CARE HOMES FOR OLDER PEOPLE
Shafto House Shafto House Shafto Way Newton Aycliffe Co Durham DL5 5QR Lead Inspector
John Trainor Unannounced Inspection 10:50 29 November 2005
th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 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.V259466.R01.S.doc Version 5.0 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.V259466.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd June 2005 Brief Description of the Service: Shafto House is a local authority care home which provides care for up to thirty people from within the categories of older persons(OP 29 places) and dementia care (DE(E) 1 place). All of the accommodation is single occupancy and on ground floor level. The home is divided into three semi independent living units. Each has its own dining room, lounge and kitchen where drinks and snacks can be prepared. There is a garden for residents to enjoy in fine weather and car parking for visitors is good. Meals are prepared in the homes main kitchen, which also provides meals for the adjoining day centre. 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.V259466.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 2 hours during which, people were spoken to about their experience of living in the home, there was a tour of the building and documents were inspected including care plans and health and safety documentation. The representative of the home was the registered manager Mr Kevin Mulvey. What the service does well: What has improved since the last inspection? What they could do better:
People’s choice would be increased by the home writing to confirm they were able to meet the assessed needs of people before they moved in, as people would be sure the home could look after them properly Daily care records were being kept separately from care plans. It was felt this would be better if care plans and records were together so care staff used care plans every day were familiar with what was in them and recorded on peoples identified care needs. This is so people can be sure their recorded needs are met and planned care is given each day. People must have their own individual toiletries and staff should not use communal bars of soap which can spread infections. It was recommended the registered person consult with the fire officer with regard to the means and frequency of fire training to see if this was good enough. Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 Page 6 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.V259466.R01.S.doc Version 5.0 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.V259466.R01.S.doc Version 5.0 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): 3 and 6. People had their needs assessed prior to making a decision to move into the home though needed confirmation the home could look after them properly. EVIDENCE: Care management assessments were in evidence on all files inspected. Care was reviewed after six weeks to ensure the appropriateness of the service. The home does not provide intermediate care. Though there was evidence people had signed the contract on some of the care files, people did not have confirmation in writing prior to making a decision to move into the home that the home could meet their needs following the assessment. Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 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, 8 and 9. People had their personal health and social care needs met. EVIDENCE: Care plans were in all files inspected though there was a separation of the care plan and daily record sheet which meant the care plan was not a working document care staff referred to every day. There was evidence in the files of both primary and secondary health care input into peoples care packages. Medication was stored administered and recorded safely and appropriately. Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed at this inspection. EVIDENCE: Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed at this inspection. EVIDENCE: Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed at this inspection. EVIDENCE: Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People could be assured their needs would be met by a staff group deployed in sufficient numbers and with sufficient skill to look after them. EVIDENCE: Staff were deployed in sufficient numbers. There was a commitment to training to NVQ level 2 or above with those qualified well over 50 of the workforce. Staff were recruited in a way which protected the safety of the people living in the home. Training was acceptable with induction and health and safety training, though fire safety was only given annually by use of a training video. Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. The home was managed with due concern to the needs of the people and with attention to their health and safety. EVIDENCE: The Manager, though not maintaining registration, had qualified as a psychiatric nurse and had NVQ 4 in care and management. Health and safety checks were conducted appropriately including checks on equipment, gas and electrical safety and risk assessments were completed. Recommendations from a recent fire officers visit had in the main been implemented with plans to complete work on all recommendations. Service user finance records were maintained appropriately and recorded in care files.
Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 Page 15 Staff were appropriately supervised in line with the National Minimum Standards. There were several bars of soap left on sink or bath sides in the home and though the manager assured me all people had their own this did suggest that communal bars were being used which is an infection control hazard. Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 Page 16 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 Page 17 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 OP3 Regulation 14 (1(d)) Requirement For all future admissions the registered person must confirm in writing that following assessment, the home is suitable to meeting their assessed needs with regard to health and welfare. Timescale for action 29/11/05 Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended daily care records are not stored in isolation from care plans so that care plans are working documents. When completing the daily record staff should refer to the plan of care recording on those identified care needs. It is recommended the registered person consult with the fire officer with regard to the frequency and means of staff fire training to ensure current measures meet recommendations. It is recommended all staff are reminded communal bars of soap must not be used, each individual must have their own as use of communal bars of soap is an infection control hazard. 2 OP38 3 OP38 Shafto House DS0000031217.V259466.R01.S.doc Version 5.0 Page 19 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.V259466.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!
