Inspection on 10/05/07 for Shakespeare House

This inspection was carried out on 10th May 2007.

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

Shakespeare House 30/06/10

Shakespeare House 17/05/10

Shakespeare House 27/05/09

Shakespeare House 27/05/08

Shakespeare House 13/06/06

Shakespeare House 22/11/05

Shakespeare House 10/05/05

Shakespeare House 22/12/04

Shakespeare House 18/05/04

Shakespeare House 15/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Shakespeare House 19 Shakespeare Road Bedford Bedfordshire MK40 2DZ Lead Inspector Sally Snelson Unannounced Inspection 10th May 2007 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shakespeare House DS0000014965.V334559.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shakespeare House Address 19 Shakespeare Road Bedford Bedfordshire MK40 2DZ 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) 01234 359224 F/P 01234 359224 Mr Sada Camiah Mrs Vijama Camiah Ms Louisa Bedeau Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18), of places Physical disability over 65 years of age (18) Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2006 Brief Description of the Service: Shakespeare House was registered to provide care for eighteen older persons who may also have physical disabilities and/or dementia. Mr and Mrs Camiah had owned the home for a number of years and participated in the operation of the home as financial manager and care practice advisor. Mrs Louisa Bedeau had managed the home for several years. The home was located in a pleasant suburb of Bedford within walking distance of the towns amenities including bus and train links. The physical environment had been suitably adapted internally to meet the needs of frail older people.. Accommodation was arranged over three floors with seventeen bedrooms, one of which could be used for double occupancy. Access was provided to the upper floors via a shaft lift. The communal dining room and lounge were located on the ground floor. A range of adapted bathrooms and toilets were located for convenient access throughout the building. The manager stated that the current fee was approximately within the range of £425-450. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection of Shakespeare house took place from 08.30 am on the 10th May 2007. The manager Ms L. Bedeau was present throughout. During the inspection the care of three people who used the service (service users) was tracked in detail. This involved reading their care notes and observing and comparing the care they received throughout the day. Staff service users and visitors were also spoken to and their comments used to inform the judgements made in this report. Prior to the inspection the manager had completed a pre-inspection questionnaire. On the day of the inspection the lift had broken and this was taken into account when observing care practices as a number of the service users had to remain in their bedroom as they were unable to mange the stairs. By the end of the inspection the engineer had found the fault. The inspector would like to thank the staff and the service users for the time they gave to this inspection. This report should be read in conjunction with the National Minimum standards for older people. What the service does well: The staff worked well together and the home had a good atmosphere. The home did not use agency staff to cover for staff absences, but engaged permanent staff to work overtime to ensure consistency in helping and supporting the service users. The staff team had a good understanding of the needs of the service users, although there was very little in place that was specific for those with dementia. Staff were good at contacting the Doctor or other healthcare professionals when a service user needed healthcare. Service users had received regular visits and appointments with General Practitioners, chiropodists, dentists and opticians. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 6 The home was clean and tidy throughout and all of the service users appeared to enjoy the variety of meals provided that included fresh foods daily. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,6, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home properly assessed service users to ensure their needs would be met when admitted, but did not always produce the necessary full range of care plans. EVIDENCE: Following the last inspection the Statement of Purpose and Service Users Guide had been updated and a copy of the document sent to us for the file. The manager confirmed that the documents were kept under review. However it was noted that there was no mention of the fees payable and the method of payments. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 9 A contract had been prepared for each of the service users and the manager confirmed that with the exception of two, which she was chasing up, the service user or their representative had now signed them all. The manager confirmed that she assessed all service users prior to admission. A pre-admission document was used that made reference to their social or emotional needs and their personal preferences. To ensure that pre-admission assessments are meaningful care plans must be developed to cover more of the activities of daily living that are initially assessed. The staff training files, for the staff on duty, showed that between them they had the necessary experience and qualifications to meet the needs of the service users living at Shakespeare House. More evidence is included in the staffing section of this report. At the time of the inspection Shakespeare House did not offer intermediate care. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care files were in good order, but the care plans needed to provide more information to ensure that a consistent standard of care was provided. EVIDENCE: After the last inspection the senior staff team had made a number of improvements to the presentation of the care files. However it was noted that the care plans, included within the files, were of differing standards. Of the three files sampled, two had care plans that clearly identified the care need, how it was to be addressed and the long-tem goal. The third was less detailed and would not provide consistent care. For example, for personal care, there was an objective that the service user should be comfortable and suitably Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 11 dressed and the action was that staff should assist with all aspects of personal care. This did not provide sufficient information for staff to know if the service user had a bath or a wash, her personal likes and dislikes etc. The manager stated that the care plans were all in the process of being reviewed and the home was working towards all plans being like the more detailed plans. It was also noted that there was not a care plan in place for all the activities of daily living and that most service users did not have a plan for eating and drinking, elimination etc unless there was a specific problem. Although there was a reminder and a record of the care plans that had been reviewed in the office it was apparent that the staff team were not managing to review each of the plans at least once a month. There was no evidence that service users or their representatives were part of the care planning process. Files included a number of assessments and the associated risk assessments for areas such as moving and handling and nutrition. These were worked out using a scoring system, but the paperwork did not always give clear instructions of what to do for the various scores identified. It was also noted that service users were weighed every month and their BMI recorded. The inspector would have expected to see a comment recorded when a new service user lost 2.3 kg in his first month at the home. Records suggested that this could well have been beneficial for him but it was not clear as he did not have a care plan associated with eating and drinking and it was therefore not apparent if the weight loss was intentional or unintentional. All of the files sampled indicated that the service users had seen an optician and a dentist within the last year. It was also apparent that health professionals such as doctors and community nurses were used appropriately. The manager stated that the home was visited by five different GP practices. One of the service users who care was case tracked had been assessed as requiring a recliner type armchair. The manger reported that the family were preparing to buy this. She was reminded that if service users were assessed as requiring specific equipment it was the responsibility of the home to provide it, although friends and family could, if they so wished, do so. . Following a number of requirements made about medication practices after the last inspection there had been a lot of improvements made. Storage of medication was noted to be in a locked trolley that was stored on the ground floor of the home and the controlled drug cupboard was on a wall in the office. Before doing the first medication round the senior carer responsible for medication, stated that under normal circumstances (when the lift was working) the trolley would be taken to each floor. However today, as a sealed dispensing system was being used, the appropriate coloured cards would be taken on a tray from the trolley up the stairs and individual medications dispensed from the tray. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 12 It was noted that the Administration of Medication Records (MAR) were well kept and clearly provided the necessary audit trail to determine when the medication had been received into the home and when and by whom it had been administered. The MAR sheets for the three service users case tracked indicated that there were no gaps and ‘as required’ medications were used appropriately. The medication policy had been appropriately reviewed and updated and included information about self-medication although none of the service users were self-medicating at the time of the inspection. It was noted that service users were dressed in their own clothes and that they were treated as individuals. Throughout the inspection staff were seen talking to service users and treating them with dignity; this was particularly noticeable at mealtimes. The service users had a good rapport with the staff and the relationship between staff and service users appeared to be that of a large family. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users had the opportunity to join in with a variety of planned activities. However it was not apparent if the activites provided met the needs of the service users as care plans for activities had not been produced. EVIDENCE: There was a structured activity programme displayed in the home which the manger said was adhered to as much as possible, but alterations were made to accommodate extra activities such a trip outs. The day before the inspection two of the service users had attended a tea dance at the Corn Exchange. An activity co-ordinator was employed to plan the activities and staff said the number of ideas she had, and her local knowledge of events impressed them. It was apparent that the activity co-coordinator planned the activities but all the staff participated. Activities were planned over a seven-day week and not Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 14 just Monday to Friday. There were photographs in the home of some of the group activites that service users had been involved in including a recent 100th birthday celebrations of one of the service users. However none of the service users tracked had a care plan for activites and consequently there was no documentation to support the benefit they got from the activities provided. On the day of the inspection, because many of the service users had had to stay in their bedrooms because of the broken lift, so there were no group activites seen. However staff were spending time with the service users in their rooms and making them as comfortable a possible. The rooms visited by the inspector had a radio on and because the home was on a main