Inspection on 20/12/05 for Shaftsbury House Care Home

This inspection was carried out on 20th December 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 no outstanding requirements from the previous inspection report, but made 13 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 02/08/06

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 20th December 2005 11:30 Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 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.V271144.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 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.V271144.R01.S.doc Version 5.0 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 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.V271144.R01.S.doc Version 5.0 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. 15th June 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 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 DS0000056401.V271144.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 4 hours between 11:40 am and 15:40 pm. The visit included an inspection of the premises, observations of care and practices, and consultation with residents, the manager and staff. Samples of the homes records, including care plans and recruitment records, were checked. Residents were consulted, either individually or observed in small groups. Since the last inspection the manager had completed registration and made improvements to the standards at the home. An allegation of abuse was reported at the home in November 2005. The home took action to safeguard residents and followed local authority procedures effectively. What the service does well: What has improved since the last inspection? Residents had had their assessed needs reviewed, and information held in care plans had improved. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 6 The plans of care included agreed approaches to health. There was a significant improvement in the décor and maintenance of the home. Shared and personal rooms had been redecorated and the entrance had been made welcoming. The home was cleaner and tidier. Clutter had been removed from shared rooms. Residents had been involved in the choosing and creating of homey touches. The manager had developed and improved the needs assessment tool. Staff roles and responsibilities had improved, and the manager had carried out supervisions with each staff member. 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.V271144.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 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 the following standard(s): 2,3 and 4. People who use the service have their needs assessed and the home works with other agencies to make sure individuals needs can be met at the home. EVIDENCE: The two care plans checked contained an assessment of the individual person’s needs, and the manager had improved the care plans to contain better information. Health or social services provided the assessments of needs for people who used the home for respite; the home developed individual plans of care from these. The manager demonstrated that he had worked with health and social services to make sure the care provided at the home, for someone with specific needs, was consistent with the ones used by other services. This helped to give the person consistent care and help manage their behaviours in a positive manner. New residents and respite care users were offered introductory visits to the home; these were based on the individuals needs. For example looking round with their family and staged introduction. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 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 the following standard(s): 6,7, and 9. Residents feel they are supported to make positive decisions. Plans of care need to be improved so that the information can be easier to use and better understood by residents and respite care users. EVIDENCE: Information was in the care plans about individual resident and respite users needs. However the information was not easy to find and use, therefore the information could be lost, overlooked or misunderstood. The design of the plans did not help the individual to understand the contents. The manager had received person centred training; this should assist in improving the plans. Records for behaviours and interventions were not sufficient enough to give a clear picture of events, the expected behaviour and the action staff take. The inspector gave the manager advice about good practice guidelines. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 10 One resident spoke to the inspector about how the home supports people to make decisions; the resident was positive and confirmed that good support was provided by the staff. The inspector observed staff encouraging residents with daily decisions, for example choosing drinks and deciding on shopping and leisure activities. Some residents had been involved in redecorating their rooms. Residents own rooms were very personalised and showed that staff respected individual’s preferences and decisions about how they wished their room to look. Risk assessments were available in the care plans, however by improving the format of the care plans it would be easier to see how the risk assessments linked with individual needs and the whole care package. (See standard 6 for the requirement) Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 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 the following standard(s): These standards were checked on the last inspection. Good social, education, leisure and community activities were available for residents; and the standards were met. EVIDENCE: Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 12 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. Residents in the main felt well cared for and their healthcare needs were met. The management of medicines was unsafe. EVIDENCE: Service users