Inspection on 24/10/06 for Shaftesbury House Residential Home

This inspection was carried out on 24th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

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 Shaftesbury House Residential Home 5 Cowper Street Ipswich Suffolk IP4 5JD Lead Inspector Julie Small Unannounced Inspection 24th October 2006 10:30 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 Shaftesbury House Residential Home DS0000067473.V315162.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. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shaftesbury House Residential Home Address 5 Cowper Street Ipswich Suffolk IP4 5JD 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) 01473 271987 01473 271987 Sanctuary Care Limited Lynne Margaret Smith Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two named service users identified in the application dated 6th September 2006 with dementia (DE(E)). 16th February 2006 Date of last inspection Brief Description of the Service: Shaftesbury House is a purpose built care home registered for 25 older people. The home is owned and managed by Sanctuary Care Ltd, who have recently taken over the home from the previous proprietors Ashley Homes. The home is situated in Cowper Street, a residential area to the east of Ipswich town centre. The home is laid out over three floors, with some car parking and enclosed private gardens. The environment is pleasant and homely and service users have a choice of communal lounges and dining rooms. The home is situated close to local shops and facilities and a main bus route into town. At the time of the inspection charges for accommodation at the home were for private residents £547.12 per week and for Social Care residents £331 per week. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a key inspection which focused on the core standards relating to older people. The report has been written using accumulated evidence gained prior to and during the inspection. The inspection was undertaken by regulatory inspector Julie Small on Tuesday 24th October 2006 between the times 10.30 to 18.00. A research student, from York University, accompanied the inspector. The manager was on leave during the inspection and was spoken with by telephone following the inspection. A tour of the building and observation of work practice was undertaken during the inspection. Records were viewed which included residents care plans, health and safety records, staff training records and medication records. Further details of records viewed can be found in the main body of this report. Four staff members, two visitors to the home, two residents and a group of residents who were relaxing in the lounge were spoken with. The inspector was made welcome in the home and information requested was provided promptly and in an open manner. A pre inspection questionnaire (PIQ) and residents ‘have your say about…’ questionnaires and staff and relatives/visitors comment cards were sent to the home prior to the inspection. Questionnaires and comment cards returned to the inspector were the pre inspection questionnaire, which was completed by the homes manager, six relative/visitors comment cards, three staff comment cards and seventeen ‘have your say about…’ questionnaires, ten stated that they did not wish to speak to an inspector and seven did not respond. What the service does well: Interaction between staff and residents was observed to be positive, friendly and respectful. The home was clean and welcoming, there were many visitors observed visiting the home throughout the day of the inspection. There was evidence that residents were involved in their care planning. The complaints records evidenced that complaints were handled appropriately. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The lounge on the ground floor was overcrowded; the home must seek methods of ensuring that there are alternatives for residents to use. There were a further two lounges, one on the first floor and one on the second floor. The lounges had items stored in them such as wheel chairs and drawers; these must be removed and made available for residents use. There was a broken light on the second floor landing, which must be replaced. There was no lampshade in the entrance area to a service users bedroom, which was situated on the first floor. There was a smell of urine detected on the ground floor. There was evidence that care plans were regularly updated, however, it was unclear which section had been updated by which staff member and when. There was an issue with the replacement of co-codimol for paracetomol when the home had run out of the medication. There were no records to indicate how and why this decision was made, if it was safe and details were not included in the residents care plan. There were gaps in MARS sheets, with no explanation. The manager advised that they are working to ensure that staff are provided with the opportunity to complete their NVQ (National Vocational Qualification). The current percentage of qualified staff does not meet the standard. Staff must be provided with POVA (protection of vulnerable adults) training, and updates provided to those who have undertaken the training some years before. It is recommended that staff are provided with personal learning and development profiles. It is recommended that the home recruits dedicated activities staff to ensure that residents are provided with sufficient activities and that residents are Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 7 consulted with regarding activities, due to comments received in resident’s questionnaires 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. