CARE HOMES FOR OLDER PEOPLE
Shaftesbury Rest Home 49 Shaftesbury Avenue Highfield Southampton Hampshire SO17 1SE Lead Inspector
Lorraine Parton Unannounced Inspection 24th January 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 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 Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Shaftesbury Rest Home Address 49 Shaftesbury Avenue Highfield Southampton Hampshire SO17 1SE 023 8058 4478 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) northoverresthomes@tiscali.co.uk Mr Roy Clive Northover Mrs Heather Northover Ms Paula Smith Care Home 17 Category(ies) of Dementia - over 65 years of age (17), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (17), Old age, not falling within any other category (17) Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Residents in the categories MD(E) and DE(E) not to be admitted under the age of 55 years 28th October 2005 Date of last inspection Brief Description of the Service: Shaftesbury Rest Home is a care home providing care and support for 17 older people with care and support needs associated with old age, dementia and mental health. Mr and Mrs Northover have owned the home for the past eighteen years. Ms Paula Smith oversees the day-to-day management of the home. The home is situated in the residential area of Highfield and within walking distance of Portswood shopping centre. Accommodation is spread over two floors and comprises of nine single bedrooms and four shared rooms. Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The second inspection of the inspection year took place over 3 hours and the purpose was to ensure compliance with previous legal requirements brought to the homes attention at the first inspection in October 2005 and to complete the inspection process for the year. The inspector audited 3 standards and reassessed 5 standards, in which the inspector had raised requirements at the last inspection. All key standards have now been assessed throughout the year. The inspection involved a walk around the home and an audit of some of the homes documentation. The inspector was assisted by the registered manager. Much of the inspection was spent talking to the service users who clearly displayed their involvement in the home. Service users spoken to advised the inspector that they enjoy living at the home and that the homes staff are ‘wonderful’, ‘kind’ and ‘caring’. What the service does well: What has improved since the last inspection?
The home has started to review service user plans and incorporate specific information into them regarding the management of mental health. The home has purchased a new telephone for both the private use of service users and for use by staff at night who had potential issues in accessing the sleep in member of staff in an emergency.
Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 6 The home has replaced several worn out chairs and has plans for replacing all the lounge chairs in the home. One room has been decorated since the last inspection. The home has reviewed and enhanced its recruitment practices to ensure all staff employed are only done so on the completion of satisfactory receipt of appropriate checks. The home has completed an inventory for all service users, which maintains a clear record of personal valuables that service users have. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: None of the standards were assessed on this occasion. Standards 2,3,4,5 and 6 were assessed at the inspection in October 05 and met. Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 10 All service users have extensive care plans. Service users privacy is maintained. EVIDENCE: The inspector audited four service user plans. The registered manager advised that three of them had been reviewed since the last inspection. The fourth plan audited was for a new service user. The home had reviewed and developed the care plans to include specific information on managing mental health issues and to ensure all plans and risk assessments were dated. The service users are involved in the formulation of the plans and they or their representatives had signed the care plans, displaying their involvement. The new service user’s plan the inspector audited was found to contain an assessment undertaken by the home and a copy of the care managers assessment both of which had been completed prior to moving into the home. These assessments had been used to develop the service users care plan,
Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 10 which although basic covered all relevant areas and appropriate risk assessments had been completed for areas identified as a risk. The registered manager advised the inspector that they had purchased a mobile phone to enable service users to receive and make calls in private if they wish. A requirement for this had been made at the last inspection. The previous inspection in October 05 identified that standards 8,9 were met. Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 11 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): 15 Service users confirmed that the home provides excellent food of their choice. EVIDENCE: Service users spoken to stated that the home provides good food and offers a choice of menu. Menus display a well balanced and nutritious variation, which, the service users stated are based on their likes and dislikes from documented service user meetings. Individual choices and needs in food are catered for and this includes likes, dietary needs and special requests. The inspector was present for the lunch time meal and it was noted to be well presented, nutritious and of a quantity that service users state meets their dietary needs. Meal times were noted to be relaxed and service users who were being supported were not rushed and their dignity was maintained. The previous inspection in October 05 identified that standards 12,13 and 14 were met. Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 12 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): 18 The home has procedures and practices in place to protect where possible service users. EVIDENCE: The home has a copy of Hampshire’s Adult Protection procedure and a whistle blowing policy. On speaking to staff they displayed their awareness of what constitutes abuse and the appropriate action to take if necessary. All staff had received training in adult abuse awareness given by the registered manager through a video and questions devised by the manager. The home has implemented suitable recruitment procedures to ensure service users are protected and three staff files were audited and found to contain all relevant information. This had been a requirement at the last inspection. The previous inspection in October 05 identified that standard 16 was met. Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 13 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 The environment of the home is being improved, however, there is a need for further improvements. EVIDENCE: Previous inspections indicated that the home needs to replace lounge chairs and implement a system for staff to summon assistance when on night duty. The manager advised the inspector that they purchased a telephone that has an intercom system that enables the waking staff to summon assistance if necessary. Several new chairs have been purchased for the lounge and the home is replacing the others on a monthly basis. The home has also decorated one room since the last inspection. Further decoration is needed and this was discussed with the registered manager. Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 29 The home has suitable recruitment procedures in place for the employment of new staff. EVIDENCE: Three staff files were audited by the inspector and found to contain all the relevant information including application form, contracts and job description, references, identification, interview records. Staff files also contained training and induction records, supervision notes and appraisals that had been carried out. The manager advised the inspector that they had reviewed and developed all their staff files since the last inspection. The home had obtained references and CRB and a POVA checks for a new member of staff before employment, since the last inspection. This had been a previous legal requirement. The previous inspection in October 05 identified that standards 27,28 and 30 were met. Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 15 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): 35 Systems are in place to safeguard service user finances. EVIDENCE: The home does manage and look after some service users money, which was stored and accounted for. The home cashes some service users money, which did not appear to have been agreed with the service users care managers. The home agreed to consult with the service users care managers who’s money they deal with to ensure that they agree the procedures followed by the home are within the current guidelines. This must be in writing. A requirement has been made. The home now keeps an inventory of service users valuables, which had been a requirement at the last inspection. Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 16 The previous inspection in October 05 identified that standards 31, 32, 33,34 and 38 were met. Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X x Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP35 Regulation 20(3) Requirement Obtain in writing confirmation of acceptance from the care managers of the service users regarding procedures where service users money is being managed by the home. Timescale for action 30/05/06 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. Refer to Standard OP7 OP33 Good Practice Recommendations Continue to develop and enhance all service user plans. Continue to develop and enhance the quality monitoring system that has been started in the home. The should include the views of all the stakeholders of the business and provide CSCI with an annual report of the survey. Shaftesbury Rest Home DS0000011848.V278167.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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