights and best interests of service users. The systems for record keeping are satisfactory ensuring service users interests are safeguarded. The home has safe working practices however the home needs to ensure service certificates are available for information. The home is financially viable safeguarding the interests of service users. EVIDENCE: The inspector noted the home had regular monthly visits (Regulation 26) to monitor the quality of the home and appropriate management action was taken to address any shortfall. The manager stated the home had regular care reviews, staff meetings and policies and procedures to safeguard the quality of the service. The home had met the previous requirements and information about the Commission for Social Care Inspection (CSCI) visit was displayed in the home. The manager is developing questionnaires to survey service users, relatives and other professionals to obtain feedback about the home. The Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 18 home had policies and procedures which were dated and signed by staff. During discussions staff stated they were aware of the homes policies and procedures which were discussed at team meetings. Records at the home were up to date, accurate and securely stored in a locked cabinet in the manager’s office. The home had a health and safety manual dated 2005 and a nominated staff with responsibility for health and safety in the home. The home had an inspection from the environmental health department on the 15/1/05 and management had taken action on the recommendations made. The inspector sampled staff training files and noted they had attended a training course in health and safety and the home had a gas certificate dated 1/8/05, a legionella test certificate dated 25/11/04 and fridge and freezer temperatures were within normal limits. The manager stated electrical contractors had visited the home on the 8/12/05 and a requirement was made for service certificates to be sent to the commission for information. The home had a business plan dated 2005-2006 and a certificate of liability insurance to safeguard the financial viability of the home. Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X 3 X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 3 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE 3SUPPORT Standard No 18 19 20 21 Stiperstone Score X X 3 2 Standard No 37 38 39 40 41 42 43 Score X X 3 3 3 2 3 DS0000013802.V256447.R01.S.doc Version 5.0 Page 20 No. 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 Standard NMS-YA21 Regulation 12(3) Requirement Timescale for action 01/03/06 2 NMS-YA32 18(1)(a) 3 NMS-YA42 23(2)(c) The registered person must ensure care plans have a section to reflect service user’s wishes concerning ageing, illness and death. The registered person must 20/02/06 ensure an action plan is completed with timescales outlining how National Vocational Training (NVQ) targets would be achieved and a copy of the action plan sent to the Commission for information. The registered person must 20/02/06 ensure service certificates for electrical appliances and equipments are available at the home and copies sent to the Commission for information. 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 Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 21 1 NMS-YA21 The registered person should strongly consider bereavement training for staff to ensure they have the appropriate skills to handle the ageing, illness and death of a service user. Stiperstone DS0000013802.V256447.R01.S.doc Version 5.0 Page 22 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. 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