Inspection on 24/05/06 for Shafto House

This inspection was carried out on 24th May 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 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

Shafto House 29/11/05

Shafto House 06/10/04

Shafto House 13/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Shafto House Shafto House Shafto Way Newton Aycliffe Co Durham DL5 5QR Lead Inspector Mr Leonard Hird Unannounced Inspection 24th May 2006 09:30 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 Shafto House DS0000031217.V294245.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. Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shafto House Address Shafto House Shafto Way Newton Aycliffe Co Durham DL5 5QR 01325 312961 01325 312961 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) Durham County Council Mr Kevin Mulvey Care Home 30 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (29) of places Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: Shafto House is a local authority care home providing are for up to 30 persons in the categories of Older Persons (OP) and 1 person in the category of Dementia Care (DE(E)) All of the accommodation is single occupancy and on ground floor level. The home is divided into three semi-independent living units. Each unit has its own dining room, lounge and kitchen where drinks and snacks can be prepared. Meals are prepared in the homes main kitchen, which also provides meals for the adjoining day centre. There is a garden for residents to enjoy in fine weather and car parking for visitors is good. Shafto House is situated in the centre of Newton Aycliffe close to the town centre and within easy reach of public transport. Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection of Shafto House took place on the 24th May between 0930 and 1530 hrs as well as the 26th May between 1130 and 1430 hrs. The inspection process considered all of the Key standard areas as identified by the Commission for Social Care Inspection within the Care Homes for Older People National Minimum Standards. These Key standards are: Choice of Home (NMS 3), Health and Personal Care (NMS 7, 8, 9 and 10), Daily Life and Social Activities (NMS 12, 13, 14 and 15) Complaints and Protection (NMS 16 and 18), Environment (NMS 19 and 26), Staffing (NMS 27, 28, 29, 30,) and Management and Administration (NMS 30, 31, 33, 35 and 38). The Commission for Social Care Inspection received 11written comments from residents and their relatives as well as 10 verbal comments on the days of inspection from residents, family members, visitors, social workers and senior visiting health professionals. Comments were also received from the registered manager, members of the care staff team and team manager. What the service does well: What has improved since the last inspection? There had been improvement in the way that new residents were informed in writing that the home could meet their needs. That documentation to electrical wiring at the home was now been kept at the home. Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shafto House DS0000031217.V294245.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 Shafto House DS0000031217.V294245.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): NMS 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Shafto House ensured that prior to admission, an assessment of the needs of the prospective resident seeking to be admitted to the home had been undertaken by suitably qualified staff. Shafto House does not provide intermediate care EVIDENCE: Care plans inspected contained records of an assessment undertaken by the local Social Care and Health Team as well as a record of assessment undertaken by the home. Shafto House following a requirement made at the last inspection had provided written confirmation to new residents that the home could meet their needs. Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 9 Residents living on the residential unit spoken with during the inspection confirmed that assessments had been made prior to admission. From discussions with a visiting a social worker to the home during the inspection it was confirmed that a full assessment of need had been undertaken prior to admission by the local authorities social care and health team. The visiting social worker also commented, “the working relationships with Shafto House were very good and this was to the benefit outcomes for the residents” Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NM S 7 NMS 8 NMS 9 NMS 10 Quality in this outcome area was excellent. This judgement has been made using available evidence including a visit to this service. Individual residents health, personal and social care needs were being set out in their care plan. Residents were able to make decisions about how they could lead their lives and were treated with respect and dignity. The homes medications policies, procedures, guidance and programme enabled staff to dispense medication to residents safely. EVIDENCE: Residents living at Shafto House had individual plans of care in place and information was being maintained on the individual residents health and personal needs. Individual residents care plans covered the areas of personal care, mobility and health requirements. Assessments of risk were included in the plans and these Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 11 training assessments took into account the individual residents views e.g. whether to self-medicate or not. Staff had reviewed individual residents plans of care and where any changes had been identified then these had been actioned. The homes registered manager confirmed that a new care plan and recording system was about to be introduced. Records were being maintained by the home of the individual residents health needs as well as records of visits made by GPs and other health professionals to the home. Records were being maintained of the training undertaken by care staff in the safe handling and administration of medication. A consultant physician who was visiting residents, in the home, on the day of the inspection commented, “that there were excellent working relationships between their specialist medical team and the homes care staff thereby ensuring that the health outcomes for residents were very positive.” A written comment received from a resident stated ‘the care I get is very good and Im very happy’ Residents commented “I see a doctor when I need to and the staff look after me” “I had to go for an operation and the staff have made sure that take my medicine at the right time” It was observed during the inspection that though the staff had very friendly and positive working relationships with the residents they treated the residents in a respectful and dignified manner at all times. Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 12 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living and activities available at Shafto House were varied and flexible and generally meeting the needs of the residents. The independence and personal choices of residents at Shafto House were being actively promoted by the home. The dietary needs of residents were well catered for with a balanced and varied selection of food being provided. EVIDENCE: It was observed that the daily routines of living were flexible and meeting the needs of residents. One resident commented in writing, ‘I feel very happy in Shafto House’ Another resident commented, “ They could get up when they felt like it” Relatives visiting the home spoke well of the homes visiting policy and a visiting relative commented “they could visit at any time to the home and staff made them very welcome ” Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 13 Activities were being arranged within the home and records were being maintained of the activities undertaken by residents. There was however not a member of staff clearly identified as the activities co-ordinator within the home and activities relied heavily on the use of the day centre facility located in the home or the involvement of Create. Residents were generally happy with this arrangement though a written comment received indicated that there were not enough activities taking place specifically designed for the residents of Shafto House Menus were being displayed in the home of the different choices of food available and special diets were being catered for where required. Residents commented, “the quality of the food at Shafto House is good and theres plenty of it” “if there is something on the menu I dont like I can choose something different” Records were being maintained of the choice of food being made by residents as well as records of the homes Menus. Records of training including Food Hygiene undertaken by the catering staff were being maintained on their personnel file. Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 14 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): Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. The complaints and adult protection policies and procedures currently being used in Shafto House provide for a safe environment for residents to live in. EVIDENCE: Shafto House had appropriate policies and procedures in place for the Protection of Vulnerable Adults. Staff had received training on how to deal with the Protection of Vulnerable Adults and records were being maintained of this training. In discussions with staff they confirmed that they were fully aware of the importance of acting quickly in cases of suspected abuse and that they would follow the homes policy and procedures if necessary. They also confirmed that they had received training in how to deal with the Protection of the Vulnerable Adult. The home also had appropriate policies and procedures in place for residents and their families on how and who to complain to if they needed. Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 15 Information on how to complain was being displayed on the notice boards throughout the different units as well as being contained in the residents guide to the home. Residents were aware of how and who to complain to. One resident commented, “that if wanted to complain they could and that they knew who to complain to” Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 16 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): NMS 19 and NMS 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Shafto House is clean, pleasant and hygienic and provides a safe and comfortable environment for its residents. EVIDENCE: Shafto House had been recently re-decorated and furnished to a pleasant and homely standard. A resident spoken with commented, “ “the room I live in is what I like and want ” The communal living areas were well decorated and maintained. Maintenance work undertaken on the homes equipment and facilities by the handyman as well outside contractors had been recorded appropriately. Shafto House is clean, tidy and free from unpleasant odours. Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 17 There were appropriate systems in place for infection control. The homes infection control policies and procedures were written in accordance with relevant legislation and professional guidance. It was confirmed by staff that they had received appropriate training in infection control and a record of this had been kept on their personnel file Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 18 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): NMS 27 NMS 28 NMS 29 and NMS 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Shafto House through its recruitment, employment and training procedures had ensured that only suitably qualified care staff and ancillary staff had been employed. Staffing levels at the home were sufficient to meet the current assessed needs of the residents. EVIDENCE: From a review of the staff rota provided it was noted that staff were being deployed in sufficient numbers as to ensure the current needs of the 23 residents were being met. There was a commitment to training for all staff at the home and currently over 75 of the homes care staff were qualified at NVQ level 2 in care or above. Staff had received appropriate induction training and there was also a rolling training programme operating in the home providing training for staff in moving and handling, first aid training, working with dementia and the Protection of Vulnerable Adults. Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 19 In documentation sent to the Commission for Social Care Inspection by the homes registered manager it was also confirmed that 16 members of the care staff had undertaken a diversity course in the last 12 months. Records were being maintained of all training given in the home and individual records of training were kept on the staffs files. All staff employed at the home had being recruited in accordance with the homes policies procedures and that of Durham County Councils. All of the appropriate employment checks prior to starting to work at the home had been undertaken and recorded accordingly. Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31 NMS and 33 NMS 35 and NMS 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Shafto House has a well-established management structure ensuring that the home promotes the health, safety and welfare of residents and Staff EVIDENCE: There were clear lines of management, accountability and support systems to be found within the home. Formal supervision sessions were being given to all members of the care staff and ancillary staff. Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 21 Records of staff supervision sessions were being maintained safely and staff confirmed that they had received copies of their supervisions. From discussions with staff it was confirmed that they were aware of the management structure within the home as well as that of the local authority. Comments received from residents, relatives and visitors during inspection were positive; “staff were kind and considerate” A written comment received from a relative stated, “the staff are brilliant and my mother is very happy living there” Regular fire alarm tests and fire drills had been undertaken at the home and records were being maintained accordingly. In documentation sent to the Commission for Social Care Inspection by the homes registered manager it was confirmed that all staff had undertaken a fire awareness course in the last 12 months. Records were also been were being maintained of when equipment had been serviced and who had undertaken and completed the work. Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP4 from OP12 Good Practice Recommendations It is recommended that when annual reviews have been undertaken and completed the home confirms in writing that it still can meet the needs of the resident It is recommended that the home identifies a member of staff to act as the activities coordinator Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shafto House DS0000031217.V294245.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!