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 8 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 Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 9 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): 1, 2, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they have a written contract including terms and conditions with the home and that they have their needs assessed prior to moving into the home and that they are provided with the information they need to make an informed choice about where to live. EVIDENCE: The home had a statement of purpose and service users guide, which were viewed. A staff member said that resident was provided with a service users guide, which was stored in their bedroom, and there was copies of the guide and statement of purpose in the manager’s office and in the entrance of the hall. A glossy brochure was also available for prospective residents, which was viewed, which gave a brief explanation of the home and the providers, directing prospective residents to contact the home for further information. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 10 Twelve residents ‘have your say about…’ questionnaires answered yes to the question ‘did you receive enough information about this home before you moved in so you could decide it was the right place for you?’ Four answered no and one answered ‘yes and no, you never really know until you move in’. Further comments made included ‘circumstances did not permit much advance preparation. One visit seemed to confirm it was a satisfactory home. This has subsequently proved to be correct’. Two that had answered no made comments that a family member had found out about the home and bought them to view it and that the home was found for them by Social Care following a closure of the home they had lived in. Nine returned ‘have your say about…’ questionnaires stated that they had received a contract; six said that they had not and two did not answer the question. Six residents files were viewed which all had written signed and dated contracts. There was a list of eight residents who needed contracts, who had recently moved into the home, taped to the desk in the manager’s office. The resident’s records were viewed and there were two which had recently signed contracts, from October 2006, and six did not have contracts. Residents records viewed had written assessments of need, some of which were completed by Social Care and had assessments completed by the homes manager prior to them moving into the home. Records contained ‘what you need to know about me’ documents which had been completed by the resident and was a yes and no answer sheet where residents identified their day to day needs and preferences. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 11 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, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect that they have a plan of care which identifies their daily living needs, that their health care needs are fully met, that they are treated with respect and their right to privacy is upheld. Residents cannot be assured that they are protected by the homes procedures for the administration of medication. Residents cannot be assured that their care plans reflect when and why amendments have taken place. EVIDENCE: Three residents care plans were viewed, all held plans and information required by those providing care for the individual resident. Care plans included information regarding what support each resident needs for using the toilet, mobility, personal hygiene, manual handling, eating and each daily activity had risk assessments and actions which should be taken to minimise the risks. The care plans and risk assessments would benefit from more detail. The risk assessments had evidence that each resident’s key worker updated Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 12 them regularly. However, the inspector was unable to track which sections had been updated, on what date, by who and the reasons for the amendment. Resident’s records viewed evidenced that they were involved in the planning for their care. There was a document ‘what you need to know about me’, which was completed by the resident. The document identified the resident’s preferences and needs with regards to the care they required. There was also a section in the care plan which identified the history and background of each resident, however, in one residents record viewed this section was left blank. A staff member said that as much information as possible about the resident was gained from the resident and their family. A question in ‘have your say about…’ questionnaires was ‘Do you receive the care and support you need?’ Seven answered always, seven answered usually and three answered sometimes. Resident’s records evidenced that their health care needs were provided for. There were records which identified appointments residents had attended including optical, doctors and visits from the district nurse. The home had a visiting chiropodist, a service which was available for residents subject to a further charge. During the inspection staff members were observed discussing the well being of one resident who had requested to see a doctor. One staff member was observed to telephone the doctor and explain their symptoms and concerns, it was agreed that they would visit the home, which they did. Resident’s records viewed included information regarding the vulnerability to pressure sores and actions required to minimise the risks. Two visitors spoken with confirmed that their family member received sufficient health care and that they had received a psychological assessment for symptoms of depression. Residents were asked ‘Do you receive the medical support you need?’ in the ‘have your say about…’ questionnaires. Ten stated always, five usually and two said sometimes. One comment was ‘recently they ran out of co-codimol and substituted paracetomol for 10 days which concerned my family’. The resident’s records were tracked and medication records identified that they had run out of co-codimol and these needed ordering. The MARS (medication administration record sheets) record evidenced that for seven days co-codimol was not available and that the resident had been administered two paracetomol, where they usually took one. A staff member spoken with said that the doctor directed them to substitute the medication. The residents records and care plan were viewed, however there was no reference to this change in medication found. Resident’s records did include a list of prescribed medication, the reasons for the medication and the possible side effects. The MARS sheet also had gaps, and provided no explanation for the gaps. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 13 Medication records included photographs of each resident and details of the medication each resident was prescribed. There were records which evidenced when medication was returned to the pharmacist. The home provided acceptable storage for medication including a locked storage room and trolley, which was used when administrating medication. There was a storage cabinet attached to the wall where controlled drugs were stored and appropriate records were kept. The tea time drug administration was observed, the staff member observed residents taking their medication before they signed the MARS records. Medication was stored securely in a locked trolley during administration. The home had a staff handbook, which was viewed and directed staff on the expected treatment of residents and the code of conduct for staff. During a tour of the building it was noted that there was a pay telephone available for residents use. Staff were observed to knock doors prior to entering and throughout the day residents were observed with their visitors. Visits were in communal areas and in resident’s private bedrooms. One resident’s records viewed identified that one resident had a birth name but preferred to be called by an alternative name, staff explained that this was respected. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 14 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, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their lifestyle matches their expectations and preferences, they maintain contact with family and friends, they are helped to have choice and control over their lives and that they receive a wholesome and appealing balanced diet. EVIDENCE: During a tour if the building it was noted that there were signs, which informed residents of forthcoming activities. Activities included a mystery tour, cream tea at a local town and a visit to a local garden centre. Records viewed evidenced that activities also available were bingo and local visits from various musical entertainers. Financial receipts of residents viewed evidenced that they had magazines and newspapers delivered. During the inspection residents were observed to be watching television, chatting together, entertaining visitors in communal areas and in the privacy of their bedrooms and completing puzzles in a magazine. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 15 One resident spoken with said that they had plenty to do and enjoyed bingo, which was free and they could win items, they had won some soap and their friend had won a flannel. The ‘have your say about…’ questionnaires asked ‘Are there activities in the home which you can take part in?, two said always, five said usually and ten said sometimes. Comments included ‘particularly likes bingo’, ‘always showing on the programme but seldom takes place’ and ‘when there is time for the girls to spend with us’. The pre inspection questionnaire stated that activities provided were trips out, bingo, cards, quizzes, exercises, sing-a-longs, guest speakers and entertainers. A staff member said that they did not have dedicated activities staff but thought that someone had applied to undertake this role. This was not confirmed at the time of the inspection. Two visitors were spoken with and confirmed that they were made welcome at the home and that the staff ‘did their best’ for their family member. They said that their family member was a wheel chair user and did not go out alone, the staff at the home had taken them for walks and to the local shops. Six relatives/visitors comment cards received all answered yes to the questions: ‘Do staff/owners welcome you into the home at any time?’ ‘Can you visit your relative/friend in private?’ ‘Are you kept informed of important matters affecting your relative/friend?’ ‘If your relative/friend is not able to make decisions, are you consulted on their care?’ One comment card marked this question not applicable (N/A). ‘Have your say about…’ questionnaires asked ‘Do the staff listen and act upon what you say?’ Fifteen answered yes, one answered no and one was left blank. Residents meeting records were viewed and evidenced that residents were supported in commenting and making suggestions about their care and that suggestions had been acted upon in issues such as food. They had asked for rolls, as an alternative to sandwiches and this was actioned. There had been concerns raised about the quality of food in the home, which was provided by a catering agency. There was evidence that the home had met with the agency and stated their concerns and expectations. A staff member said that the quality of food had improved. They said that residents were provided with two choices for each meal and if they did not like what was provided they could have an alternative. Residents spoken with said that the Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 16 food was good and they have plenty to eat, one resident said ‘they do their best’. Residents were observed enjoying their evening meal and they were provided with a choice. Residents were provided with four meals a day, breakfast, lunch, dinner and supper. The main meal of the day was provided at lunch time. Residents were observed to be provided with a choice of drinks and biscuits throughout the day. There were large bowls of fruit around the home which included grapes, strawberries, apples, oranges and bananas which residents could help themselves to. A staff member said that there were no residents who were vegetarian or had cultural needs regarding food. There were residents who required a low fat diet and this was provided. Their care plan was viewed and details of their required diet were outlined. Residents were asked ‘Do you like meals at the home?’ in the ‘have your say about…’ questionnaires. Four said always, four said usually, eight sometimes and one never. Comments made included ‘Not quite home cooking’, ‘food very poor. Not always cooked thoroughly. If dinner inedible never offered an alternative just left to go hungry’, ‘I don’t like the way the tables are cleaned before we have finished eating’ and ‘more variety needed’. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 17 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their complaints will be listened to and acted upon and that they are protected from abuse. The whole of the staff team should receive up to date POVA (protection of vulnerable adults) training. EVIDENCE: The staff training records were viewed and evidenced that seven staff had received up to date POVA training. Records showed that some staff had received POVA training two to four years ago, they would benefit from updated POVA training. There was evidence that the manager had forwarded e-mails to the providers to request that staff receive updated training and training be provided to new staff. There were training materials such as a no secrets video in the home and local authority POVA information. There was no secrets information posted in the entrance hall to the home. The staff handbook viewed provided information about keeping residents safe and the procedure of not accepting gifts from residents. The PIQ stated that the home had procedures which included adult protection and the prevention of abuse, concerns and complaints, which had recently been updated to Sanctuary Care procedure, gifts to staff management of Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 18 service users money, valuables and financial affairs, aggression towards staff and whistle blowing. Three staff comment cards were received, all stated that they were aware of the homes abuse and complaints procedure. The homes complaints procedure was displayed in the entrance hall to the home and provided details of CSCI. Complaints records were viewed and evidenced that a recent complaint had been managed positively. The complaint was from a resident’s power of attorney regarding the quality of food and receipt of an incomplete complaints procedure. The manager had responded in writing, provided a complete complaints procedure with an explanation of that the part which was relevant to them. They were then provided with information how the manager had discussed issues with the catering agency and arranged for the complainants to discuss concerns with them directly. Five relatives/visitors comment cards stated that they were aware of the complaints procedure and one was left blank. The ‘have your say about…’ questionnaire asked ‘Do you know how to make a complaint?’ Ten said always, six said usually and one said no. They were asked ‘Do you know who to speak to if you are not happy?’ Eleven said always and six said usually. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 19 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, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a safe, well maintained environment which is clean, pleasant and hygienic and that they have safe, comfortable bedrooms with their own possessions around them. They cannot be assured that there are sufficient communal areas to relax in and that there are no unpleasant odours in the home. EVIDENCE: The homes front door bell had been repaired since the last inspection. During a tour of the building it was noted that the home was well maintained, warm throughout and clean. A staff member confirmed that there was three domestic staff who work hard to maintain the cleanliness of the home. Handover records evidenced that night waking staff were also responsible for Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 20 some household chores during their shift. The homes maintenance records were viewed, which had required repairs and the maintenance staff had ticked when the work was completed. The last entry was for June 2006, with a message from the staff member stating that they had enjoyed working at the home. A staff member said that there was a new maintenance worker who had recently been recruited to the home, the manager confirmed this. Residents ‘have your say about…’ questionnaires asked a question ‘Is the home fresh and clean?’ thirteen answered always and four answered usually. Further comments made in the questionnaires included ‘I would like to see the windows cleaned’ and ‘The lounge is crowded and could be bigger to cater for the number of people in the room’. Comments made in two returned relatives/visitors comment cards were ‘Lounge could be bigger’ and ‘Some concern about the lack of room in the communal lounge if too many residents want to sit there’. During a tour of the building it was noted that the exterior of a ground floor window could do with cleaning. A staff member said that they did have the windows cleaned regularly by a local company, but was unsure if this had changed since the new proprietors had taken over the home. The manager said that they had recently contacted the window cleaning contractors and requested that they clean both the inside and outside the windows. The main lounge on the ground floor had several chairs close together and a group of residents spoken with said that the room gets very crowded. One resident pointed out a portable heater, which was being used in the lounge and said that the gas fire was broken. A staff member confirmed that they were waiting for a part for the fire. The dining area was next to the lounge area and the kitchen led onto the dining area, so making a very busy and hectic part of the home. A staff member said that there had been some discussions about extending the lounge through an unused storage area or a conservatory. The manager said that they listened to resident’s choice regarding which lounge they chose