Inspection on 15/06/05 for Shaftsbury House Care Home

This inspection was carried out on 15th June 2005.

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

Other inspections for this house

Shaftsbury House Care Home 24/07/07

Shaftsbury House Care Home 02/08/06

Shaftsbury House Care Home 20/12/05

Shaftsbury House Care Home 09/02/05

Shaftsbury House Care Home 16/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Shaftsbury House Care Home 53 Mount Vernon Road Barnsley South Yorkshire S70 4DJ Lead Inspector Sue Stephens Unannounced 15 June 2005 13:00 - 18:30 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Shaftsbury House Care Home Address 53 Mount Vernon Road Barnsley S70 4DJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01226 786611 01226 786622 None Sun Healthcare Limited Lee David Watson (not yet registered) PC Care home only 10 Category(ies) of LD Learning Disability (10) registration, with number of places Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing levels are maintained at, at least the levels required by the Residential Forum `Care Staffing in Care Homes for Younger Adults` published April 2002. The manager is employed to work full time (40 hours a week) and these hours are over and above those required by the Residential Forum Guidance. Date of last inspection 9 February 2005 Brief Description of the Service: Shaftsbury is a care home for younger adults with learning disabilities; it provides personal care and accommodation to 10 residents. Sunhealth Care Limited provides the care and accommodation. Shaftsbury House is situated within easy reach of Barnsley town centre. The home is close to a bus route and has its own transport. The home is set in its own grounds with gardens accessed via a spacious conservatory. There is ground floor and first floor accommodation and a lift accesses both floors. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 5 hours, between 13:00pm and 18:30 pm. A partial inspection of the premises was carried out. Consultation with residents, staff and the manager took place. Samples of the homes records, including three residents’ records, were checked. Five residents were consulted, either individually or in small groups; and observations were made of the resident’s daily routines, and their relationship with staff and the manager. Staff were consulted, or observed carrying out their duties. Over the past 12 months there had been a turnover of three managers and this had affected the continuity of the homes management; a new manager has been appointed and has applied to the commission for registration. The residents, staff and manager are thanked for the welcome they gave to the inspector and their assistance during this inspection. What the service does well: What has improved since the last inspection? A new appointed manager was providing better consistency for the homes aims and values. The manager had begun to introduce better systems and provide staff with direction. Work had been done on some care plans to improve the information and format. Most staff had now received adult protection training. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 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. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3 Resident’s needs were assessed prior to being admitted to the home, reviews on their assessments were needed to ensure their changing needs are met. EVIDENCE: The manager said assessments were carried out with the resident’s participation before being admitted to the home. The manager was revising the homes assessment tool; to provide a more thorough assessment of residents needs. For example environmental issues had been raised for people who use wheelchairs; this was not included in the homes present assessment tool. Because the assessment and care plan documentation had not been maintained in consistent order it was difficult to see if all care needs had been appropriately assessed and reviewed and followed up in the care plan. The manager said he was reviewing care planning and care practises including introducing a more person centred approach for residents. The manager and staff said they were pleased with how new residents had settled in and were pleased that some residents behaviours had improved. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8 and 9 Although improvements to care plans had been made, some plans were still not clear about changing needs, risk taking, choices and preferences; this may limit independence, safety and good care practises for individuals. The introduction of resident’s meetings promoted their involvement about life at the home; introducing a person centred approach could further develop this. Advocacy support was good, this supported residents with decision-making. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 10 EVIDENCE: Care plans contained information including the action staff were to take when dealing with behaviours; however, some of the information was not clear and easy to find; and the plans lacked a person centred approach, they were not designed in a format easy for the resident to understand. Risk assessments were in place, however these needed to be reviewed to reflect residents changing needs. The manager was working with senior support workers to make improvements and clarify care planning roles and responsibilities. Residents consulted confirmed they felt included in making decisions, and staff were observed encouraging residents to make choices; for example, helping a resident to choose and buy jewellery and encouraging a resident to choose items for their bedroom. Where residents used independent advocates this had been recorded; residents were supported in using advocates and other external advisers, for example social workers. Resident meetings had recently been reintroduced and this encouraged participation and to discuss their wishes about the home. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,16 and 17. Residents were involved in educational, occupational, leisure and community activities; this promoted positive and enjoyable experiences with choices about their daily lives. Resident’s privacy was respected promoting their rights and choices. Meals were nutritious and included healthy options, residents had choice and flexibility with their meals and mealtimes. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 12 EVIDENCE: Residents talked about enjoying voluntary work; and attended college, daycentres and workshops. Sections of the garden were designated for residents who enjoyed gardening and a barbeque was planned for the weekend. Residents were encouraged to participate in the kitchen and help themselves to drinks. Residents were seen relaxing at the home, with the main lounge as the most popular choice; some chose to spend time in their rooms, playing music and spending time on their own. Staff were respectful about entering residents bedrooms and residents had keys to their rooms where this was suitable, allowing them independence and privacy. Residents said they enjoyed their meals and could help themselves to drinks and snacks. A planned menu was provided, however meals were often chosen on the day. The staff member interviewed had a good understanding about special diets; the food at the home was fresh and plentiful and raised tables were provided for wheelchair users. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20. Residents received good personal and health care; however resident’s preferences needed to be reflected in the care plans to ensure a safe and consistent approach. Resident’s medication safety, independence and choice could be put at risk because medication systems were not robust. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 14 EVIDENCE: Residents had good relationships with staff, and residents were included in conversations. Technical equipment was provided for people with physical disabilities and staff said they followed physiotherapy and other professional advice. Because person centred planning principles had not yet been introduced, preferred personal care routines, likes and dislikes were often based on individual staff knowledge rather that a consistent agreed approach. Health care was recorded, and access to G.P, and NHS health care including dentist and optician was provided. Medication storage was tidy and organised however the drugs cabinet was cleaned on an, ‘as and when’ basis; as a result of this some dirt was beginning to accumulate. One medication was not given consistently with prescribed instruction and one staff member did not have signature and name crossreferenced for identification on records. Medication training had been provided however training did not include an assessment of staff competence. Consent for medication had not been recorded and an assessment to identify how to encourage residents to take a more independent role in their medication was not in place. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Residents could express their views and complaints were acted on. All staff need to be trained in adult protection and understand whistle-blowing procedures to continue safeguarding against the risk of abuse to residents. EVIDENCE: A complaints policy was in place and staff interviewed knew what to do if a complaint was raised. Residents, who were able, could discuss any concerns with staff, and could contact their advocates or social workers if they wished. The home had received a complaint; correct procedures had been followed including informing appropriate agencies, the home followed local authority advice and carried out an investigation. As an outcome the home identified changes to records and systems to improve safeguarding residents. The area manager was in the process of auditing finance records; these were not checked on this inspection. Most staff had received adult protection training and the policies and procedures for guidance were accessible. One staff member was unsure about the whistle blowing procedures. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29 and 30. The daily upkeep and general maintenance of some areas of the home did not promote a homely, comfortable and safe environment. Because the en-suite lacked suitable basic facilities, resident’s dignity, respect and independence was compromised. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 17 EVIDENCE: Residents said they were happy with the home and their rooms, and they were comfortable. Most internal walls were painted in the same colour, some of the walls, including corridors were scuffed and marked, or damaged by wheelchairs, this did not give a homely, well maintained look; and some shared rooms lacked homely touches, for example pictures on walls. The external part of a fire door was without paint. Day to day maintenance had not been carried out, for example a corridor had not been vacuumed, empty carrier bags had been left as litter in one room, the kitchen window sill was cluttered and kitchen files were not clean and tidy, a cracked and broken linen basket was still in use. The conservatory was used and liked by residents, however it was untidy with clutter and equipment had been inappropriately stored there. The bedroom used for short-term care had an en-suite facility, however the sink was a small hand-wash basin and was unsuitable for personal washing; the en-suite lacked basic homely touches, for example hooks for towels and clothes and a shelf for toiletries. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32, and 36. Inconsistent leadership has led to a lesser understanding of roles and responsibilities, aims and values; the staff team need these to be reestablished to maintain resident’s welfare and good quality care. EVIDENCE: Because there had been a change of managers over the past 12 months there had been some loss of clarity about job roles, and the homes main aims and values. The manager was reviewing this and working with staff to establish roles and responsibilities, for example the responsibilities of senior support workers. Staff had received training in dealing with physical and verbal aggression and the manager was reviewing the homes training needs. All staff were training towards LDAF (learning disability awards framework) accreditation; and some staff were completing National Vocational Qualifications in care. Most staff had received a one-to-one supervision with the manager; this provided an introduction to the manager and gave leadership direction, however follow on supervisions had not yet been arranged for staff. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,40 and 42. The introduction of good leadership and management systems will benefit residents. Focus on staff support and development, improving records and improving the environment will benefit and safeguard residents welfare. Because fire systems were not robust resident’s safety could be put at risk. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 20 EVIDENCE: The manager had been in post for 3 months, he has had at least two years experience managing at a senior level and is a qualified RNMH (registered nurse learning disabilities). The manager had an understanding of his role and had applied to the commission for registration. The residents and staff team had experienced a change of three managers within the past twelve months and had not had a consistent approach towards achieving the homes purpose. The manager was in the process of reviewing the recording systems, these had not been well maintained, and some information was not easily retrievable. The manager had identified where staff needed safe working practice training and had made arrangements to bring all staff up to date. Fire records were checked; night staff had not been included in fire drills, and fire drill records did not identify used scenarios, the name of the person conducting the drill and individual’s names and signatures. The person nominated to manage fire training and records had not received additional training and certificates were not available for fire detection and the homes fire risk assessment. A wheel chair had been stored in front of a fire door. Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 2 x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 2 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score 2 3 x x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shaftsbury House Care Home Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 3 2 x x 2 2 x J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 2 3 6 Regulation 14 15 15 Requirement A review of assessed needs must be carried out for all residents. See requirement for standard 6. Timescale for action 31.08.05 31.08.05 4. 5. 6. 7. 8. 7 9 18 19 20 15 15 12 12 13 Care plans must be reviewed and 31.08.05 based on individual assessed needs. They must include the details outlined in standards 6,7 and 9. See requirement for standard 6. 31.08.05 See requirements for standards 2 and 6. Plans of care must include residents preferred personal care routines, likes and dislikes. Plans of care must include agreed approaches to health care. Medication systems must comply with The Royal Pharmacuetical Society of Great Britian guidelines. A routine cleaning system must be introduced. Complete records of initials and signatures for identification must be maintained. Medication must be given as prescribed, and queries about 31.08.05 31.08.05 31.08.05 31.07.05 Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 23 prescribed medication must be clarified with the G.P of pharmacist. residents consent for medication must be recorded. Residents must be assessed to identify independence and support needs in taking medications. A planned maintenance and renewal programme for the fabric and decoration of the premises must be produced and carried out. Daily cleaning and maintemnence routines must be carried out. Procedures must be put in place for the prompt removal and replacement of damaged household items. Fittings must be provided in ensuite facilities which meet at least residents basic needs. Shared rooms must be kept free of clutter and storage staff who have not received adult protection training must do so. Records must be maintained in line with National Minimum Standards and Care Home Regulation requirements fire precautions must be carried out in line with local fire authority requirements. 9. 24 23 31.07.05 10. 11. 12. 13. 26 28 23 41 16 23 12 17 31.07.05 31.07.05 31.08.05 31.08.05 14. 42 23 31.07.05 Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 24 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. 4. 5. 6. 7. Refer to Standard 2 6 20 28 31 36 38 Good Practice Recommendations continue to develop the homes assessment tool to improve identifying residents changing needs. Continue to work on improving plans and base these on person centred approaches. All staff giving medication should be assessed for competence. Residents should be involved in choosing and creating homely touches for shared rooms. the manager should continue to work with staff to establish and develop roles and responsibilities. Staff supervisions should be increased until roles and responsibilities and aims and values are re-established. See recommendations for standards 31 and 36 Shaftsbury House Care Home J51 S56401 Shaftsbury House V232303 150605 UI Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Ground floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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