Inspection on 13/07/05 for Sundial House

This inspection was carried out on 13th July 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sundial House 19/10/06

Sundial House 09/01/06

Sundial House 17/11/04

Sundial House 02/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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 Sundial House Orchard Lane East Molesey Surrey KT8 0BN Lead Inspector Mr P Benthom Announced Inspection 13 July 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sundial House Address Orchard Lane East Molesey Surrey KT8 0BN 020 8398 7258 020 8398 7258 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) The Sons of Divine Providene Mrs Deborah Ann Hart CRH (PC) 7 Category(ies) of Learning Disability (LD) 7. registration, with number of places Mental Disorder, excluding learning disability or Dementia (MD) 1. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 30 - 65 years. 2. One (1) service user in the category LD may have a mental disorder. Date of last inspection 17 November 2004 Brief Description of the Service: The Home provides accommodation for young adults with learning difficulties. It is situated in a quiet residential road and benefits from an adjoining Horticultural centre where some of the service users attend. The home is a two-storey building with bedroom accommodation on both levels. The lounge and dining areas are spacious and homely. The garden is extensive with a small patio garden in the front of the building where there are parking facilities. There is a newly appointed games room adjacent to the lounge, which has been decorated and furnished to a very high standard. The home is owned by The Sons of Divine Providence, which is a Roman Catholic order of priest and brothers who are dedicated to the care of adults with learning disabilities. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection to be undertaken in the Commission for Social Care Inspection year April 5 to March 2006. On the day of the inspection the service users appeared well cared for and were being supported by one permanent and one Agency member of staff. Some service users were out at day centres or in the local community. One Service User requested to meet the inspector and freely spoke of how he likes living at Sundial house. The Home’s performance was measured against the National Minimum Standards for Care Homes for Young Adults. A tour of the premises took place and care, training and Health and Safety records were inspected. Two Service Users were spoken with during the course of the inspection. What the service does well: What has improved since the last inspection? There has been considerable investment in improving the physical standards of the home by providing new flooring downstairs and carpeting upstairs. The environment is modern, tastefully decorated and furnished to a homely and comfortable standard. It is to be very highly commended. There is also a very good in-house quality assurance system in place that the manager has developed in order to gain daily feedback and response from Service Users about the care they receive from the service. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 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 standard(s) 1, 2,3,4 and5 Service users are admitted only following a full assessment undertaken by people trained to do so. The registered person was able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: The Statement of Purpose was seen to be in place and contained all information required in Schedule 1 of the Care Home Regulations 2001. The Service User Guide benefited from written and symbol form making the guide more accessible to service users. The initial assessment was used to form the basis of the care and the support plan, which identified the actions that carers should follow to assist an individual living at the home. Care plans were noted as including comprehensive assessments of service users prior to admission. Written contracts between the home and service user were seen. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 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 standard(s) 6, 7, 8, 9 and 10 The systems for Service User consultation are good with evidence that their views are sought and acted upon. EVIDENCE: Extensive care plans have been drawn up, with the help of the service user wherever possible and relatives/representatives. Care plans were well documented and highlighted all areas of care needs for each service user. All care plans showed evidence of regular reviews. Risk assessments were in place where appropriate. During the inspection it was evident that staff respect the Service Users’ right to make decisions. Evidence was provided with examples of the Service Users’ opportunities to participate in the day-to-day running of the home e.g. helping with food shopping, assisting with meal preparation. Staff enabled Service Users to take responsible risks - wherever possible – and this was clearly documented in each individual care plan. Risk assessments were being carried out as/when necessary and existing ones regularly updated. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15, 16 and 17 Links with relatives, friends and the local community are good. These links support and enrich Service Users social and educational opportunities EVIDENCE: Examination of the home’s records confirmed a high degree of personal empowerment and choices in services users daily lives. They were encouraged and supported in the use of community amenities and in maintaining relationships with friends and families. Service Users attend various day centre and adult education activities. A different variety of community-based activities are available. The activities programme was individualised in accordance with Service Users wishes and made appropriate use of college courses, community amenities and facilities. All Service Users go out into the local community on a regular basis supported by members of care staff. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 11 The manager stated that Service Users are going out on excursions and holidays, risk assessments were seen as part of the daily activity programme in the home. Service Users had access to a range of appropriate leisure opportunities in accordance with individual preferences. They were encouraged to pursue individual interests and hobbies. Staff attempt to maintain links with Service Users’ families. Any visitors could be entertained either in the service user’s own room or in the garden. Friends are invited to visit. The home has maintained some good family links. There are no restrictions in terms of visiting times. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 12 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 standard(s) 18, 19 and 20 The healthcare needs of Service Users are well met with evidence of good multi – disciplinary working taking place on a regular basis. EVIDENCE: The home has a key work system in place. Key workers are responsible for ensuring that Service Users receive personal support in a way they prefer and/or require and this is documented in the care plans. Bathrooms and toilets were fitted with locks for privacy. Staff were observed to respect the privacy of Service Users’ bedrooms within appropriate guidelines and procedures. All Service Users are registered with the local GP and have access to all NHS healthcare facilities as required. Service Users will receive support from members of staff e.g. offering support to and from appointments. The home’s GP has a good knowledge and understanding of the needs of the Service Users and provides good support to the home. All Service Users attend the optician, chiropodist, dentist and physiotherapist as needed. Adequate arrangements were in place to meet the health care needs of Service Users. The organisation has a policy governing all administration of medication and the medication is stored securely in a locked cabinet in the office. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 13 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 standard(s) 22 and 23 Service Users are well protected by the organisation’s training policies and procedures with regard to the protection of vulnerable adults. EVIDENCE: The complaint procedure was compliant with statutory requirements. Complaint forms were available for recording complaints. Records demonstrated there had been no formal complaint received by the home or CSCI within the last twelve months. Some service users have limited ability to communicate verbally, however staff have developed positive knowledge and awareness of their needs and are able to accurately assess their concerns or dissatisfaction. There was evidence of this communication throughout the course of the inspection. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 14 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 standard(s) 24, 25, 26, 27, 28, 29 and 30 The standard of décor and equipment in this home is very good with evidence of improvement through continual maintenance and refurbishment. EVIDENCE: The location of the home is suitable for its stated purpose; it is accessible, safe and well maintained, meeting service users’ individual and collective needs in a comfortable and homely way. Service users bedrooms were found to contain furniture and fittings that were homely and non-institutional and provided with maximum consultation with service users. There are two bathrooms and toilets available for service users. The home has a separate dining room and a comfortable sitting area with a television and a video recorder, which is enjoyed by the service users. There is also a well-equipped games room that is of a very high standard of décor and furnishing. Service users use their own rooms or the office as a private area if required. The communal and private areas in this home are of a very high standard. All rooms were bright and adequately ventilated Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36 The staff have a good understanding of the needs of the Service Users in this home. This is evident from the positive relationships that have been formed between the staff and the Service Users. EVIDENCE: There are good training opportunities in place for staff. There are arrangements in place for all staff to have regular access to training and a commitment from the organisation to provide staff with NVQ training. 80 of staff have NVQ Level 2 and four members of staff hold current first aid certificates. The Home has a policy whereby all gaps in the staff rota are met by using existing staff from the Home as bank staff or limited use of agency staff. The manager is involved in all aspects of staff recruitment and policies and procedures were in place for recruitment and employment. Records of good practice were seen in the Home. The recruitment procedure was observed to be robust. There are arrangements to carry out CRB checks and two written references are required for all staff. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, 42 and 43 The manager is well supported by the senior staff team and by the organisation in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The manager has almost completed NVQ Level 4 and has had extensive relevant experience. She is employed full time and works alongside other staff on the rota. Records examined included; care plans, medication procedures, staff meeting minutes, risk assessment policies and service user activity programmes. They were observed to be in good order, with the exception of staff records that lacked some important information: • Two written references are required for each member of staff • A clear and full induction record is required for each member of staff • A clear record of training for all staff Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 17 • • • Evidence of CRB clearance being received for all staff A completed application form for employment for all staff An up to date photograph of the staff member Please see requirements on Page 20. Detailed policies and procedures were in place in relation to safe working practices. Staff were trained in First Aid, Food Hygiene and other aspects of Health and Safety. Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 18 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 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sundial House Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 3 3 H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 19 yes 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 YA41 Regulation 19 Schedule 2 Requirement It is required that all information contained in Schedule 2 of the Care Home Regulations 2001 is contained on all staff personnel files Timescale for action 31 August 2005 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 Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 20 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 Sundial House H58 H09 s13806 Sundial House v216569 130705 Stage 4 ann.doc Version 1.40 Page 21 - 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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