to relax in and were looking at options to ensure it was not so crowded. They said that the home had regular sessions where the residents get their hair done and have chats over coffee using the first floor lounge, which they enjoyed. There was a smaller lounge with two easy chairs, a piano, television and small table, across the hall from the main lounge where two residents were watching television. One said that they had recently moved into the home and the main lounge was too crowded, so they use the smaller one. There was a lounge on the first floor and second floor of the home. A staff member said that these were rarely used. The lounge on the first floor had comfortable chairs and a table and chairs, there was two sets of drawers, which a staff member said had come from bedrooms and had to be moved to storage. The manager said that they might be sold during the coffee morning planned for December or donated to a charity. There was also a hoist stored in the lounge, which a staff Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 21 member said was its usual storage area. The lounge on the second floor also had comfortable seating and table and chairs, this room also stored a hoist and several wheelchairs. There was a light on the second floor landing, which was flashing and needed replacing. The hallway to a resident’s bedroom, which was situated on the first floor, had no lampshade. Bathrooms were viewed and noted to be sufficient for the use of the residents and there was a choice of bath or shower. A staff member said that the shower was being renewed in the near future and having a more effective drainage area provided. Each resident’s bedroom had an en suite consisting of a toilet and hand washbasin. Four residents bedrooms viewed had appropriate furnishings and were light and airy. Bedrooms were noted to be personalised with memorabilia and a staff member confirmed that residents could bring in their own furnishings if they wished to. Residents records viewed evidenced that residents were provided with a key to their own bedroom. A staff member, who stated that residents were also provided with a lockable space in their bedroom, confirmed this. Two residents said that they were happy with their bedroom. Two visitors who were spoken with said that they were satisfied with their family members bedroom and the cleanliness of the home. The laundry, which was situated on the first floor, was viewed and was clean and tidy. A staff member showed the inspector bags, which residents put their laundry in, this assisted in identifying individuals laundry, they said that residents chose if they wished to label their clothing with their name. There were sufficient hand washing facilities in the home, all bathrooms had hand wash gel and disposable paper towels. There was antiseptic gel in areas around the home for use by visitors, staff or residents. There was a good stock of disposable gloves situated around the home. There was a smell of urine detected in an area on the ground floor. A staff member confirmed that there had been quotes made to replace a bedroom carpet with an alternative flooring, the carpet was cleaned regularly and showed the inspector spray air fresheners in the hall area. The homes manager had telephoned the inspector prior to the inspection to discuss the options of providing an alternative flooring for the bedroom. Shaftesbury House Residential Home DS0000067473.V315162.R01.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. 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 using available evidence including a visit to this service. Residents can expect that they are supported by appropriately trained staff and they are in safe hands at all times. Staff would benefit from updated POVA training. EVIDENCE: The homes rotas were viewed and evidence that the home had completed a breakdown of residents individual needs and work hours required was forwarded with the PIQ. There was evidence that agency staff had been used at the home to cover for vacancies and sickness. Staff spoken with said that the home was fully occupied and that residents were more dependent than previously. They said that they were not able to spend as much time with individual residents as they had previously when the home was not fully occupied. However, they stated that there had been three staff members recently recruited to the home. A recent regulation 26 report forwarded to CSCI stated that there had been staff recruited to the home which would prevent the use of agency staff. The PIQ stated that there was twenty one staff employed at the home and bank staff. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 23 Relatives/visitors comment cards asked if there were sufficient staff at the home one said yes and five said no. There were several comments made in the ‘have your say about…’ questionnaires stating that there were not sufficient staff at the home, that staff were not always available, were very busy and could not spend as much time with residents as they would like. Comments included that two residents did not like to call the staff to help them, as they were so busy. A staff member said that residents have said this to them, but they are reassured that the staff were there to help them and meet their needs. One resident commented that they had to wait a long time for staff to come when they were called during handover. A staff member said that this had been approached and the manager had ensured that there was staff available during handover. The manager confirmed this. The questionnaires were complimentary about the staff at the home, including one comment ‘God bless them all’. The PIQ and staff training records viewed showed that 35 staff working at the home had achieved at least NVQ (National Vocational Qualification) level 2. The home had not yet achieved the 50 target of staff to have achieved the qualification. There was evidence that the manager had secured places for staff on a future NVQ intake. The manager confirmed that