Inspection on 09/01/06 for Sundial House

This inspection was carried out on 9th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 13/07/05

Sundial House 17/11/04

Sundial House 02/07/04

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Insight - Eastchurch

Southfields

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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 Peter Benthom Unannounced Inspection 10:00 9th and 12 January 2006 th Sundial House DS0000013806.V252690.R02.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 Sundial House DS0000013806.V252690.R02.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. Sundial House DS0000013806.V252690.R02.S.doc Version 5.0 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.V252690.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One (1) service user in the category LD may have a mental disorder. The age/age range of the persons to be accommodated will be: 30 65 Years 13th July 2005 Date of last inspection 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.V252690.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection to be undertaken in the Commission for Social Care Inspection year April 5 to March 2006. The inspection took place over two days and was carried out by one regulation inspector. The process of inspection included obtaining feedback from staff and the sampling of written documentation including service users care plans. Service users were not consulted as part of the process on this occasion. Part of the focus for this inspection was a matter referred under the local authority procedures for safeguarding adults. This matter has now been satisfactorily resolved and concluded. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sundial House DS0000013806.V252690.R02.S.doc Version 5.0 Page 6 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.V252690.R02.S.doc Version 5.0 Page 7 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): 1,2 3, 4 and 5 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: A Statement of Purpose was in place and contained all the required information. The Service User Guide was available in written and symbol form making the guide more accessible to service users. An 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. Sundial House DS0000013806.V252690.R02.S.doc Version 5.0 Page 8 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): 6, 7, 8, 9 and 10 Individual care plans were in place for service users and the systems for Service User consultation provided evidence of service users views were accurately reflected. EVIDENCE: Each service user had been involved in the development of their care plans. These care plans clearly identified the service users wishes and expectations and full information about service users likes and dislikes. Evidence was found that service users are involved in day-to-day participation in the running of the home and are given the opportunity to be involved in activities. Staff enabled service users to take responsible risks - wherever possible – and this was documented in each individual care plan. Sundial House DS0000013806.V252690.R02.S.doc Version 5.0 Page 9 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, 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: Service users are encouraged and supported in the use of community amenities and in maintaining relationships with friends and families. A different variety of community-based activities are available. Service users attend various day centre and adult education activities. The activities programme was individualised in accordance with service users wishes and made appropriate use of college courses, community amenities and facilities. Sundial House DS0000013806.V252690.R02.S.doc Version 5.0 Page 10 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): 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. The personal care and support needs of service users were being met. EVIDENCE: The home has a key worker 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. Privacy was promoted in the home and all bathrooms and toilets were fitted with locks for privacy. Adequate arrangements were in place to meet the health care needs of service users. 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 organisation has a policy governing all administration of medication and the medication is stored securely in a locked cabinet in the office. Sundial House DS0000013806.V252690.R02.S.doc Version 5.0 Page 11 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 and 23 There was evidence that the service users were consulted regarding the operation of the home and to obtain their views regarding the service provided. A recent incident was referred as required under the local authority safeguarding adults’ procedures to ensure the safety and protection of those involved. EVIDENCE: As required, the staff referred a matter for consideration and investigation under the local authority (i.e. Surrey County Council) procedures for safeguarding adults. This matter has now been satisfactorily resolved and concluded. Two of the staff on duty were reported to have completed training in respect of safeguarding adults. A recommendation has been made that all staff receive regular updates of such training to promote the safety and well being of service users. Sundial House DS0000013806.V252690.R02.S.doc Version 5.0 Page 12 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): N/a These standards were not assessed at his inspection. EVIDENCE: These standards were not assessed at his inspection. Sundial House DS0000013806.V252690.R02.S.doc Version 5.0 Page 13 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, 33, 34, 35 and 36 A training programme was in place for staff, which included National Vocational Qualifications. EVIDENCE: There is commitment to National Vocational Qualifications and other training opportunities for staff. Whilst this was in place at the last inspection, it was good to note that even more members of the staff team have been afforded appropriate support and training. (Please also refer to the comments under the previous standard regarding safeguarding adults training for all staff). Sundial House DS0000013806.V252690.R02.S.doc Version 5.0 Page 14 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): 37, 38, 39, 40, 41, 42 and 43 The standard was not fully assessed at the time of the inspection. However, it was noted that the provider must ensure that all events affecting the well being of service users be notified to the Commission without delay. EVIDENCE: This standard was not fully assessed and will form part of the focus for the next inspection. It was noted that the matter referred to under standard 23 had not been reported to the Commission by the registered person, although it had been reported to the local authority as required. The provider stated that the local authority informed the provider that they had already informed the Commission. A requirement has been made in respect of this matter. Sundial House DS0000013806.V252690.R02.S.doc Version 5.0 Page 15 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 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 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 X X X X X 2 X DS0000013806.V252690.R02.S.doc Version 5.0 Page 16 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 YA23 Regulation 37(1)(e) Requirement It is required that all notifiable events that effect the well being of any service user be reported to the Commission without delay. Timescale for action 31/01/06 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 23 Good Practice Recommendations That all staff receive regular updates in relation safeguarding adults training. 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