Inspection on 31/07/07 for Old Shenfield Place

This inspection was carried out on 31st July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Old Shenfield Place 02/12/09

Old Shenfield Place 03/12/08

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Old Shenfield Place 2 Hall Lane Shenfield Essex CM15 9AB Lead Inspector Sarah Buckle Unannounced Inspection 31st July 2007 10:00 X10015.doc Version 1.40 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 Old Shenfield Place DS0000069547.V343440.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 Older People. 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. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Shenfield Place Address 2 Hall Lane Shenfield Essex CM15 9AB 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) 01277 220636 01277 223638 Mr Rajan Dhirjal Madlani Mrs Valerie Carmella Edwards Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First inspection since new registration. Brief Description of the Service: Old Shenfield Place is an attractive 17th century building, which has been renovated and refurbished to provide comfortable accommodation for 31 older people. There is a choice of three lounges, a dining room and a visitor’s room. 21 bedrooms are single and five are double. The majority of rooms have an ensuite hand washing and WC facility. A separate hairdressing room is available. The gardens are well maintained and accessible to residents. To the front of the house there is limited space for car parking. Old Shenfield Place is situated close to local shops, bus and train services. The home has use of a mini bus for outings. The current weekly fees are from £580.00 for a twin room en suite, from £650.00 for a single room en suite, from £670.00 for a bed-sit and £825.00 for a twin room en suite single occupancy. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was undertaken as part of the key inspection of Old Shenfield Place. Six and a half hours were spent at the home over one day. During this time a number of residents and staff were spoken with. The manager was also spoken with. A tour of the premises was undertaken and records, policies and procedures were sampled. Care files for three residents were case tracked. Discussion of the inspection findings took place with the manager at the end of the site visit. Completed questionnaires were received from nine residents and seven relatives/representatives and the information contained within these will be reflected within the body of the report. What the service does well: What has improved since the last inspection? This is not applicable as this is the first key inspection since registration. Old Shenfield Place DS0000069547.V343440.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. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. EVIDENCE: The care plans of three residents were examined in relation to initial assessment. The initial assessment document lists possible support areas and then provides a tick chart ranging from able to unable in relation to this. There is space underneath the tick chart for comments. The assessment covers areas such as mobility, continence, communication, pain, sleep patterns, orientation, sociability, dressing, breathing, bathing, challenging behaviour, oral hygiene, foot care, personal safety, pressure ulcers, hobbies etc. The resident’s personal details, preferred name, next of kin and any medical history are also included in the assessment. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 9 The manager at the home stated that the admission procedure usually starts with a relative phoning the home for information. The manager speaks with them and explains the admission criteria. If this is compatible with the needs of the relative the manager goes to meet the prospective resident and family or representative and completes the initial assessment. A brochure, statement of purpose and service user guide is given to the family. She stated that there is a one-month trial period for prospective residents, but that this could be extended if need be. The manager also stated that the prospective resident could come and visit the home, sit and talk to the other residents and staff and have lunch. She said that this is helpful as it gives her increased awareness of the person regarding their assessment. There is currently one resident within the home on respite care, and an initial assessment had been completed for this person in the same way as for the permanent residents. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each individual within the home has a care plan, however, these do not consistently contain enough specific information. The health needs of residents are monitored and appropriate action taken as required. The medication procedures within the home are well managed. EVIDENCE: Three care plans were sampled during the inspection. The first of these was completed in some detail and was personal to the resident concerned. There was detailed information provided from their family regarding personal history. Care plans were in place regarding breathing, communicating, personality, eating and drinking, eliminating, personal hygiene and sleeping. There was a risk assessment in place regarding the self-administration of medications. In the residents pre-admission assessment it stated that they had a history of falling, however, although there was a risk assessment in place within the care Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 11 plan this did not detail how this might be managed to minimise the risk. The care plan regarding mobility stated that they have a walking frame indoors, but that owing to poor vision rely on others to keep them safe when out of doors. It was positive to note that the care plan supported the residents independence i.e. for personal hygiene the plan stated “When in the right frame of mind to get up in the morning (the resident) now requires assistance, prompting to wash where (they) can reach and help where (they) can’t, this also applies when dressing as we wish for (the resident) to keep as much of (their) independence as possible”. However, there was no care plan in place regarding the residents frame