told the inspector that the staff were helpful and treated them with dignity and respect. One resident said he was “happy” with the staff and manager, and said staff “look after everyone very well”. One resident did raise a concern about the support they received in one area of personal care. The manager agreed to look into this with the resident and staff. Staff supported residents to attend health care appointments. (See standard 6 about improving access to information in care plans, this includes information about health). The inspector checked the medication receipt, storage administration and recordings relating to three residents. The medication systems were not safe and the home was required to make immediate improvements. Examples of the poor medication systems found by the inspector included: Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 13 • • • • • • • • • Loose medication in the cabinet. Medication not locked away in the cabinet. The cabinet was untidy. Blood lancets were not stored hygienically. Prescribed creams were not locked away. Signatures for medicines administered had been missed. Hand written instructions did not have two signatures, and the instruction for one was misleading. The purpose of the medication for each individual was not easily available. Some medication receipts had not been recorded. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 14 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. Residents are able to raise concerns and complaints. The homes adult protection policies and procedures were effective. EVIDENCE: Two residents told the inspector that they could raise concerns or make complaints and they knew they would be listened to. One resident also described how they had access to other outside agencies who would help them if they were worried about anything. Adult protection policies and procedures were available in the office for staff to access and staff had received adult protection training following the previous requirement. The manager had followed adult protection procedures effectively. He took immediate action and involved the appropriate people and agencies when it was suspected an individual was not cared for safely. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 15 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, 26, 29 and 30. The home was warm, clean and comfortable and it suited the needs of residents and respite care users. EVIDENCE: Some areas of the home had been redecorated; and residents told the inspector they were happy with this and the way the home was furnished. They confirmed they felt comfortable and warm. The manager said he had good feedback from respite users families about the homes environment. The garden area had improved, to include a shed and paved area; some residents were involved in the planning and maintenance of the garden. Two residents invited the inspector to see their rooms. Both residents said they were very happy and proud of their rooms. The rooms were very personalised and reflected the needs and preferences of each person. This included storage space, lockable rooms and personal aids and adaptations. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 16 Basic fittings in one en-suite were inadequate; for example the en-suite did not have hooks for towels and clothes, a mirror and homely effects. The washbasin was a small hand washbasin and not suitable if a person wished to use the room for a proper wash. This was a previous requirement. The room was used for respite care. The home was clean and tidy and the manager had introduced a new cleaning schedule. Staff had not signed some of the cleaning schedule records; this could lead to the hygiene standards slipping or important cleaning tasks being overlooked. See standard 41 for requirement about records. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 17 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): 31,32,33,34,35 and 36. Better clarity of staff roles will benefit resident and respite care users care and safety. The training schedule identified staff needs; the training must be given to make sure resident and respite care users needs continue to be met. The recruitment processes of the home were in the main well carried out and robust. EVIDENCE: The manager had reviewed staff roles since he started nine months ago. Further work was needed to make sure the team worked consistently and understood the aims and values of the home. An example of this was the poor practices with medication administration. Clear staff responsibility and reporting should have prevented this. Clear staff responsibility and reporting should also apply to the signing of cleaning records. The manager’s role should include regular auditing of all staff practises. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 18 National Vocational Qualification training in care was available to staff; and the home was working towards meeting the 50 target. The manager had assessed the staff teams training needs, and a training schedule was in place designed to bring all staff up to date with training. The training schedule included managing aggression and physical intervention training. The inspector gave the manager advice about making sure that appropriate physical intervention training was used. The Learning Disability Award Framework had not been continued for staff. This needs to be provided to make sure all staff have a good understanding of the basic care principles for people with learning disabilities. The inspector checked three recruitment files; thorough recruitment checks had been carried out however one file did not have a legible photograph of the staff member. This is a requirement as part of the Care Homes regulations to ensure robust recruitment checks. Staff had received a one to one supervision from the manager in the past 6 months. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 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 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): 37,38,39,41 and 42. EVIDENCE: The Commission for social Care Inspection had registered the manager. The manager had previous management experience and had a nurse qualification in learning disabilities. The manager had undertaken NVQ 4 in management. The staff interviewed said they had seen improvements at the home since the new manager had started, this included the manager being supportive and approachable and good improvements on the homes environment. The inspector advised that the manager continues to get support from senior management whilst he establishes a clear sense of direction and leadership within the home. Reasons are given under standards 20, 30 and 31. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 20 The manager had introduced some quality assurance systems. He had carried out a survey for respite care users and their families. The survey gave positive feedback about care at the home and identified service needs. The inspector advised the manager to share the information with the respite purchasing authority. A senior manager did provider visits monthly, however the commission had not received the reports. For examples of where the manager needs to improve regular auditing of staff practises see standards 20,30 and 31. Records were securely stored and the manager was working on improving record systems. See standards 6, 20 and 30 for requirements relating to records. The home had carried out a fire risk assessment and had taken action where the assessment identified safety risks. For example repairing areas above fire doors. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 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 3 3 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 2 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 2 2 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shaftsbury House Care Home Score 3 3 1 X Standard No 37 38 39 40 41 42 43 Score 3 2 2 X 2 3 X DS0000056401.V271144.R01.S.doc Version 5.0 Page 22 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 YA6 Regulation 15 Requirement Plans of care must be improved. They must be developed using a person centred approach and produced in a format that is easier for the residents to understand. Better descriptions of behaviours must be recorded in the care plans. Good practice guidelines and procedures must be followed and recorded in care plans for people who may need physical intervention. (For example Department of Health physical intervention guidelines) All sections of the care plans must be signed and dated. Immediate Requirement The medication receipt, storage, administration and records must be maintained in accordance with The Royal Pharmaceutical Guidelines and National Minimum Standards by 12 noon 21.12.05. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 23 Timescale for action 31/03/06 2 YA20 13 21/12/05 3 YA20 13 Immediate requirement 30/12/05 4 YA20 13 An investigation must be carried out to identify what errors have been made where the medication had been written twice on the MAR sheets. Medical advice must be sought for the individual if they received over or under the prescribed dose. The outcomes must be forwarded to the commission. Immediate requirement 31/01/06 All staff must be retrained on the administration of medications, they must be assessed for their competencies and this must be maintained in their personal or training file. The medication systems must be audited on every regulation 26 visit until the next inspection. The findings must be recorded in the report provided to the commission. 30/12/05 Carried forward from previous inspection: A routine cleaning system must be introduced. Medication must be given as prescribed, and queries about prescribed medication must be clarified with the G.P of pharmacist. Resident’s consent for medication must be recorded. Residents must be assessed to identify independence and support needs in taking medications. Previous timescale: 31.07.05. 5 YA20 13 Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 24 6 YA26 16 Fittings must be provided in ensuite facilities, which meet at least residents’ basic needs. Previous timescale: 31.07.05. Records to demonstrate that cleaning and hygiene maintenance has been carried out must be properly recorded. The clarity of staff roles must continue to be developed. 50 of care staff must achieve a care National Vocational qualification at level 2 or better. Legible staff photos must be maintained in their personal file. Training as identified in the training schedule must be provided to staff to bring the team up to date with their training needs. All new staff must be provided with the Learning Disability Award Framework training. Provider visit reports must be submitted to the commission for social care inspection. See standard 6 for related requirement. Record systems as identified in the relevant sections of this report must be improved. See standards 6,20,30 for examples. 31/03/06 7 YA30 13 and 17 30/01/06 8 9 10 11 YA31 YA32 A34 YA35 18 18 19 31/03/06 31/03/06 30/01/06 31/03/06 Schedule 3 18 12 13 YA35 YA39 18 26 30/01/06 30/01/06 14 YA41 17 30/01/06 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 YA23 Good Practice Recommendations It is recommended that staff access the local authority adult protection training. DS0000056401.V271144.R01.S.doc Version 5.0 Page 25 Shaftsbury House Care Home 2 3 YA35 YA38 It is recommended that the physical intervention training is checked for accreditation on the BILD website (British Institute of Learning Disabilities). The manager should continue to receive support from senior managers to enable good leadership and direction to be established. Shaftsbury House Care Home DS0000056401.V271144.R01.S.doc Version 5.0 Page 26 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. 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