Inspection on 30/08/06 for Shadon House

This inspection was carried out on 30th August 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Shadon House 26/01/09

Shadon House 12/12/07

Shadon House 24/01/06

Shadon House 17/08/05

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 Tyne and Wear DH3 2AP Lead Inspector Miss Nic Shaw Key Unannounced Inspection 9:00am 24 & 30th August 2006 th 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 Shadon House DS0000038099.V304225.R02.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. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shadon House Address Northumberland Place Barley Mow Birtley Tyne and Wear DH3 2AP 0191 410 2816 0191 411 1209 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) Gateshead Council Care Home 23 Category(ies) of Dementia (23), Dementia - over 65 years of age registration, with number (23), Mental disorder, excluding learning of places disability or dementia (5), Mental Disorder, excluding learning disability or dementia - over 65 years of age (5), Physical disability (5), Physical disability over 65 years of age (5) Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: Shadon House 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 or for an assessment. 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 en-suite 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 separate hairdressing facilities, kitchen, laundry and a range of staff rooms, including a sleep-in room, the latter being available on the first floor of the home. There is a spacious enclosed garden, fully accessible to service users, and separate car parking facilities are available. Local shops, places of worship and other community facilities are located a short distance from the home. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days in August 2006 and was a key unannounced inspection. The inspection included information which had been provided by the manager in a questionnaire. Eight completed service user and six completed relatives/visitors comments cards were also received. Time was spent talking to the manager, approximately fourteen service users, six day staff, two nightstaff and two visitors. A lunchtime meal was taken with the service users and some time was spent touring the building, including a number of service users bedrooms, the garden and communal areas. A sample of staff records were also examined. The inspection particularly focussed on four service users with very different needs, known as “casetracking”, and looked at what it was like, from their point of view, staying at Shadon House, either on a permanent basis, for a short break or for assessment purposes. This involved talking with those service users, observing staff’s care practices with them and checking that information obtained from discussion and observation was accurately recorded in the care records. The weekly fees payable range from £64.65 to £566.44. What the service does well: There are good assessments in place so people who stay at Shadon House know that their needs will be met there. Some people stay at Shadon House in order that a full assessment of their needs can be carried out. The home is good at this which helps to identify what people need to so that they can continue to live in their own home. There is very good contact with local community groups, such as the Alzheimer’s Disease Society and the manager and staff work hard to make sure that the home is viewed as a positive feature of the local community. They do this by inviting people into the home to take part in some of the inhouse events such as the healthy lifestyles programme. Family and friends can visit the home whenever they like. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 6 The meals provided in the home are good and the staff make sure that the service users right to privacy and dignity is respected. There are good complaints procedures in place so that everyone knows, whatever their ethnic background, how to make a complaint. The staff have also been trained so that they know what to do if they witness or suspect abuse. The home has been especially designed to help people with dementia remain independent. There is a safe, secure garden which people can use independently so they can get access to lots of fresh air. Staff training and recruitment is excellent. All staff have been especially “handpicked” to work with people with dementia and all have received specialist training in this area. The manager and staff are friendly and approachable and there are excellent procedures in place to make sure that the views of the service users are listened to. These include “mystery carers” from the Alzheimer’s Disease Society who are soon to visit the service as prospective service users to test the quality of information given to them by the staff. Everyone has been given training on equality and diversity so that they know what to do to meet the very different needs of everyone who stays at Shadon House. Everyone spoken to without exception spoke highly of the staff and the standard of care provided at Shadon House. Service users said: “the staff are nice” “the foods good” “the rooms are nice” “I love it here” “I can keep my door locked” “I am well cared for”. Relatives said: “ the staff are very committed and very involved” “the home is always clean” “the ethos of the place shows through the training” “I feel sorry for anyone with dementia who doesn’t live here”. Two relatives took time to write to the Commission to praise the home. They said “Shadon House is an excellent care home, I feel Gateshead should use Shadon House as an example of good practise, the staff are genuinely concerned about all of the residents” and “the commitment and professional approach of staff at all levels, including the cleaner is impressive”. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 7 Staff said: “the training is excellent” “I love my job” “Andy is very approachable” “there is no set routine in the home”. What has improved since the last inspection? What they could do better: There needs to be a bit more detail in the care plans so that staff know exactly what to do to meet the more complex needs of the service users. Medication administration and recording systems could be better to make sure that people always get their prescribed medication at the right time. The range of activities needs to improve and this should include trips out. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 8 There was a strong odour in a small number of bedrooms and this needs to be sorted out. The number of staff on duty, particularly during the night, needs to be looked at to make sure there are enough staff around to promote the health, safety and welfare of the service users. . Some of the beds need casters on the wheels to stop them from moving when sat on by service users. Some improvements need to be made to the service users financial procedures to ensure that those people assessed by their social worker as being financially at risk are fully protected. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 9 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 DS0000038099.V304225.R02.S.doc Version 5.2 Page 10 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 Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 11 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 the following standard(s): 3,5&6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The admissions process ensures that service users are adequately assessed prior to care being offered. This means that service users are offered the right type of care at the home. Service users are able to visit the home, prior to receiving a short break service, so that they can assess for themselves the services, facilities and suitability of the home. Intermediate care is not provided at Shadon House. EVIDENCE: Of those people chosen to casetrack a full comprehensive social work assessment had been obtained from their social worker. In addition to this the staff had also completed a pre-visit assessment document. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 12 Shadon House offers a specialist assessment service for a small number of people with dementia. Consequently the staff use a range of assessment documents specifically designed for people with dementia such as the “well being and ill being” and “mini-mental tests” tools. These are used not only to make sure that the service user’s needs can be met whilst staying at Shadon but also to identify what they might need to continue to live independently when they return home. During the inspection a prospective service user and their relatives were visiting the home in order to decide whether or not they would like to use the services on offer. Service users are also able to “test” the service prior to arranging a short break service by using the day care facility available in the home. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 13 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 the following standard(s): 7,8,9&10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The care planning process has improved since the last inspection, however, further developments are needed to ensure that the service users health needs are fully met and that continuity of care is provided. Improvements need to be made to the medication storage and administration procedures, particularly for those people who are in receipt of the short break service, in order to minimise the risk of errors occurring and to ensure that the service users receive the medication for which they have been prescribed. Arrangements are in place to help preserve service users privacy and dignity. EVIDENCE: A review of the quantity and type of care plan document has been carried out since the last inspection. One standardised format is now in use which specifies the aim of the plan followed by actions needed of the staff to fulfil the aim. This format is clear and easy for staff to follow with clear guidelines Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 14 available advising them of what they need to do to meet the service users assessed needs. From discussion with staff and observations there has been some recent significant changes to one service users needs, however, the information available in the care plan did not support all of the positive work carried out by the staff. For example; a recent nutritional assessment completed for them identified that they were at probable risk. Although there was a diet care plan in place this had not been up-dated to include this information and what action staff should take at meal times when this service user becomes agitated. Monitoring charts were in place in relation to this particular need, however, some of these had not been dated and therefore were of little value. In another service user’s file there were many care plans in place covering such issues as personal care, mobility, daily living and communication. Although it had been identified in their communication care plan that in order to meet their needs when they become agitated staff should “distract” them, details of what this should involve had not been recorded. It was positive to note that the staff continue to write night care plans and the level of detail recorded in these was good. For example: for one service user this includes ensuring that they are offered a cigarette before retiring to bed. Service users health care needs are fully met in the home. In response to concerns about one service users health staff made sure that the GP was immediately contacted. Currently on offer in the home is a healthy lifestyle programme. Each week a different health care professional is invited to the home to talk about a particular health care issue. This has included “know your blood pressure” and “falls prevention” and is also available to people with dementia who live in the community. The home is currently working with Northumbria University in relation to a research project on falls prevention. It was evident from records that those people identified at risk of falling are quickly referred to the falls prevention team so that appropriate preventative measures can be put in place. Medication is stored in a secure location within the home. Locked medication trolleys are used to safely transport the medication around the home. For those people who live permanently in the home the pharmacist dispenses their medication each month in a sealed “blister” pack. However, for those people who stay in the home for a short period of time only, staff ask their relatives to bring their medication with them to the home. Staff said that sometimes medication does not arrive in the original pharmaceutical container and as such they are not able to administer it. Sometimes relatives do not always bring in all of the medication a service user may require. This occurred during the inspection, and although the relative brought the medication in the following day, this meant that the service user had gone without some of their Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 15 prescribed medication for a short period of time. In this particular situation staff said that they did not know that this service user had been prescribed any additional medication and agreed that the home needed to review the admissions procedure to ensure that this issue is fully addressed. In some instances the Medication Administration Record (MAR) had not been completed to show how many tablets had been received and therefore it was not possible to complete an audit of the medication