of mind, and how they might present if they did not feel like getting up in the morning, or what steps to take to encourage this. The resident also had district nurse intervention for pressure sores and had a pro pad mattress in place, however there was no care plan in place regarding how to manage this, and no risk assessment in place regarding pressure ulcers and their management. A second care plan examined had no risk assessments in place. The resident concerned suffered with anxiety and had a psychiatric history; however there was no support plans in place in relation to these areas. The review and updating of care plans varied considerably. One had been reviewed and another had no evidence of this. There was clear evidence of GP and district nurse intervention when required and of chiropodist visits. The home uses the Boots monitored dosage system (MDS) of medication. The medication trolley was stored in a basement floor area and was attached to the wall. There was no evidence to suggest that the temperature of the area was taken on a daily basis to ensure that the medication was stored appropriately. The medication administration records (MAR) were examined. It was positive to note that all staff members who administer medication had provided a sample signature and that there was a photograph of each resident was attached to the front of their MAR sheet. It was also positive to note that some residents within the home manage their own medication and that this is risk assessed. There were no omissions noted on the MAR sheets, however, some residents were refusing medication and there was no clear outcome regarding what action the home had taken in relation to this. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 12 Handwritten medication profiles were not countersigned as a safety precaution and there was no evidence of ‘as and when’ medication protocols being in place. It was positive to note that changes in medication need were contained within the MAR file. Controlled drugs were stored appropriately. There was a file to log these as they arrived at the home and a register kept. All signings were witnessed and the amount of drugs available tallied with the record. Observations of the residents within the home during the course of the site visit demonstrated that they were treated with respect for their dignity. Seven of the residents surveys completed and returned to the Commission stated that they always receive the care and support they need, one stated that they usually do and one that they sometimes do. Eight of the surveys stated that the staff listen and act on what they say and one survey said that they do not. Seven surveys stated that the staff members are always available when they need them; one stated that they usually are and one said that they are sometimes available. Five of the relative surveys completed stated that Old Shenfield Place always supports people to live the life they chose, one comment stated, “Very much so, wherever possible”, and two stated that it usually does. One relative stated that the home “Caters for all the resident’s needs and ensures that they are well looked after”. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Old Shenfield Place are involved in appropriate daytime activities and are involved in choosing these. EVIDENCE: During the site visit to Old Shenfield Place, an activities therapist was observed within the lounge talking in a meaningful way on a one to one basis with residents. The activities therapist was familiar with the residents and supportive of them and they clearly enjoyed having a lengthy chat with her. The therapist also painted some of the residents nails as she spent time with them. The activities therapist visits the home twice each week for three hours each time. She said that she spends time with different residents on each occasion that she visits. She also stated that she sometimes sits with a group of residents and prompts discussion amongst them. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 14 The manager stated that there is a pat dog that comes into the home every fortnight and a general quiz in the main lounge each Thursday. A visiting exercise person comes into the home once each week on a Wednesday and there are entertainers on a fortnightly basis. There is a hairdresser who visits the home weekly and church services. The garden is accessible and it was positive to note that some residents had chosen to go and sit outside. The manager said that people who use wheelchairs are able to access the garden. There was evidence to demonstrate that the residents are taken out on trips into the community. There had recently been a visit to Hyde Hall Gardens and a garden party at the home was in the process of being organised. The activities therapist holds residents meetings where people can discuss the things they like to do. During the site visit some residents were observed knitting or reading the papers. Other residents were chatting amongst themselves. In the afternoon some staff members played a game of ball with some residents and George came in to do exercises with them. One relative stated, “The care home knows each resident well. The varied social programme at Old Shenfield Place is excellent”, a second relative stated, “…All staff are always cheerful and enjoy social activities with the residents i.e. music afternoons with an entertainer”. The dining area within the home was pleasant and well laid. Residents were offered a choice of menu a day in advance. There was a good selection available including a vegetarian option a main choice and an alternative choice. Nutrition records are kept daily, however the amount eaten is not recorded and there were no weight charts contained within care plans. Two resident surveys stated that they always like the meals at the home; four stated that they usually did and three said that they sometimes like the meals. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an open culture, which allows residents and their relatives/representatives to express their views and any concerns. There is clear understanding within the home of procedures for Safeguarding Adults. EVIDENCE: The manager stated that a copy of the complaints procedure is sent out to all prospective residents and their family/representative. The complaints log was examined and there had been no complaints about Old Shenfield Place since it’s new registration. Seven of the residents surveys completed stated that they always know who to speak to if they are not happy, one said they usually do and one that they sometimes do. All nine of the surveys said that they know how to make a complaint. All seven of the relative surveys received stated that they know how to make a complaint about the care provided by the home if they need to. Three relatives stated that the home always responds appropriately to any concerns raised. One relative stated that this was not applicable. Two people did not complete this section, however they did add comments. The first comment stated, “I complained once, because my (relatives) medication had run out. I wrote to (the then provider), he answered the letter to say that Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 16 there would be an enquiry, and let me know in a months time, but he didn’t write back”, the second stated, “The care of my relative has never given cause for concern”. The final survey said that the home usually responds appropriately to any concerns raised. All of the staff members bar one at the home had completed training in abuse awareness to ensure knowledge of safeguarding vulnerable adults. Two members of staff were spoken with and both were clear on the procedure to be followed if they suspected an incidence of abuse. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people that live there. The home is clean and tidy. EVIDENCE: A tour of the premises was undertaken on the day of the site visit to Old Shenfield Place. The environment was well maintained, however, there were some areas requiring refurbishment, for example, one shower curtain was stained and torn and in need of replacement and two areas of carpet were also stained, particularly the area leading in to the dining room. These were discussed with the manager during feedback. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 18 The lounge main was comfortable and homely and the dining room well presented. A number of residents were sitting in the reception lounge and this was also a comfortable and homely area. All of the bedrooms seen were clean, tidy and personalised with photographs and artefacts belonging to the residents. All nine of the resident surveys completed stated that the home is always fresh and clean. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are consistently enough staff available within the home to meet the needs of the people who live there. Recruitment is robust and training is given a high priority and is well managed. EVIDENCE: The staffing levels within the home are maintained at a good level. They are usually, one senior carer and four care staff in the morning, one senior carer and three care staff in the afternoon/evening and one senior carer and two care staff awake all night. There is limited use of agency staff within the home. Staff recruitment files were examined and these contained all of the specified information, including application form, employment history, proof of identity, CRB checks and POVAFirst checks. There was also evidence of induction in line with the common induction standards, and of a training plan. There is a full-time training manager employed at the home. The training matrix was examined and this demonstrated that training is a high priority and is comprehensive and on going. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is competent to run the home. EVIDENCE: There is a new manager in post at Old Shenfield Place and since the site visit to this service the Commission has received their application for registration as manager. The manager was previously a deputy manager for three years and therefore has experience of management. She is registered to undertake both the NVQ4 and the Registered Mangers Award. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 21 Quality assurance information has been collected by the home, however this has not yet been collated into a report and forwarded to the Commission. The training manager carries out regulation 26 visits on a monthly basis. Residents monies were examined and the receipted amounts tallied with the money available. Supervision has been undertaken with some staff members however a comprehensive system is not yet in place. Health and safety certificates were examined and these were current. There are regular fire checks carried out within the home and these are recorded. The last fire drill was in March 2007. Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 Requirement The registered person must ensure that a comprehensive care plan is devised in consultation with the resident concerned or there representative and that this is centred on their personal support needs. The care plan must be kept under review and changed in consultation whenever there is a change in need. Timescale for action 31/10/07 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 OP9 Good Practice Recommendations The home would benefit from ensuring the temperature of the medication storage area is recorded on a daily basis to ensure it is kept within the specified temperature. It is good practice to counter sign all handwritten medication profiles to reduce the risk of error in the Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 24 recording. Medication protocols should be put in place for all ‘as and when’ medication. The home would benefit from some refurbishment, particularly to areas of carpet that are stained or worn. A report detailing the findings from the quality assurance audit should be forwarded to the Commission annually, outlining any plans for improving the service. The staff team would benefit from a consistent supervision system in line with the National Minimum Standards. 2. 3. 4. OP19 OP33 OP36 Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Old Shenfield Place DS0000069547.V343440.R01.S.doc Version 5.2 Page 26 - 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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