Care Home: Shenehom

What the care home does well Feedback from the expert-by-experience and findings from this inspection indicate that the service is run in the best interests of the people who use the service and that they are at the forefront of any planning and decisions made. The atmosphere is relaxed and comfortable, and we observed positive interactions between the people who use the service and the staff. What has improved since the last inspection? At the previous inspection there had been seven areas where the service had to improve. The service has taken action on all of these areas, which represents a positive response to the findings of the inspection and good developments to the service. In particular, good improvements had been made to the environment and the recruitment checks of staff. What the care home could do better: Areas where the home could be doing better are highlighted in the report and were discussed with the manager during the inspection. These include improvements to the risk management plans to ensure people who use the service are safe, and ensuring that food is managed safely at the service through staff training and appropriate labelling of opened food packets.ShenehomDS0000017393.V378049.R01.S.doc Version 5.3 Key inspection report CARE HOME ADULTS 18-65 Shenehom 31/32 Ranelagh Avenue Barnes London SW13 0BN Lead Inspector Louise Phillips Key Unannounced Inspection 7th October 2009 9:30am Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Shenehom Address 31/32 Ranelagh Avenue Barnes London SW13 0BN 020 8876 2199 020 8876 6336 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) RCHT/Shenehom Housing Association Caroline Monaghan-Fox Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 13 27th November 2007 Date of last inspection Brief Description of the Service: Shenehom provides accommodation and support for a maximum of thirteen people who experience enduring mental health issues. The service is provided by Richmond Upon Thames Churches Housing Trust (RUTCHT) who lease the property from the London Borough of Richmond. Staff do not provide personal care but if required in the short-term this can be provided by an external agency. Shenehom is a large Victorian style house, with a small parking area at the front of the home. It is in a quiet location, close to a park and local amenities, including Barnes train station. The home is situated in a pleasant residential area, close to local shops and public transport networks. Parks and open spaces are within easy reach and the River Thames is nearby. The current fees for the service are £726.13 per week. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. This inspection took place over one day and included a visit to the service by a Regulation Inspector, where we looked at records and relevant documentation held at the service. For part of the inspection we were joined by an ‘expert-by-experience’ (sometimes referred to as an ‘expert’ in the report), who has a specific role in talking to the people who use the service about their experience of living at the home. They speak to staff that work at the service and provide feedback to the manager. They also observe what is going on and the interactions between the staff and people who use the service. Following the inspection the expert compiled a report of their findings and this has been referred to in the report. What the service does well: What has improved since the last inspection? What they could do better: Areas where the home could be doing better are highlighted in the report and were discussed with the manager during the inspection. These include improvements to the risk management plans to ensure people who use the service are safe, and ensuring that food is managed safely at the service through staff training and appropriate labelling of opened food packets. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 6 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 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 Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who move to the service are involved in the assessment process and planning their move to the home to ensure it is the right place for them to live. EVIDENCE: Prior to people moving to the home, they are provided with information about the service and asked to complete an application form. Their social worker also completes a referral form and provides a current assessment of the needs of the person. We looked at the care files for two people who use the service. The files contain relevant information about the referral and assessment process, along with a wealth of information from relevant health and social care professionals involved with the person. These include a report from the psychiatrist, information from a recent Care Programme Approach meeting and a social work report, which include a history of risks that the person has presented to themselves and to other people. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 9 There are records to demonstrate that people who move to the home are interviewed, and also involved in planning their trial visits and subsequent move to the service. During the interview, the person is informed of the aims of Shenehom and the expectations of them when they move to the home. Following the meeting the team discusses how Shenehom can meet the needs of the person, and a formal offer of accommodation is then made. Admissions to the service are planned, taking place through day visits and overnight stays. People move to the service for an initial period of six weeks, and a support plan is developed for this period, which includes supporting the person to settle in, registering with a local doctor and getting familiar with the local area. The support plan also includes their being involved in chores and meetings at the service, as well as ensuring appropriate processes are in place for managing their medication and mental health needs. New residents are offered a trial period to ‘test drive’ the home, with this reviewed after a period. If this is successful the resident is then given a contract and licence agreement with RUTCHT, and they can also choose the colour that they wish their new bedroom to be decorated in. Records seen in peoples care files confirm that they are consulted about what colours they would like their bedroom to be decorated in. The expert-by-experience spoke to a number of people who use the service, where they said they “…could not imagine life anywhere else…” One person said that they had been “…passed on like a parcel to nine different homes before coming to Shenehom…” they added that since being at the service they had “…rediscovered happiness and self respect…” Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The needs of people who use the service are appropriately identified and relevant support plans in place. Improvements need to be made to the information in risk management plans to ensure that all risks to people who use the service are minimised and appropriately managed. EVIDENCE: The expert-by-experience spent time talking to some of the people who use the service about their experience of living at the home. The expert commented that “…residents feel that they are respected and their individual needs are met ‘more than adequately’…” For example, they are able to discuss any personal issues with their key worker (member of staff)…” Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 11 Also that, “…residents said that they are encouraged by staff to pursue personal development interests…” The expert-by experience reported that they felt the people who use the service have good control over their lives and are able to make personal decisions about their life. The said that they observed “…very good relaxed peer relationships amongst residents as well as staff…staff are well regarded and trusted by residents...” During the inspection we looked at the care files of two people who use the service. These were seen to be reviewed every six months or more frequently where needs have changed. People who use the service have signed these, which demonstrate that they were involved in identifying their needs. Each person has care and support plans that are individualised to their needs. The care plans identify needs in number of areas, such as the person developing positive relationships with staff and other people who use the service, support with their emotional and cognitive needs and independent living. The care plan around cultural needs states ‘none’, and further work is needed to ensure that all people’s cultural needs are identified and addressed. The support plans are more person centred and provide a summarised history of the person and information about things they like, and don’t like. They also detail people’s daily routines and particular areas of support such as assistance to the person to keep their room clean and their collecting their medication. A risk assessment is also in place for each person, that identifies areas in relation to risks to self, others and risk of neglect. The format for this is that each area has a tick box of sub-areas, for current and past areas of risk, such as for risk of neglect. The sub-areas are the person not eating or drinking properly or them wearing inappropriate clothing. Following on from this is the risk management plan which allows for the areas of risk to be put into a risk management plan. However, we found that in the two files we looked at not all the areas identified in the risk assessments had been put into a risk management plan. Also, where risk management plans had been written they were quite brief and did not always address the risk area. An example of this is that for one person their risk assessment identifies areas such as inappropriate anger, paranoid delusions, exploitation of others, impulsive acts and their being verbally threatening. However, the risk management plan is for verbal aggression only. Similarly, for another person, the risk assessment for ‘risk to others’ indicates incidences of violence, paranoid delusions, signs of anger, suspiciousness and them being a challenge to the service. The risk management plan for this area says ‘encourage to stay for meeting’ only. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 12 The risk assessment and risk management plan for people going on holiday was very detailed, including what to do if they became unwell, if the person got lost, sunburn and financial abuse. Risk assessments around people smoking at the service are kept in the ‘fire file’, and it is recommended these are added to the risk assessment held in each persons care file. The previous inspection required that risk management plans be put in place for all areas identified. Whilst this has been met in some areas, not everyone has a detailed risk management plan. Requirements have been made for the service to address this area to ensure that they are appropriately detailed. A record must also be in place to demonstrate that audits by the manager take place to ensure these are in place. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 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): This is what people staying in this care home experience: 11, 12, 13, 14, 15, 16 and 17 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are supported to pursue individual interests and activities both inside and outside the home. People say that they like living at the home, and there is a relaxed, warm atmosphere which is enhanced by the positive relationships between the staff and people who use the service. EVIDENCE: The manager demonstrated to us that the service has a ‘travel and outings budget’ that has allowed for people who use the service to go on two holidays in England this year. She said that this was used in 2008 for everyone to take a holiday abroad. People we spoke to about the holidays said they really appreciated that they are able to go on a holiday that is funded by the service. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 14 The expert-by-experience spent time talking to some of the people who use the service about their experience of living at the home. They were able to spend the majority of their time with the people who use this service, and below is a report of their findings: “…During our visit lunch time was a very communal effort with both staff and residents at ease at preparing lunch together; sharing jokes and laughter. This was good indication that it is the usual daily task and how things are done at Shenehom. Our lunch time conversation was relaxed, dominated by individual views on sports of which there were lots of contributions…” “…I felt welcomed and relaxed and everyone was happy to talk to me. Discussion flowed into topical issues and personal experiences and I was really touched by residents asking me about myself and where I originated from. I was very impressed by individual knowledge on global issues, one resident who was very educated about the people and politics of South America…” “…They are able to arrange to go out on social visits and enjoy individual leisure activities…” “…Another resident said that they like going out and often do so accompanied by a member of staff. When asked how they felt about being accompanied, they confidently responded that they understand that it is difficult for them to go out on their own and sees being accompanied as “staff supporting me to enjoy one of the things I like doing”. The activities that people get involved in are varied around their individual commitments, such as where one person does voluntary work whilst another goes to college. However, there is a structured programme where people who use the service get involved in doing household chores, which are divided up during the house meeting each morning. People were observed going about their daily routines, such as doing their laundry, and one person went out to the local shops to purchase the daily newspapers for the service. On display in the hallway we observed a ‘cultural evening list’, where people who use the service choose a monthly theme night of eg. Greek, Chinese, Indian, where they make plans to celebrate the culture through a quiz, discussion, dancing, or food relevant to the particular culture. The expert-by-experience reported that people who use the service said that they like the in-house activities of music appreciation and bingo, but that they would like more board games. They said they would also like more outings at weekends, such as going to see a show. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 15 The expert also reported that: “…I understood from both staff and residents that often they would accompany individual residents to football matches in support of an individual’s team…some residents have very good contact and relationships with family and friends who often visit them…” And the expert suggested that the service could “…consider tapping into local support organisations to explore more creative activities...” When we summarized the inspection to the manager at the end of the inspection she said that the service is currently exploring other social support facilities such as the MIND ‘buddy’ scheme to encourage people with no extended family and friends to develop other social relationships. The manager said that the service is looking having a training budget for people who use the service to do short courses in areas such as health and safety or equality and diversity, so that they can develop their skills and knowledge in these areas. When we looked at the food provided by the service, we observed a variety of foods that were fresh, frozen and dried. On entering the kitchen a large tray of fruit was available for people to help themselves to, as well as a lot of fresh vegetables to cook. The menu planned for the week was on display in the kitchen. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported appropriately with meeting their health and social care needs. EVIDENCE: People who use the service are independent in attending to their personal care needs. The expert-by-experience said that they observed that people who use the service take pride in their appearance. The manager told us that each person who uses the service is given a clothing allowance of £300 per year, and this was confirmed in the budget report for the service. The care files holds records of all healthcare appointments that people attend, and care plans also detail the level of support that people want regarding their going to see their GP. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 17 Regular reviews of peoples care takes place with the involvement of the Community Mental Health Team (CMHT) and the person. The in-house care plans are reviewed six monthly, or more frequently where the persons needs change. Where any person who uses the service has diabetes, a care plan is in place to manage this. However, this was seen to be quite brief and needing to provide more details how this is being managed, the support being given and areas that need to be monitored. A number of the people at the service manage their own medication, and the manager described that this is on different levels, depending on the person. This means that the person might administer their medication in the presence of staff, or they are involved in collecting their prescription and medication. This is detailed in the persons medication profile, which also lists the medicines the person takes and any allergies they might have. People who receive depot (injection) medication have this administered by a Community Psychiatric Nurse (CPN). We looked at the medication held for two people who use the service. This is appropriately stored and the information on the Medication Administration Record (MAR) corresponded in most cases with that on the medication. One discrepancy we did find was where for one person their Procyclidine 5mg medication label on the bottle said it was to be administered twice a day, which is what the medication profile stated. However, on the MAR it said this was to be given as a PRN (as required) medication. This was pointed out to the manager at the time of the inspection. Since the last inspection the service has introduced weekly audit to check the medication held at the service. This is currently in a basic recording format, with just the date and initials of the manager, where it is recommended that a document is developed for this audit, to record what is actually looked at, eg. labels, MAR chart, dates, returns, discrepancies found and actions taken to address these. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service feel confident to raise any issues and to make a formal complaint should the need should arise. The home manages any safeguarding issues appropriately. EVIDENCE: The home has a satisfactory complaints procedure and format for the logging of complaints. Since the last inspection the procedure has been updated to include details of the CQC, and up-to-date chairperson for the home. No complaints are recorded as having been received by the service this year. The expert-by-experience reported that the people she spoke to at the home are aware of the complaints procedure, but that they have never felt the need to make any formal complaints. People who use the service said that they are able to raise issues with their key worker, and that they are encouraged to be very open during the house meetings. However, they were not aware of the CQC and they should be provided with information about the role and functions of the Commission, should they feel the need to contact us. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 19 The home has demonstrated that it appropriately reports any safeguarding issues to the relevant local authority to investigate. The training records indicate that staff have received training in safeguarding vulnerable adults, and that this is planned to be updated in the near future People who spoke to the expert-by-experience said that they feel safe and secure at Shenehom, though said that sometimes they are concerned where someone might “…kick off…”, or where “…things get a bit hairy…”. Requirements have been made under the ‘Individual Needs and Choices’ part of this report to ensure that risks to people are managed and people are safe living at the service. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements to the environment have been made in the best interests of the people who use the service, to make a more homely, modern and comfortable home for them to live. EVIDENCE: Since the last inspection of the home a number of improvements have been made to the environment for the benefit of the people who live there. Some of these improvements include the external re-decoration of the home and new modern bathrooms throughout the service. A room that was previously used as a meeting room has now been converted into a relaxation/ entertainment room, and is homely and comfortable. The manager said that there is also an ongoing programme of redecoration of people’s bedrooms that has been taking place. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 21 The expert-by-experience reported that people who use the service had commented about their “…lovely comfortable rooms with great views…” The manager told us about plans for re-designing the back garden, and the installation of a summer house. We observed the manager discussing with a member of staff that the plans for this might need to be adapted following feedback from a person who uses the service. The home is decorated with various works of art, some of which had been produced by a person who uses the service. They are of a high standard and really enhance the environment. The observations of the expert-by-experience about the environment are: “…The internal ‘feel’ of the property is that of a relaxed ‘family’ home that smells fresh and clean. It has several large lounge rooms and these have plenty of natural lighting; there is a leisure space (with TV, sofas and an electric keyboard) and a smoking room. The walls are lined with pieces of skilful and intelligent art work…” “…The large kitchen diner seems to be the most popular room with residents and staff…”. “…There was a vase of fresh flowers on the large kitchen table…adding to the homely feeling…” The people who use the service and the staff are involved in maintaining the cleanliness of the home on a rota basis, with the support of a cleaner for five hours a week. The home was observed to be generally clean throughout, though the carpeted stairs and hallways needed to be hoovered. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff undertake training relevant for their role. Appropriate recruitment checks minimise risks to people who use the service. EVIDENCE: The expert-by-experience spoke with a number of people who use and work at the service. They reported that they believe the staff are sincerely committed to caring for the people who use the service, and that they have a very good understanding of responding to individual needs. The staff complement at the service is for seven staff to be employed, including the two deputy managers. At the time of inspection the manager told us that they are in the process of recruiting for one project worker and relief staff. The recruitment files for two staff were looked at and seen to contain the required information about recruitment checks, such as two references and Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 23 copy of proof of identification. They also contain information regarding the staff member’s application, a copy of the records of their interview and correspondence relating to the offer of their job. We saw evidence to confirm that new staff receive an induction to working at the home, and also that they are reviewed for a period of probation. Staff spoke about the good training budget at the service, and that they are supported to do training to progress their professional development. This includes training in counselling, psychotherapy and National Vocational Qualifications (NVQ) that are funded by the service. A staff training and development plan is in place that includes staff doing training in mandatory areas such as fire and first aid, plus plans for staff to do diabetes and team building training. This records when training has been done and the date that this is next due. There were no records to indicate the last time staff had done Basic Food Hygiene training, and the manager said that she had not done this for about eleven years. It is required that all staff undertake this training, and that this is updated at least every three years. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is competent and understands the responsibilities of their role. Feedback from the expert-by-experience and findings from this inspection indicate that the service is run in the best interests of the people who use the service and that they are at the forefront of any planning and decisions made. Appropriate health and safety checks are carried out to minimise risks to the people who use the service. EVIDENCE: Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 25 Since the last inspection the manager has been registered with the Commission to be the Registered Manager for Shenehom. The manager says that she feels well supported by the Trustees of the home and she spoke positively about the good teamwork at the service. Staff spoke positively about the home and their work, and how they feel well supported by the manager. They also say that they are supported to keep upto-date in their work. The service carries out an annual review of the service each November which involves sending surveys to the people who use the service to gain feedback about the home. The results of these are then discussed with the Trustees and people who use the service, and an action plan drawn up to ensure the feedback is used to develop the service. The weekly community meeting and daily house meetings also enable people to feedback about the service, and they can also provide anonymous feedback in the two ‘suggestion boxes’ that we saw in prominent areas at the service. The service holds relevant certificates and records to indicate that appropriate checks are carried out areas of health and safety, including the fire system, electrical testing and gas safety. However, we observed that in the kitchen cupboards and fridge there were a number of opened food jars and packets that were unlabelled. These must all be labelled with the date of opening and date to be disposed of, according to the manufacturer’s instructions on the label. A health and safety risk assessment has also recently been carried out at the service regarding hazards in the environment and service specific issues, such as risks of slips, violence and aggression, stress and hazardous products. All accidents and incidents are recorded, with good details about each incident, including statements from witnesses where necessary. The service notifies the CQC appropriately about any incidents that occur. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 26 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 X 2 4 3 4 4 X 5 X 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 X 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 4 14 4 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 4 4 X X 2 X Version 5.3 Page 27 Shenehom DS0000017393.V378049.R01.S.doc Are there any outstanding requirements from the last inspection? NO 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 YA9 Regulation 13(4) Requirement Each person must have a detailed risk management plan that addresses all the areas identified in the risk assessment. The Registered Persons must ensure that they audit the care files regularly to ensure that detailed risk assessments and risk management plans are in place for each person who uses the service. These audits must be recorded. All staff must complete up-todate basic food hygiene training, and this must be updated at least every three years. Timescale for action 30/11/09 2. YA9 13(4) 30/11/09 3. YA35 13(4) 31/12/09 4. YA42 13(4) Opened food jars and packets 31/10/09 must all be labelled with the date of opening and date to be disposed of, according to the manufacturers instructions on the label. Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 28 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. 2. Refer to Standard YA7 YA9 Good Practice Recommendations The cultural needs of people should be fully detailed in their care plan. It is recommended that the risk assessment for people smoking at the service is added to the individual risk assessments in the care files. It is recommended that a document is developed to record the processes of the weekly medication audit checks. 3. YA20 Shenehom DS0000017393.V378049.R01.S.doc Version 5.3 Page 29 Care Quality Commission London Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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