they had recently managed to secure places for staff to commence their award. The homes recruitment records were not available during the inspection, staff working at the time did not have access to the records. However, the previous inspection found that this standard was met. The recruitment procedure and templates were viewed. This included the procedure for making applications, interview, recruitment and checks required. There was a staff handbook which included the terms and conditions of working at the home, code of conduct and expectations the proprietors have of their work force. Staff training records were viewed and evidenced that staff were provided with regular training including first aid, person centre planning, manual handling and fire training. There was evidence that the manager had contacted the homes proprietors to request training for newly appointed staff. The staff team would benefit from POVA training including updates for those who had completed the training some years earlier. There was evidence that new staff were provided with Skills for Care induction. One staff member who was recently employed at the home confirmed that they had received Skills for Care Induction and were provided with regular supervisions while they were working their probation period. They said that they were provided with sufficient training to undertake their role. Three staff comment cards stated that they were provided with sufficient training. Shaftesbury House Residential Home DS0000067473.V315162.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they live in a home which is managed by a person fit to be in charge, is run in their best interests, that their financial interests are safeguarded and that the health, safety and welfare is promoted and protected. EVIDENCE: The homes manager had proved that they were competent and fit to undertake the role of registered manager through the CSCI application process. The homes manager was on leave during the inspection. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 25 There were regular regulation 26 visits made to the home which support the internal quality assurance process. The reports for the visits were routinely forwarded to CSCI. The manager was spoken with following the inspection and confirmed that they had recently began undertaking customer satisfaction questionnaires to inform their practice. They said that they had been received well by the residents and they were negotiating how often they would complete them. The manager said that they would use the outcomes to improved the service and care provision. Evidence of the questionnaires was not seen. Residents financial records were viewed which included a balance of their monies kept in the home and receipts for their spending such as paying for newspapers, chiropodist and hairdresser. There were records for each individual living at the home. A staff member confirmed that their power of attorney pay money into the home for the resident, which is kept in the safe if required. The home’s certificate for employers liability insurance and contents insurance was viewed. Fire records were viewed and evidenced that fire drills and fire safety checks were regularly undertaken. The home had a fire risk assessment and risk assessments in case of crisis. The PIQ stated that fire training was provided to staff January 2006, staff training records, which were viewed, confirmed this. There was evidence viewed that the homes gas supply was regularly serviced, electrical items were checked and water temperature and legionella checks were regularly made. The home had health and safety procedures which included accidents to service users and staff, communicable diseases and infection control, COSHH (control of substances hazardous to health), disposal of clinical waste, emergency and crises, fire safety, hygiene and food safety, health and safety at work, moving and handling and risk assessment. Procedures were viewed to be stored in the office at the home and were available for staff to refer to. Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 26 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 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 2 3 2 X X X 3 X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13 (2) Timescale for action The registered person shall make 30/11/06 arrangements for the recording and safe administration of medicines The registered person must 30/11/06 ensure staff are appropriately trained and updated with regards to POVA Care plans must evidence when 30/11/06 updated, why and when there has been a change and the individual must sign the record The registered person must 30/11/06 ensure there are no offensive odours in the home Residents bedrooms must have 30/11/06 lampshades The registered person must 30/11/06 continue to ensure that the staff team are appropriately qualified to meet the 50 target of staff to have achieved at least NVQ level 2. The registered provider must 30/11/06 ensure that the ground floor lounge is not overcrowded The first floor and second floor 30/11/06 lounge must be available for use and items such as wheelchairs DS0000067473.V315162.R01.S.doc Version 5.2 Page 28 Requirement 2. OP18 OP30 13 (6) 18 (c)(i) 15 (b)(c) 3. OP7 4. 5. 6. OP26 OP24 OP28 16 (k) 16 (c) 18 (a) 7. 8. OP20 OP20 23(e) 23 (l) Shaftesbury House Residential Home 9. OP20 23 (p) must be stored in an alternative area The light on the second floor landing must be replaced 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP12 OP12 OP30 Good Practice Recommendations It is recommended that the home recruits dedicated activities staff It is recommended that the home asks residents for their suggestions on activities and they be provided on a more regular basis It is recommended that staff are provided with individual learning and development profiles Shaftesbury House Residential Home DS0000067473.V315162.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. 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