Inspection on 02/08/06 for Shaftsbury House Care Home

This inspection was carried out on 2nd August 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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shaftsbury House Care Home 24/07/07

Shaftsbury House Care Home 20/12/05

Shaftsbury House Care Home 15/06/05

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 S70 4DJ Lead Inspector Mrs Sue Stephens Unannounced Inspection 2nd August 2006 12:20 Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 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 Shaftsbury House Care Home DS0000056401.V303454.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 Adults 18-65. 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. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 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 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) 01226 786611 01226 786622 inquiries@sunhealthcare.org Sun Healthcare Limited Mr Lee David Watson Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 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. 20th December 2005 Date of last inspection 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 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 and parking space. There is ground floor and first floor accommodation and a passenger lift gives access to both floors. Shaftsbury house provides two of its beds for respite care. The manager provided the information about the homes fees and charges on 27th April 2006. The manager said fees are based on individual’s needs and assessments. If there are any additional charges these are agreed in the contract of care. Enquiries about the homes fees can be discussed with the manager. Prospective residents and their families can get information about Shaftsbury house by contacting the manager. The home will also provide a copy of the statement of purpose and the latest inspection report. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced; it took place between 12:20:pm and 6pm. The inspector sought the views of 4 service users (including 2 on respite), 2 relatives, and 3 staff. The manager was off duty and the deputy manager, Debbie Ramsden, assisted with the visit. Checks were made on samples of documents relating to the residents care and safety. During the visit the inspector also looked at the environment, and made observations on the staffs manner and attitude towards the residents. The inspector tried to contact two visiting professionals about their views of the home; unfortunately they were off duty at the time of the calls. The inspector checked a sample of records. These included three assessments and care plans, three medication records, three staff recruitment files, training records, and health and safety records. The inspector looked at other information before visiting the home, this included reports made by the provider about the home, and the pre inspection questionnaire (information about the home given to the Commission for Social Care Inspection (CSCI) before the visit). There had been no concerns, complaints or allegations about the home made to the commission. An allegation of abuse had occurred at the home, this was investigated and the home took the appropriate action to keep people safe. The inspector did not issue surveys to residents, families and other professionals on this occasion, this was because the visit to the home took place before the inspector had prepared the relevant surveys for the home. The inspector would like to thank the residents, relatives, deputy manager and staff for their assistance with this inspection. What the service does well: Residents have their needs assessed before they come to live at the home. People are given information about the home and the residents get a contact about their care and accommodation. The care plans tell staff how to care for and support people. People can express their likes, dislikes and aspirations. The home will work towards achieving these with the person. The residents and relatives were satisfied with the personal and health support the home provides. A resident said about their care, “(staff) make sure I’m not poorly” Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 6 Relatives said about the care, “Staff are marvellous” and “(family member name) seems quite happy”. The staff support the residents to make safe personal choices and encourage them to be independent. The residents said they were satisfied with their lifestyle at the home. One relative said staff had “bent over backwards” to help their family member enjoy positive daily routines and activities. A resident said they had developed their own activity plan. The home provided good nutritious food and gave residents choice about what they wanted to eat. The medication systems were safe and managed well. Residents and relatives were comfortable that they could raise concerns or complaints with the home. The home followed adult protection procedures to make sure residents were kept safe. The residents were happy with the homes environment and their bedrooms. The home was clean, comfortable and well maintained. 60 of the staff had a National Vocational Qualification in care; this meant that the residents received consistent and professional care. There was always sufficient staff on duty to meet the residents needs. The manager managed the home well. There were good quality audits that checked the residents’ safety and that staff carried out safe practices. What has improved since the last inspection? The home had made excellent progress at improving the standards at the home. And there was strong evidence that the staff were committed to improving the residents’ lives and giving them good experiences. The home had met all the previous requirements. They had acted promptly to medication requirements; the medication system was now safe and managed well. Staff had put better information into the care plans, and they had begun to use person centred approaches to make the plans better for the residents. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 7 Staff said the home was much more organised and they had good leadership. This had benefited the residents because they had more activities and staff gave them consistent care. The cleanliness of the home had improved, the home had employed a cleaner and staff understood their duties better. The home had looked at the training needs of the staff and had arranged the training they needed. The provider had carried out regular visits to the home; these visits had focused on the need for improvements (for example medication). This had helped the home achieve the improvements. 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 DS0000056401.V303454.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 2 The quality outcome of this area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Shaftsbury House has good information about the home; this helps people to choose if Shaftsbury is the right home for them. The residents have their needs assessed, before they move in, and they are given a contract that tells them about the service they will receive. EVIDENCE: The inspector checked three care plans; the plans included individual assessments of need for each person. Social services and the home carried out the assessments. The home developed the residents’ care plans based on the information from the assessments. Where a person had very complex needs the home had worked closely with other professionals to assess the persons needs. There was evidence that for residents who were able, they where encouraged to be involved in their own assessments. This included telling the home about their likes, dislikes and wishes. The deputy manager said they were developing this further with person centred approaches. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 10 Each person had a copy of their contract kept with their care plan files. One relative said the home gave them brochures and information before their family member moved in. They said the information was helpful and said they were given “quite a bit of information”. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 6,7 and 9. The quality outcome of this area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Individuals are involved in decisions about their lives; and they can play an active role in planning their care and support. EVIDENCE: The deputy manager said the home was improving peoples’ care plans to make sure they had a better person centred approach. This means that the plans focus on the person’s likes and dislikes, and their aspirations. This is good practice and encourages the residents to make decisions about their own lives. Some of the plans had not yet changed to a person centred approach, however they did hold good information about the individuals. The plans gave staff clear instructions about how to support peoples’ individual needs and their behaviours. The home invited residents (who were able) to sign their own plans. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 12 One resident said they had developed their own activities plan. The resident said they had support from staff to do this and they could change it whenever they wanted. One relative said the home involved them in planning care for their family member and said “We can ask for chats about (family member’s) care whenever we want”. The staff gave good examples about how they encourage the residents to make personal choices. These included helping some one to choose how to spend their day, working with advocates and other professionals, and explaining to people what the risks might be from some of their decisions. The staff interviewed made the following comments: “We encourage people and guide them”, “we try to get them to make their own decisions”, and “we talk it through with them”. The staff gave clear and consistent guidance to people who had limitations on their freedom and choice. This was also set out in the care plans. The residents said they felt that in the main they could make their own decisions. If staff did not support their decision the staff explained to the resident why. For example it was because it did not promote the residents welfare. Residents had risk assessments drawn up for their individual needs. Staff explained that they discussed risks with the residents, and prompted them to make decisions that would keep them safe. The relatives said they felt that the home encouraged their family members to make decisions, whilst respecting the individual’s capacity to understand that decision or choice. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 12,13,15,16,and 17. The quality outcome of this area is good. This judgement has been made from evidence gathered both during and before the visit to the service. People who live at Shaftsbury House are able to make choices about their life style, and staff support them to develop their life skills. Social, educational, cultural and recreational activities meet the residents’ expectations. EVIDENCE: The staff and relatives said the activities had improved. Staff said people got out more now and did more activities. One resident said, “I didn’t go out at all before I moved here, now I do”, “I’ve been to the shops today and I have done some exercises”, and “I have made my own activity plan”. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 14 There was a busy atmosphere at the home during the early afternoon. Residents were coming and going from shopping trips, outings with staff, and day centres. Some residents planned their own daily routines independently. And staff supported residents who could not do this. One care plan illustrated that the home had worked very closely with the day centre and other professionals to encourage a resident to maintain a structured daytime routine. The resident’s relative said the home had “bent over backwards” to help their family member. One relative said the home had supported their family member to take a holiday with the family. Staff said they planned to have a holiday for some residents later in the year. Staff explained some of the things the residents liked to do and these included, bowling, pictures, day trips, seaside trips, Chinese meals and shopping trips. The residents said they enjoyed their meals. One resident confirmed they could choose what they wanted. Snacks and drinks were always available. One resident said the staff had encouraged them to follow a healthy eating plan. A staff member confirmed this and said “we have to respect their decision if they don’t feel like following the plan all the time”. A resident said, “you can have what you want, you can tell staff and they will cook it” A relative said, “We call at weekends and the dinners look really good with lots of fresh veg” and “they have BBQs, which they enjoy”. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 18,19 and 20. The quality outcome of this area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The residents receive health and personal care that is based on their individual needs. The residents benefit from the homes principles of respect, dignity and privacy. EVIDENCE: The relatives said they were satisfied with the personal support their family members receive. One relative said the home had worked well to help their family member and described their family member as having made “great strides” and “real progress” and “doing really well”. One relative said the staff were excellent at giving them regular information about their family member’s progress. The staff interviewed understood the principles of personal care well. They described how they supported people and encouraged them to be independent with their personal needs. They also understood the needs of the residents who were less able, and understood how to maintain the residents’ privacy and dignity. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 16 The residents and relatives said the home gave good support to people with health needs. One resident said “they get me to make an appointment with the doctor” and they help with medication to “make sure I’m not poorly”. The management of the medication had improved significantly since the last inspection. The storage of the medication was very clean and organised. It was easy to identify individuals’ medication, and the records were neat and up to date. The systems were safe and organised, and staff had easy access to the medication procedures and information about individuals’ medication. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 22 and 23 The quality outcome of this area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. People are able to express their concerns. The home has a robust and effective complaints procedure, which protects people from abuse, and protects their rights. The home needs to review how it can protect residents who are uncomfortable with other people’s behaviours. EVIDENCE: The staff knew what to do if someone wanted to make a complaint and the procedure was on display in the entrance hall. However staff were unable to find the complaints book on the day of the inspector’s visit. One resident said they were able to raise concerns or complaints and said, “I can complain to the manager Lee, and he would listen to me”. The relatives also confirmed that when they had raised concerns or complaints the home took action and followed them up. Two residents and one relative said they were concerned about another resident’s behaviour. The residents said they felt “threatened” when they hear swearing and doors slamming. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 18 During a quality audit the home had discovered that a resident’s welfare and safety was at risk. The home had taken immediate action and followed robust adult protection procedures. The home worked closely with social services, the police and the commission for social care inspection to ensure the persons safety. Good quality audits had highlighted the concern at an early stage. The staff said they had received adult protection training and knew how to report poor practice. However two staff members did not know where the adult protection procedures were in the home or about their contents. Some staff had not had adult protection training. The deputy manager said she was aware of this and had included this in the homes training plan. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 19 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 the following standard(s): 24 and 30 The quality outcome of this area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The physical design and layout of the home enables the residents to live in a safe, well-maintained and comfortable environment, which encourages their independence. EVIDENCE: The residents and relatives said they were happy with the home’s environment. Staff said that the home carries out repairs in good time. A maintenance person had redecorated areas of the home. The home looked fresh, clean and homely. There were a variety of rooms to sit in and all had comfortable chairs. There were pictures on the walls and the colour schemes were bright and fresh. The home employed a cleaner as well as care staff having cleaning duties. One staff said they encouraged the residents to be involved in some of the cleaning and in taking pride of their own bedrooms. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 20 The bedrooms were personalised with how the residents liked their rooms. Staff encouraged residents to enjoy shopping for nice things for their rooms, and encouraged the residents to use their rooms as their personal space. The relatives said about the home: “It’s clean”, “beds are changed regularly and there are always clean towels”, “Its lovely just now” and “It all looks nice”. There was level access to the gardens; these were well maintained and pleasant to sit in. The garden had good quality garden furniture, a rockery and waterfall and space for residents to do their own gardening if they wished. The residents and relatives said they were satisfied with the homes laundry facilities. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 21 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 The quality outcome of this area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. In the main staff are trained, skilled and in sufficient numbers to support the residents, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: The residents and relatives said, about the staff: “They are kind and friendly” “The are good” “They have been marvellous” “They (managers and staff) are nice with the residents”. One staff said “its great here, I love it”. The staff interviewed understood their roles, they had good principles of care and spoke confidently about promoting peoples independence and respecting their rights. One staff member said the management of staff had got “much better”, there was clear leadership and staff knew what to do. The staff understood people’s diversity needs and they could explain what it meant to the individuals. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 22 There was a positive atmosphere amongst the staff, the staff were welcoming, and they chatted, laughed and smiled with the residents and visitors. Some staff had not had the training to deal with challenging behaviours. This included understanding de-escalation techniques and some physical restraint. One staff commented, “It is easy with someone who has done the training”. The deputy manager said the manager had qualifications suitable to train the staff to deal with challenging behaviours and physical intervention. The deputy manager said she had set dates for the remaining staff to receive the training. One staff said there had been “excellent improvements” in the training available to staff. Dates had also been set with the local authority for staff to attend positive behaviour management. This was good practice because the training was relevant the specific and complex needs of the residents. The manager confirmed in the pre-inspection information that 60 of staff had a National Vocational Qualification in level 2 or above. And he said this was now about 65 at the time of the inspectors visit. This was a good achievement; it exceeded the National Minimum Standard guidance of 50 and enabled staff to be knowledgeable and competent in their roles. The deputy manager said the home is “never understaffed” because they have their own bank of staff and do not need to use agency. This is good practice and enables the residents to receive care from a consistent staff team. The inspector checked three staff recruitment records. The records were up to date and well maintained. The home had followed robust procedures to make sure they employed the right people to support the residents. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 23 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The quality outcome of this area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The management and administration of the home is open and respectful. The quality assurance systems are effective; and a qualified and competent manager manages them. EVIDENCE: The manager had sufficient experience and suitable qualifications to manage the home. Mr Watson has introduced good improvements to the home; this has included employing a deputy manager and therefore providing the staff team with increased leadership and support. The home carried out effective quality assurance. For example the home intercepted a risk presented to the residents at the early stages (See standard 23); and the manager audited the medication systems regularly to confirm that staff followed safe practices. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 24 The provider carried out regular visits to the home and checked with the residents and staff about their views on the home. The manager had reviewed safe working practice policies and procedures and the health and maintenance checks were up to date. The manager confirmed this in the pre inspection information. The fire maintenance book was up to date. Safe working practice training had improved, however it was still not up to date, and some staff were without basic training, for example, moving and handling, first aid and fire awareness. The deputy manager was aware of this and had planned training dates into the homes training programme. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 26 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 YA22 Regulation 22 Requirement Timescale for action 02/09/06 2 YA23 13 The complaints records must always be available. This must be kept in a place where the appropriate staff know where to find it. The home must consult with the 02/09/06 residents and identify those who may feel threatened or intimidated by other residents’ behaviours. The home must take action to support and safeguard residents who are concerned about this. This must be part of the persons care plan. The home must ensure that all staff receive adult protection training. All staff must be made aware of where they can access the adult protection procedures in the home. The home must take action to make sure staff are aware of the contents of the procedures. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 27 3 YA35 13 4 YA42 13 The home must make sure all staff complete the planned training on physical intervention and dealing with aggression. The home must make sure that all staff complete the planned safe working practice training. 02/09/06 02/09/06 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 Refer to Standard YA6 Good Practice Recommendations The inspector recommends that the home continue to make good progress with the person centred approaches and care plan developments for all residents. Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sheffield Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Shaftsbury House Care Home DS0000056401.V303454.R01.S.doc Version 5.2 Page 29 - 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!