Care Home: Shepherds Corner

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What the care home does well The home has a settled staff group and has the numbers and skill mix of staff sufficient to meet residents` needs. Residents were observed to be treated with respect by staff and to have their privacy and dignity respected. Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them. The home`s recruitment procedures protect the residents through vigorous staff vetting. What has improved since the last inspection? Residents` care plans are being drawn up with the involvement of the resident together with family, friends and/or advocate as appropriate. The administration/non-administration of all medication are being recorded accurately for the health and safety of residents. Progress has been made with regards to the frequency of staff supervision. What the care home could do better: All staff must be up to date with their mandatory training to ensure residents continue to receive care as is reasonable to meet their needs. CARE HOME ADULTS 18-65 Shepherds Corner Shepherds Corner 132-134 St James Road Croydon Surrey CR0 2UY Lead Inspector Mohammad Peerbux Key Unannounced Inspection 22nd September 2008 08:50 Shepherds Corner DS0000063517.V372651.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 Shepherds Corner DS0000063517.V372651.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. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shepherds Corner Address Shepherds Corner 132-134 St James Road Croydon Surrey CR0 2UY 020 8689 5709 020 8683 2263 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) Glen Care Group Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD (of the following age range: 18 years to 65 years) The maximum number of service users who can be accommodated is: 13 19th August 2008 2. Date of last inspection Brief Description of the Service: Shepherds Corner is an establishment in the heart of West Croydon and provides accommodation for 13 people with varying degrees of learning disability. Each resident has his or her own bedroom, situated on either the ground or first floor of the building. As there is no lift, the home is ideally suited to ambulant residents, particularly as its domestic size does not lend itself to wheelchair users. The home is well situated to allow residents to engage within the local community. The transport links are excellent and the main shopping centre of Croydon is within reasonable walking distance. The home provides an in-house daycare programme, which is used by the majority of the current residents. The weekly fees start from £900 and are then tailored to meet the individuals’ requirements and needs. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. he quality rating for this service is two stars. This means the people who use this service experience good quality outcomes. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2008/2009. In writing the report, consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. The acting manager and shift leader facilitated this inspection. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. A tour of the building was also carried out. All registered adult services are now required to fill in an annual quality assurance assessment (AQAA).It is a self-assessment that the provider (owner) must complete every year. The completed assessment is used to show how well the service is delivering good outcomes for the people using it. Some information from this AQAA is included in the report. What the service does well: What has improved since the last inspection? Residents’ care plans are being drawn up with the involvement of the resident together with family, friends and/or advocate as appropriate. The administration/non-administration of all medication are being recorded accurately for the health and safety of residents. Progress has been made with regards to the frequency of staff supervision. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 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 Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 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 home undertakes an assessment of the healthcare needs of residents prior to their admission to ensure that their needs would be met. EVIDENCE: Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Prospective residents are invited to visit the home and to stay overnight. Since the last inspection there has not been any new admission to the home. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 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. 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. Generally, residents’ care plans include detailed information about their needs and personal goals. This helps staff to know the residents’ needs and how to meet them. EVIDENCE: The key principle of the home is that people using the service are in control of their lives and they direct the service. Staff are fully committed in supporting individuals to lead purposeful and fulfilling lives as independently as possible. People using the service make their own informed decisions as far as possible and have the right to take risks in their daily lives. All residents have an individual plan which they are working towards. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 10 Maintaining independence and enabling residents to make their own decisions about how they wish to live is a key objective of the home. The home recognises the right of individuals to take control of their lives and to make their own decisions and choices. There is some evidence that individuals are involved in decision making about the home, such as day to day living and social activities. All residents are also supported and encouraged to have an active role in the community. Each care plan includes a risk assessment, which is reviewed regularly. The management of risk is positive in addressing safety issues while aiming for improved outcomes for people. Where there are limitations, the decisions have been made with the agreement of the person or their representative. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 11 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): 12,13,15,16 and 17 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. Residents are being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: The service has a strong commitment to enabling residents to develop or maintain their skills, including social, emotional, communication, and independent living skills. Individuals are supported to identify their goals, and work to achieve them. Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 12 and capabilities. The home is in the process of recruiting an activity coordinator. People who use the service have the opportunity to develop and maintain important personal and family relationships. The staff practices promote individual rights and choice, but also consider the protection of individuals in supporting them to make informed choices. The home has an ‘open’ visitor’s policy and simply recommends that visitor’s telephone to say they are coming. The home tries to be flexible and attempts to provide a service that is as individual as possible, using its resources effectively. The service actively supports people to be independent and involved in all areas of daily living in the home. The acting manager stated that the residents are involved in the planning of the menu. Residents are offered a choice of suitable menus, which meet their dietary needs, and which respect their individual preferences. Presently the menu is being reviewed to give residents more choice. There is also plan to recruit a cook. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 13 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 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. Overall the arrangement for health care needs of the residents is good and they receive personal support in the way they prefer. EVIDENCE: People receive personal and healthcare support using a person centred approach. Personal healthcare needs including specialist health requirements are clearly recorded in each person centred plan or health action plan. They give a comprehensive overview of their health needs and act as an indicator of change in health requirements. The home has access to a wide range of health professionals to ensure that all needs are being met. This includes services from dieticians, physios, speech and language etc. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 14 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 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. Complaints are generally managed well, which should ensure that residents’ and relatives’ concerns are listened to. EVIDENCE: The home has a complaints procedure that is clearly written and easy to understand. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. Refresher training in Safeguarding Adults is being arranged for staff working at the home. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 15 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 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. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the residents’ health and emotional well being. EVIDENCE: The home provides a physical environment that is appropriate to the specific needs of the people who live there. The well-maintained environment provides specialist aids and equipment to meet their needs. Some are the flooring are due to be replaced. The provider has also identified where improvements are needed and these are being addressed. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 16 The home is kept very clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 17 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 People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has the numbers and skill mix of staff sufficient to meet residents’ needs and ensure their safety. This ensures that staff fulfil the aims of the home and meet the changing needs of residents. EVIDENCE: There are consistently enough staff available to meet the needs of the people using the service. The staffing structure is based around delivering outcomes for the people using the service. There is plan to recruit more staff and the shift pattern is also being reviewed. The home has a good recruitment procedure that clearly defines the process to be followed. One newly recruited staff file was examined and found to contain the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 18 The home recognises the importance of training, and tries to deliver a programme that meets any statutory requirements and the National Minimum Standards. The acting manager is aware that there are some gaps in the training programme however these are being addressed and further training sessions have been arranged. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 19 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): 37,39 and 42 People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home management generally provides guidance and direction to staff to ensure residents receive consistent quality care. There is a quality monitoring system and this ensures the home is run in a way that is in the best interests of the residents. EVIDENCE: Since the last key inspection the previous manager is no longer in post. A new acting manager has been recruited. She is qualified and has the necessary experience to run the home. She is aware of and works to the basic processes set out in the NMS. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 20 Effective quality assurance and quality monitoring systems, based on seeking the views of residents, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. The AQAA was received on time and contains clear and relevant information. The AQAA lets us know about changes the home has made and where they still need to make improvements. Records with regards to health and safety are of a good standard and are routinely completed. Certificates relating to health and safety were up to date servicing certificates. Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 21 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 3 3 X 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 X 28 X 29 X 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 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 22 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 YA35 Regulation 18(1) Requirement Timescale for action 22/12/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Shepherds Corner DS0000063517.V372651.R01.S.doc Version 5.2 Page 24 - 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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