to ensure that this had been administered correctly. In addition to this the instruction on the MAR sheet did not always correspond to the original dispensed pharmaceutical label. One MAR sheet had been signed by staff to show that a service user had been given their prescribed medication only once a day when the administration instructions stated that this should be given twice a day. Other issues identified in relation to medication include the need to develop clear guidelines for staff so that they know exactly when to give “as and when” required medication, particularly when this is to be given if a person becomes agitated, also the need to ensure that all medication is stored at the correct temperature. An immediate requirement notification was issued to the manager in relation to medication and the Commission have since been notified that appropriate action has been taken to address these issues. Service users right to privacy and dignity was promoted by the staff. Staff knew the service users preferred mode of address, which is recorded in the pre-admission information. There is a telephone booth where service users can make and receive telephone calls in private. In addition to this all bedrooms have been equipped with a telephone. Relatives said that the staff “value” the people who live in the home. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 16 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 the following standard(s): 12,13,14&15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The number and range of activities available needs to improve so that service users are provided with the opportunity to lead active fulfilling lifestyles. Community contact is good with lots of opportunities being provided for the permanent service users to maintain contact with their family and friends. This ensures that service users do not become socially isolated. Staff are excellent in actively encouraging service users in exercising choice and control over their lives. This can help promote their independence. Service users are provided with a good, varied and well presented, choice based, menu which helps to promote their general health and wellbeing. EVIDENCE: Service users were observed to follow their preferred daily activity. One service user likes to spend time in their room and their choice to do so was respected by staff. Nightstaff said that should a service user be awake during the night then they did not ask them to return to their room, the philosophy of Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 17 the home being to ensure the routines of daily living are flexible to suit the individuals needs and choices. There is no activities co-ordinator and one relative and a number of staff commented that this would be beneficial. There is, however, an activities programme available and this is displayed within the home. This includes activities such as reading the newspapers, (one member of staff was observed to take turns to sit with a small number of service users reading this with them), exercises and “discussions about your interests”. Photographs of some activities which have taken place in the home were on display including cooking and quoits. Although one relative said “the staff have got my mam doing things she hasn’t done in years” and feedback from relatives indicated that they felt that the service users were “stimulated”, there was no evidence of trips out, for example, to the Theatre or local places of interest. Staff said that they tried to provide opportunities for people to go out and on one occasion had visited the local garden centre, however, such activities are arranged on a spontaneous basis depending upon availability of staff and are very few and far between. Some of the service users also commented that there was little for them to do. In order to address the differing religious needs of the service users a lay preacher and two “friends” of the local church, as well as a priest, regularly visit the home. A positive feature of the service is the easily accessible garden and some service users had chosen to spend time sitting and chatting on the garden seats provided for their use. Much work has been undertaken by the staff to ensure that Shadon House is viewed as a positive feature of the local community. As well as the healthy lifestyle programme, positive links are being made with local community groups such as “Equal Arts” and the Alzheimer’s Disease Society. A steady flow of friends and relatives visited their family members during the inspection. Staff also provide support and advice to relatives and friends and help them to understand their family members dementia. Lots of opportunities are provided for service users to make choices and to take control over their lives. One person continues to manage their own financial affairs. People are also involved in the care planning and some people have signed their plans as evidence of this. Service users are offered the opportunity of using an advocacy service and some have an advocate. Service users choice in relation to their sexuality is fully respected. In order to address the service users needs in relation to this issue the home has established links with local gay/lesbian befriending scheme. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 18 A lunchtime meal was shared with the service users. This was served to service users by staff from the main kitchen, located adjacent to the dining area. A choice of main meal was provided and menus, in large print, were placed on each table to help remind people of the meals available. The tables were nicely presented with napkins and individual teapots so that people could help themselves. Where service users required assistance, this was provided discreetly and sensitively by the staff. Some of the service users enjoyed a glass of wine with their meal and everyone spoken to said that the food was good. Advice was offered as to how the mealtime experience could be improved for people with dementia, for example noise reduction, and the manager was receptive to the advice offered. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 19 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 the following standard(s): 16&18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a satisfactory complaints system. Complaints are handled appropriately and the outcomes used to improve the service. Policies, procedures and staff training ensures that the service users are protected from abuse and potential harm. EVIDENCE: The complaints procedure is available in a range of different formats including Braille, large print and a number of different languages for example Bengali, Chinese and Polish, in order to meet the needs of people with a visual disability and people from ethnic minority groups. The complaints procedures are displayed in the entrance foyer of the home. Service users said that although they had no complaints to make they would feel able to make a complaint if they were unhappy with any aspect of service provision. There have been no complaints made since the last inspection. Staff said that they have completed training in the prevention of abuse and were familiar with the Local Authority Adult Protection Procedures. Service users said that they felt safe living in the home. One relative said that since their family member had been living in Shadon House they no longer felt it necessary to visit them every day as they knew they were safe. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 20 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 the following standard(s): 19,20,24,26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Shadon House offers service users a clean, comfortable environment which has been specifically designed to meet the needs of people who have dementia, However, in a small number of bedrooms there was a strong odour which compromises the dignity of those service users in these rooms. EVIDENCE: The building offers service users 23 single 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 be seen. Walls and floors are also in contrasting colours so that service users can easily distinguish between them. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 21 Lighting in WC’s is sensor controlled and automatically illuminates when this area is entered. A multi-sensory area has also been created which provides service users with a relaxing, yet stimulating area in which to spend time. Assisted bathrooms and shower areas are clearly labelled. They are bright and airy, although the manager agreed that these areas could be further enhanced if made to feel more “homely”. The manager also said that bathroom cabinets are to be purchased so that plastic gloves and aprons can be stored discreetly. Corridors have been named after streets in the area, which is good practise in dementia care and gives people a sense of living in a small community. Their bedroom door, in this way, becomes their front door and helps to detract from the notion of people living in a large care home. Service users spoken to said that they had keys to their rooms and could keep their doors locked if they wanted to. A number of service users were wearing a pendant. Service users said that this can be used by them to alert staff should they require assistance in any area within the home. There is a spacious garden area, with ramped access, which can be freely explored by the service users. However, on the day of the inspection this area lacked colour and the manager agreed that the garden required further development, an issue he has began to address. The manager also confirmed that solar lighting and a water feature are to be installed in the garden to further enhance this area. Although all communal areas were clean and everyone spoken to commented on the high standard of cleanliness at all times in the home, there was a strong odour in two of the service user’s bedrooms. The domestic staff were eager to discuss their stringent cleaning regime, which involves cleaning these particular carpets every day, however, despite this they agreed that the strong odour remained. Staff demonstrated an awareness of the prevention of cross infection by using protective gloves and aprons where appropriate. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a staff team who have received excellent training, however, staffing levels are not sufficient at all times of the day and night and therefore staff may not be able to meet service users needs effectively. The staff recruitment procedures fully protect the service users. EVIDENCE: Relatives spoke positively of the staff and the way in which they supported and cared for their family members. Staff said that the training was “excellent” and records showed that in addition to NVQ training in care, all of the staff have completed training in dementia care, quality assurance and equality and diversity. A deputy member of staff has completed training in dementia care mapping (a method of ensuring that people with dementia receive quality interactions from staff) and said she is looking forward to implementing this within the home. However, discussion with staff, observations and feedback from some relatives indicated that staffing levels are not sufficient at all times of the day and night. Staff said that often, on the late shift there have only been three staff on the floor with the 4th person, (due to the nature of the service i.e. people regularly being admitted and discharged), often being “tied up” with the office. As has been previously mentioned in the report this has prevented staff from taking Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 23 the service users on outings or trips out in the local community. Staff said that at least one service user requires 1:1 support, whilst in another service users care plan review it was identified by the social worker that “if there is a shortage of staff the staff, find it difficult to give the time they need”. Day staff said that they “felt sorry for the nightstaff” as there is only two of them on duty. Nightstaff said that no two nights were the same. They said that sometimes it can be quiet yet on other nights a number of people can be awake. They said that they do not ask people to return to bed, rather they work with people and try and support them if they are awake. Sometimes a number of people choose to go to bed later at night, but this means that there are only two staff to assist sometimes as many as 15 people. Nightstaff spoke of one service user who had recently had a very unsettled night and was “screaming” most of the time. They described another situation where two people left the building and one occasion the nightstaff had to follow them, leaving only one member of staff in the building. They said that sometimes some service users need one to one support, and on occasion, due to the need to carry out safe moving and handling techniques, one service user requires two staff to support them. In the latter situation this would mean that no-one is available on the floor should anyone else require assistance. Due to the nature of the service provided at Shadon House there is a constant changing population of service users. Everyone admitted to the home will have a diagnosis of dementia which may impact upon their ability to settle in an unfamiliar environment. As such an immediate requirement notification was issued to the manager requiring him to review staffing levels, particularly at night. The Commission have since been notified that a risk assessment has been carried out in relation to