Inspection on 19/10/06 for Sundial House

This inspection was carried out on 19th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Sundial House 09/01/06

Sundial House 13/07/05

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 Sundial House Orchard Lane East Molesey Surrey KT8 0BN Lead Inspector Mary Williamson Key Unannounced Inspection 19th October 2006 11:00 Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 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 Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sundial House Address Sundial House Orchard Lane East Molesey Surrey KT8 0BN 020-8398 7258 020 8398 7258 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) The Sons of Divine Providence Mrs Deborah Ann Hart Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 30 65 Years One (1) service user in the category LD may have a mental disorder. Date of last inspection 9th January 2006 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 DS0000013806.V316502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was undertaken by Mary Williamson who is a Regulation Inspector. Beborah Hart the registered home manager was present throughout the inspection. The service manager Father Stephen was present for the feedback on the inspection findings. 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. These included care plans, medication recording charts, menus, staff duty rotas, and staff recruitment files. Six service user comment cards, eleven relative/visitors comment cards, one health care professional comment card, and two placement officer comment cards were returned to the inspector, all of which has positive and favourable feedback regarding the home and the care provided. There was a relaxed and comfortable atmosphere in the home with good interaction observed between the service users and the staff team. There were no relatives or visitors in the home during the inspection. All the service users were busy following their planned activities programme. One service users had been shopping and another preparing to go out for a fish and chip lunch. It was also possible to talk with some members of staff who confirmed some of the training they had undertaken and felt supported by the management structure in place. The inspector would like to thank the service users and staff team for their hospitality, and help during the inspection process. What the service does well: The home provided a safe and comfortable environment for the service users living there. The statement of purpose and service users guide is available to all service uisers in both print and symbol format. Individual activities programmes allow service users to develop living skills and undertake a wide and varied range of leisure recreational and activities. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 6 Arrangements in place are suitable to meet the health and personal care needs of service users. There is a stable staff team in place who have a good understanding of the needs of the service users they support. There is also a staff development programme in place, which includes formal supervision. The home is well managed and both service users and staff felt supported by the management structure within the home. What has improved since the last inspection? What they could do better: There have been no requirements as an outcome of this inspection. The service continues to provide care and support to service in a sensitive and dignified manner. There were two minor shortfalls noted with the environment, which have been highlighted in the main body of the report. These had been identified by the management team and included in the budget plan for the coming year. A recommendation has been made that the provider informs The Commission for Social Care Inspection once the work has been completed. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 8 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 Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information available to service users enables them to make an informed choice about the home. Needs assessments are in place and trial visits offered. EVIDENCE: There is a statement of purpose and service user guide in place and all the service users have access to a copy of this, which is also available in picture format. The seven service users living in Sundial House have been there for many years. The last service user admitted was four years ago. The manager stated that all prospective service users would have a needs assessment undertaken by her prior to admission. Needs assessments were seen for MR, JL, and KW. These were informative and reviewed on a regular basis. The manager explained how trial visits were offered to the last service user who was admitted. These ranged from short visits to weekend visits until the prospective service user was confident with his new home. This also provided the staff team to determine the suitability of the placement, and if the service could meet his needs. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 10 Contracts of occupancy are in place and have been signed by the service users. Contracts are also in place between the funding authorities and the provider and have been signed by the care manager and the company secretary on behalf of the provider. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, and10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessed needs are reflected in individual care plans, which also include risk assessments. Service user information is handled in confidence. EVIDENCE: Individual care plans are in place, which reflect service users individual needs and goals. Care plans were seen for MR, JL, and KW. These are well written based on input from the service users and information gathered at care management reviews. The car plans also include risk assessments for all identified risks. K stated that he participates in home meetings where he is supported and encouraged to make decisions regarding all aspects of the home, and how he spends his leisure time. Minutes of house meetings were sampled. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 12 There is a policy in place relating to confidentiality and all records containing service users information is kept secure when not in use. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to participate in leisure and community activities. Family links and maintained and nutritional needs are met. EVIDENCE: Service users are supported to follow appropriate educational and development programmes. Some attend various day centres, and educational sessions while others undertake horticultural activities provided in the adjacent unit. Currently one service user is seeking part time employment. Community participation is supported and the local college provided cooking classes, art and craft, fitness club, drama club, and horse riding. K stated that he enjoys going out for a curry, visiting the pub, and going to the cinema. Other activities include trips to the local theatre, shopping for food and clothes, bowling, and day trips. K was shopping for winter clothes during the Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 14 inspection and was keen to show these to the inspector on his return from his shopping trip. The service users stated that they had been on holiday to Blackpool, Selsey, Lancashire, and Rome. Family and friendship links are encouraged and relatives are welcome in the home at any reasonable time. Family are also encouraged to attend care reviews. Ten relative and visitor comment cards were received by the inspector which all contained positive feedback regarding the home and their involvement. Service users can bring friends into the home. The manus are planned over a four -week period by the service users. They are currently compiling a winter menu with support from staff. The choice of food is wholesome and appetising. Service users accompany staff when doing the food shopping. The manager stated that some service users will help with laying the tables and tidy up after meals, and they will also make their packed lunches. Service users have the opportunity to make their own drinks when they wish. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Personal support is offered in a sensitive manner and the health emotional and medication needs of the service users are being met. EVIDENCE: Service users receive personal support as outlined in individual care plans. All service users are registered with a local GP and can visit the surgery when required. They also have six monthly dental check ups, chiropody treatment every three months, and visit the optician yearly. The manager was able to demonstrate a health action record in individual files. Specialist input is available on referral by the GP and one service user was going to the local hospital out patients during the inspection. The home has a policy in place for the administration of medication. This is familiar to all staff who undertake medication administration. The medication recording charts were seen and these are well maintained. Kent Pharmacy supplies the medication to the home and also undertake medication audits. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The complaints, and adult protection procedures in place protect the service users in Sundial House. EVIDENCE: The home has a complaints procedure in place and all service users have a copy of this. Staff are also familiar with this procedure. There have been no complaints since the last inspection. There is also an abuse awareness policy in place and all staff have training in this policy during their induction training. This training is updated yearly and the manager stated that five staff were due to undertake their update training the week following the inspection. The home also has a copy of Surreys Multi Agency Safeguarding Vulnerable Adults Policies and Procedures in place. The manager has undertaken this training and has cascaded this throughout the staff team. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, and 30. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable, and safe environment, which is clean and hygienic. EVIDENCE: The home is clean and tidy providing a comfortable and homely environment for service users to live in. The lounge has been redecorated and refurbished to a high standard. The hobbies room adjacent also provides additional recreational space, which is frequently used. There is a large dining room, which has also been refurnished providing a relaxed and comfortable atmosphere where meals can be taken. Bedrooms are single occupancy, which have been personalised to reflect individual interests and hobbies for example football and books. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 18 The standard of cleanliness is good and service users are supported to keep their rooms clean and attend to their laundry. Some minor environmental issues for example a damp patch on an internal wall and carpets due for replacement were noted. These issues had also been identified by the manager and the service manager and included in the budget for the coming year. A recommendation has been made that The Commission for Social Care Inspection is informed in writing once the work has been completed. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. A competent and qualified staff team supports service users. The recruitment procedures protect the service users. EVIDENCE: The staff duty rota was seen and the number and skill mix of staff on duty was sufficient to meet the assessed needs of the service users. The manager was able to demonstrate the flexibility of the rota to accommodate individual activities and appointments. The organisation is committed to the development of staff. Training records were sampled and indicated that all staff undertake induction training in accordance with LDAF framework. This included food hygiene, fire safety, first aid, infection control, abuse awareness, health and safety and health action planning. NVQ is ongoing with several staff having achieved NVQ Level 3. The organisation has a recruitment policy in place, which protects the service users. Employment records for two new staff were seen. These are well maintained and included all the required documentation. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 20 Staff confirmed that they receive formal supervision every six weeks. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, and 42. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home, which promotes health and safety. EVIDENCE: The home is well managed by an experienced manager with a good knowledge of the service users in her care. She has worked for the organisation for thirty years and in the home for six years. She is currently undertaking her Registered Managers Award, which she stated she had almost completed. She is supported by two senior care support workers. There is an open and inclusive management approach in the home with service users and staff having constant assess to the office and in formation. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 22 Quality assurance is monitored by monthly regulation 26 visits, a quality assurance check list undertaken every Sunday, an annual development plan for the home, and service user meetings at which minutes are recorded. The standard of record keeping is good and records sampled included care plans, medication charts, duty rotas, staff recruitment files, menus, and service users financial records. All service users have an individual bank account, which is operated with the help of staff. All transactions are signed and witnessed by two staff. Health and safety policies and procedures are in place and these were sighted throughout the inspection. All staff have training in these procedures and The COSHH procedures were observed to be in use and understood. Fire safety records were seen and are well maintained. Fire alarms are tested weekly and there is a contract in place for the maintenance of fire fighting equipment and emergency lighting. Accidents and incidents are record, and accident records are well maintained. Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 3 3 X Sundial House DS0000013806.V316502.R01.S.doc Version 5.2 Page 24 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. 1 Refer to Standard YA24 Good Practice Recommendations It is recommended that the registered person informs The Commission for Social Care Inspection in writing once the environmental issues relating to the damp wall and the replacement of individual carpets have been acted upon. 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