Inspection on 17/08/05 for Shadon House

This inspection was carried out on 17th August 2005.

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

Shadon House 26/01/09

Shadon House 12/12/07

Shadon House 30/08/06

Shadon House 24/01/06

Similar services:

The Highlands

Blenheim House

1 Lanark Close

Beaconsfield Court Care Home

Ann Charlton Lodge

The Gardens Care Home

Westmoor View Nursing Home

Ashlea Mews Residential Home

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

CARE HOMES FOR OLDER PEOPLE Shadon House Northumberland Place Barley Mow Birtley DH3 2AP Lead Inspector Nic Shaw Announced 17 & 26 August 2005 at 10:00am th th 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 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. Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Shadon House Address Northumberland Place Barley Mow Birtley DH3 2AP 0191 410 2816 0191 411 1209 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Gateshead Council Mr Keith Andrew Hogan Care Home only 23 Category(ies) of DE Dementia (23) registration, with number PD Physical disability (5) of places MD Mental Disorder (5) DE(E) Dementia - over 65 (23) PD(E) Physical dis - over 65 (5) MD(E) Mental Disorder -over 65 (5) Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23rd January 2004 Brief Description of the Service: Shadon House is is a Local Authority owned home which can provide personal care for up to 23 people who have dementia, 5 of whom may have mental health needs, and 5 of whom may have a physical disability. The home provides accommodation for 11 permanent service users whilst 12 of the beds are available to people who wish to stay in the home for a short break. Nursing Care cannot be provided but District Nursing services can be accessed as required. Accommodation comprises of 23 single bedrooms on the ground floor level, all with ensuite facilities and located along three corridors. Assisted bathing and shower facilities are located along two of the corridors and in addition to the three communal lounges and spacious dining area service users have access to a multi-sensory room in which a range of equipment such as fibre optic lighting, soothing music and pleasant aromas are provided. There are two seperate hairdressing facilities, kitchen, laundry and a range of staff rooms, including a speep-in room , the latter being available on the first floor of the home. There is a a spacious enclosed garden, fullly accessible to service users, and seperate car parking facilities are available. Local shops, places of worship and other community facilities, including Dobbies garden centre are located a short distance form the home. Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This scheduled announced inspection was carried out over 2 days in August 2005. The home has been closed for some months now in order for extensive building work and re-furbishment to be carried to provide a specialist environment for people with dementia. This inspection was carried out prior to the home re-opening, which was arranged for Monday 29th August 2005. The inspection process involved meeting with all of the staff during a staff meeting, discussion with the manager and a tour of the premises including all communal areas and a sample of bedrooms. As there were no people living in the home at this time it was not possible to obtain their views or to examine care plans and this will be the focus of the next inspection. What the service does well: The Local Authority is committed to providing staff with a range of training. As well as NVQ training and training in relation to health and safety issues all of the staff have been provided with in-depth specialist training which will help them to meet the needs of people who have a dementia type illness. The staff and manager are clearly enthusiastic and motivated and when talking to them it was evident that they were very much looking forward to the home opening. The manager gives a clear sense of direction and has high standards and expectations and comments received from staff in relation to him included “his enthusiasm is passed on”, “he makes us feel important” and “everyone is treated as part of a team”. The environment has been adapted in order to meet the needs of people with dementia, including colour schemes which will help people to find their way around the home, clearly labelled WC’s and bathrooms and lights which automatically illuminate when a service user enters a WC. All bedrooms have en-suite facilities and will provide the service users with their own comfortable, safe personal area. The staff team have been selected from well over a hundred people who were interviewed. The interview process involved asking staff specific questions on dementia so that only those people with an understanding of the needs of people with this illness were selected. Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion and will be considered during the next inspection. EVIDENCE: Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion and will be considered during the next inspection. EVIDENCE: Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion and will be considered during the next inspection. EVIDENCE: Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 There are satisfactory procedures in place which will protect the service users from abuse. EVIDENCE: Discussion with the staff confirmed that, as part of the induction process, they have all received training in relation to the Local Authority Adult Protection Policy and Procedure. A copy of the policy and procedure is available in the home and this provides staff with clear information and guidance on action they should take if they have any concerns in this area. In order to further support the service users and their relatives if they have any concerns in relation to abuse the manager stated that the confidential helpline number of “Elder Abuse” will be prominently displayed on notice boards throughout the home. In addition to this the manager stated that it his intention to further raise awareness of this issue through meetings with service users and their relatives. Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,25 The environment will provide service users with a homely, comfortable place in which to live which is suitable to meeting their needs in relation to dementia whilst maximising their independence. EVIDENCE: Discussion with the manager and the “special projects manager”, whose responsibility it was to create a building suitable for people with dementia, concluded that much thought has been given to providing a specialist environment. The building has undergone major re-development to offer 23 bedrooms with en-suite facilities, three lounges, two hairdressing facilities and a spacious dining area. The decoration throughout the home has been chosen specifically to assist people with dementia. This includes grab rails and doors painted striking contrasting colours in order that they can easily been seen. Walls and floors are also in contrasting colours so that service users can easily distinguish between them. Lighting in WC’s is sensor controlled and automatically illuminates when this area is entered. A multi-sensory area has also been created which will provide service users with a relaxing, yet stimulating area in which to spend time. Assisted bathrooms and shower areas are clearly labelled, bright and airy. Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 13 The temperatures of the bath and shower water was tested at all outlets and in 3 instances was found to be in excess of the recommended 43 degrees centigrade and in one case was found to be as high as 52 degrees centigrade. The manager was advised that this matter must be addressed as a matter of urgency. In order to encourage relatives to bring their children to the home a “children’s corner” has been created in the dining room. Discussion with the manager concluded that the aim of providing this facility is to change the view that some people may have that it is not appropriate for children to visit their grandparents in a care home. Corridors have been named after streets in the area in order to give people a sense of local identity and seated areas, enhanced with aromatic objects such as soaps and reminiscence items, such as old newspapers, are located along these. Tasteful pictures of items such as “Pears Soap” have been placed along corridors outside of bathrooms to help service users find their way around the home. Particular attention has also been paid to the colour scheme with red used to donate areas of danger, blue for bathrooms and green for safe areas. There is a beautiful spacious garden area, with ramped access, which can be freely explored by the service users. On the day of the inspection a large quantity of lavender bushes were being planted in the border areas surrounding the garden. It was positive to note that prior to decorating the home resources were available for the “special project manager” to visit the dementia care unit at Stirling University for guidance on what is considered to be an appropriate environment for people with dementia. The policy of the home is that of “no locked doors”. Two of the fire exists lead to the gate through which service users may leave the building. Advice was given of the need to carry out risk assessments for these fire doors and identify any preventative action which should be implemented to reduce or minimise any potential hazard identified. (Risk assessments have since been forwarded to CSCI in relation to these issues). Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29&30 The service users are in safe hands with their personal care needs being met by a well-trained staff team. EVIDENCE: Discussion with the manager and staff confirmed that, when open, the minimum staffing level which will be provided during the week day will consist of the manager, assistant manager, senior support worker, 3 support workers, 2 domestics and 1 cook. Staff spoken to stated that from the day of opening, even whilst service users are gradually being introduced to the service, these staffing levels will be provided. The manager stated that having undertaken some research into the area of staff shift patterns, in order to promote the well being of the staff team, he has developed the rota so that staff work 4 consecutive late shifts as opposed to a late followed by an early shift. Research has indicated that such shift patterns provide staff with the time they need to rest in between shifts. Discussion was held with all of the staff during a team meeting in which they confirmed that, as part of their induction process, they have received in-depth training in relation to the needs of people with dementia. This has included the completion of distance learning courses on the topic of dementia as well as group training sessions being provided by the Alzheimer’s Disease Society, training sessions on “memory tools”, “life story work”, and “dementia care mapping”. Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 15 In addition to the above all of the staff have completed the NVQ level 2 training in care, training in falls prevention, nutrition, continence and Parkinson’s disease. Discussion with the manager and a sample of documents used during the recruitment procedure concluded that a thorough recruitment process has been carried out. The manager confirmed that 124 staff were short-listed and interviewed and that during the interview process prospective staff were asked specific questions in relation to the needs of people with dementia. In addition to this a personality test was carried out in order to identify each individual’s personal strengths. Although not examined during this inspection the manager confirmed that an Enhanced Criminal Records Bureau check and two written references had been sought prior to offering the prospective staff member a position in the home. Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 The manager demonstrated that he is a hardworking and experienced leader who has successfully developed the service ensuring that it will meet the needs of people with dementia. EVIDENCE: There was a positive rapport observed between the manager and staff. It was evident that manager’s enthusiasm for the successful development of the service has had a positive impact upon the staff team. The staff spoken to confirmed that the manager is open and approachable offering a clear sense of direction, treating each member of the team with equal respect. In order to ensure that Shadon House provides a quality service for people with dementia, based upon current good care practise, the manager has spent much time undertaking research and training in this area which has included visits to specialist facilities in other parts of the country. Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 3 x 3 x 3 x 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 Standard No 16 17 18 Score x x 3 3 x x x x x x x Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 18 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 19 Regulation 13 Requirement Bathwater and shower tempertatures must be maintained at 43 degrees centigrade. Timescale for action 26/08/05 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 Good Practice Recommendations Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Baltic House Port of Tyne South Shields NE34 9PT National Enquiry Line: 0845 015 0120 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 Shadon House B52 B02 S38099 Shadon House V244749 17 Aug 2005 Stage 4.doc Version 1.40 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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