this issue. Although it was positive to note that within this risk assessment a third member of staff will be provided during the night if this is felt necessary, the risk assessment needs to include further information to justify the continued provision of only two nightstaff. The dependency levels of the people using the service and the support they require during the night must form the basis of the risk assessment. There has been no turn over in staff since the home opened last year, which is excellent in terms of promoting continuity of care. As such no staff records were examined as last year the home demonstrated that they had carried out a thorough recruitment procedure. This involved during the interview process asking prospective staff 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. The manager confirmed that an Enhanced Criminal Records Bureau check and two written references are sought prior to offering the prospective staff member a position in the home. This information is available for inspection at the Gateshead Civic Centre. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,&38 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The service users health, safety and welfare is promoted by a well managed staff team. The service users financial interests are safeguarded by robust policies and procedures, however, improvements need to be made to these procedures to fully safeguard those people who have been assessed by their social worker as being financially at risk. Quality assurance systems are excellent and ensure that the home is run in the best interests of the service users. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 25 EVIDENCE: Since the last inspection there has been a change in manager who is currently completing the NVQ level 4 qualification in care as well as the Registered Managers Award. He has also completed training in a range of other subjects such as equality and diversity. Although he has not completed any specialist training in the area of dementia it is his intention to undertake this training as soon as possible. There are excellent quality assurance systems in place. There is the “CARED 4” quality assurance tool, which involves a monthly assessment of the home’s success in achieving the standards outlined in the policy and procedure documents. The home’s line manager also carries out detailed audits of the service each month, a copy of which is forwarded to the Commission. In response to these monthly reports the manager prepares an action plan detailing how he will address any issues raised. Service user questionnaires are also used to gather information on the performance of the service and people staying in the home for a short break or assessment are asked to complete one of these prior to them leaving. Feedback received from relatives is recorded in a diary and suggestions made acted upon. An example of this is a suggestion made by one relative that they would like to meet the nightstaff which is being organised by the manager. The manager is currently in the process of arranging for “mystery carers” from the Alzheimer’s Disease Society to visit the service in order to “test” the response they receive from staff to enquiries they make either over the telephone or during a visit. A report will be completed and forwarded to the manager as an additional quality assurance check. For all financial transactions made on behalf of service users double signatures are recorded as well as receipts obtained for any purchase made. In addition to regular internal audits of service user monies regular external audits are also completed. However, when large sums of money are given to service users, who have been assessed by their social worker as being financially at risk, there was no detail recorded in the transaction sheet of what this money had been requested for. Discussion was held with the manager of the benefits of completing financial risk assessments in such situations. There are excellent health and safety procedures in place, particularly in relation to fire safety. All of the staff knew exactly what to do in the event of a fire and confirmed that they receive regular fire instruction and drill. A detailed fire risk assessment is in place and this has recently been up-dated to Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 26 incorporate the temporary measures in place whilst the conservatory is being built. Bathwater temperatures are checked regularly and the manager confirmed that recently these had been adjusted as some were found to be above the recommended temperature of 43 degrees centigrade. The service user beds are on wheels, which do not have brakes attached to them. Staff expressed concern at this potential hazard as sometimes they had found service users on the floor by their bed. The manager has purchased casters and fitted these to some, but not all, of the wheels to prevent the beds from moving. The manager agreed that, in view of the potential risk, each wheel on each bed should be fitted with a caster to prevent them from moving. An appropriate record of accidents is maintained. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 27 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 OICE 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 X X X 3 X 2 STAFFING Standard No Score 27 2 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 2 X X 2 Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes 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(1) Requirement Care plans must continue to be developed as discussed in the body of the report. (Timescale not met 30/06/06). Medication records must be completed correctly in order to minimise the risk of medication errors occurring. Service users must receive the medication for which they have been prescribed. Timescale for action 31/12/06 2 OP9 13(2) 30/08/06 3 OP12 16(2)(n) 4 OP26 16(2)(k) The activities programme must 30/11/06 be developed to include outings as well as more entertainment within the home. The strong odour in service users 30/11/06 bedrooms must be effectively addressed. A review of the staffing levels during the night and late shift must be carried out. Casters must be fitted to all wheels to prevent the beds from slipping. 30/08/06 30/09/06 5 6 OP27 18(1)(a) 13(4)( c ) OP38 Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 29 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 OP35 Good Practice Recommendations The service user financial procedures should be developed to include financial risk assessments for those people assessed as being financially at risk. Shadon House DS0000038099.V304225.R02.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock 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. 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