road the net curtains had been pulled back to allow service users a clearer view of what was going on outside the home if they were interested. During the inspection one of the service users was given a duster to help with the cleaning because she wanted to, and another service user was involved in the folding of laundry as it came out of the machines. Service users had the opportunity to meet with their visitors in the lounge or in their own rooms. It was noted that a tray of coffee was made for the visitors of a service user as soon as they arrived. Staff confirmed that religious services were bought into the home and other community groups visited. A member of staff was seen to give service users a biscuit from a large biscuit tin to go with their afternoon cup of tea. There was no restriction to the number of biscuits offered but the service users were not given the opportunity to choose their biscuit. The member of staff said that this was how she had been shown to do the ‘teas’. She said she had learnt what service users like to drink so did not individually ask them every day. This was discussed with the manager who was unaware of service users not being offered the biscuit tin and allowed to make a choice. She agreed it should be altered immediately. Most of the service users choose to have their spending money controlled by their families or the home. See next section of this report. At the beginning of the inspection service users were having their breakfast, most in their bedrooms. Where help was required this was provided in a relaxed way. Nutritional risk assessments were seen within the service users care records, but as already stated it was not apparent if the result influenced the care provided. For example the service users had a MUST (nutrition) tool assessment relating to their weight, but did not necessarily have a care plan for eating and drinking. However where a weight was of concern there was evidence that a GP had been consulted and a food supplement prescribed. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 15 The cook offered service users an alternative to the meal advertised for lunch, before the meals was served. This was good practise but there is a lot of evidence that offering a choice to people with dementia in advance of any activity is not productive, as they will not remember their decision. The best practise for a care home specialising in dementia care is to offer plated meals, at the time of serving. Observation of the lunchtime meal showed it to be unrushed and enjoyed by the service users. All were positive about their meal of sausages, mash, cabbage, carrots and gravy followed by chocolate sponge and custard. It was also noted that service users who required a pureed diet were given a meal that was attractively presented. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home must have adequate procedures in place to ensure service users are protected from all forms of abuse including financial abuse. EVIDENCE: The homes had a robust complaints procedure. It gave simple guidance on how to make a complaint and gave timescales in which the home would respond to a complainant; however it had not been reviewed and updated. The manager stated that the home had not received any complaints since the last inspection. The inspector discussed the importance of recording any concerns raised by service users and visitors in the complaint file so that there was an audit of how concerns were dealt with. The home had a number of compliments from families about the care provided to their relatives. None of the service users spoken to were able to detail exactly how they would make a complaint but it was clear that they knew how to put across a view or a concern to staff. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 17 The homes policy on abuse did not reflect the most recent multi agency guidance on how to report a suspicion or alleged abuse. Staff training records also showed that all staff at the home had received training in this area but some were in need of an update. When checking the money held by the home on behalf of service users the inspector was concerned that there were often discrepancies of a few pennies between the money held and the money recorded which corresponded to the receipts held. The manager agreed to look into the shortfalls immediately and audit the accounts held so they there was no possibility of financial abuse. It appeared that when staff went shopping with service users they took out money in the form of notes and often rounded up the money returned (to the advantage of the service user) to cut down on the amount of small change held. A requirement has been made that the manager checks all the service users personal monies and audits the files at least monthly so that any inaccuracies can be identified early. The requirement made at previous inspections that service users families should be part of the auditing process has been removed from this report but would be considered as good practise. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Shakespeare House provided service users with a homely place in which to live. EVIDENCE: The home was clean and tidy throughout. During the inspection communal and individual accommodation was viewed. All accommodation was appropriate for the needs of the service users although nothing was specific for service users diagnosed with dementia. The laundry Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 19 room was small and was situated close to the lounge meaning that soiled laundry had to be bought within close proximity of the service users. The service users were able to access many areas of the home, with appropriate restrictions on the laundry room and the basement. Service users communal areas were a large lounge and a dining room, and in the summer a back garden with seating areas. Service users bedrooms could be personalised. Those seen had pieces of furniture and ornaments from home in them. Previous inspection reports, dating back to 2004, had required the home to provide a planned maintenance programme. This was still not in place but the requirement was not re-stated as there was evidence that routine decoration and emergency repairs were not carried out appropriately. However this would still be considered a useful document. At the time of the inspection a bedroom had become vacant and was being decorated before it was shown to a potential new service user. Care staff appeared to routinely put washing into the washing machines and fold it and put it away when it came out of the tumble drier. Designated staff were employed to keep the home clean. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Between them the staff had the necessary training and experience to meet the assessed needs of the service users. However care must be taken that training is updated regularly to ensure that the care provided is the most appropriate and evidence-based. EVIDENCE: The home ran with three staff on duty morning and afternoon and evening in addition to the cook and the cleaner. The manager was supernumerary. The duty rota did not clearly indicate who was senior in the absence of the manager and who was responsible for the administration of medication. One senior member of staff was on-call at all times. On the day of the inspection the manager was off-duty, but had come into work to be extra on the floor, because the lift had broken and she felt extra staff would be necessary. Also on duty was a student from the local college who was planning to be a midwife. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 21 Seven of the 14 care staff had an NVQ. The standard required 50 of staff to be trained to NVQ standard by 2005; therefore by now it would be expected to be greater to show a continued commitment to learning and improvement. Staff confirmed that the manager supported, and indeed encouraged them, to attend training courses. Training courses were available both externally and inhouse. The files of the staff on duty were examined to look at recruitment practices at the home All contained application forms, evidence of identification, two appropriate references and Criminal Records Bureau checks. At the time of the inspection the home had a vacancy for a carer and a part-time cook. Staff reported that they were happy to do extra shifts to cover colleague’s absenteeism. The training files for all the three staff members on duty were sampled to look for evidence that the staff had received the necessary training to meet the assessed needs of the service users. In addition evidence of mandatory training for medication and POVA was looked for. In addition to mandatory training staff had received training in falls awareness, dementia awareness, infection control, challenging behaviour, Alzheimer disease, end of life care communication skills and diabetes, which reflected the needs of the service users at the home. The home would benefit from a training plan to ensure that staff training was appropriate and kept updated. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has a clear vision for the home which she shared with the care staff and the other stakeholders. EVIDENCE: The manager had a number of years of experience of working with people with dementia; she also had the Registered Managers Award (RMA). Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 23 It was apparent that the staff team worked well together and respected the manager. The home had sent out questionnaires to relatives to gain their views of the standard of care at the home. The manager stated the responses were coming back and when they had the relatives would be asked to help service users complete forms. It was unsure if advocates would be involved and if the questionnaires would be extend to visiting health professionals. The inspector spoke to the manager about the importance of auditing the responses and ensuring practices changed if necessary. Since the last inspection seven service users had died. All the deaths and other incidents such as falls had been well recorded and appropriately referred to necessary agencies. Staff attended regular staff meetings and the manager held monthly residents meetings where activities and menus were always discussed. The proprietors visited the home regularly and produced a report following their visit. Service users monies have already been written about in this report. All staff were receiving supervision, however the sessions were not a frequent as required. Staff said that in addition to supervision sessions they could speak to the manager at any time and were always given confidentiality. Some of the documents seen in care files had not been reviewed and updated as often as required. It was also noted that some of the homes policies and procedures had not been updated and at times, when superseding information was included in the file, without removing the current information, could be confusing. Documents pertaining to the management of Fire, environmental Health and internal safety checks were seen. All were up-to-date for the previous month but had not been carried out for May. In addition to routine regular fire checks staff ensured that fridge water temperatures were regularly recorded. The moving and handling techniques observed during the visit were good, with appropriate use of slings, and the use of footrests on wheelchairs to avoid injury to staff and residents. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X 2 2 2 2 Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 25 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 Standard OP3 OP7 Regulation 15 Requirement Timescale for action 01/08/07 2. OP7 15 The manager must ensure that the service users have a care plan for all their assessed needs, even when they appear routine. This will ensure consistency of care. Care plans must be reviewed and 01/08/07 updated at least monthly to ensure that the documented care needs of service users are the most current. Any health care needs recorded, and the subsequent assessments, must be clear and the scores used to provide appropriate care. These must be regularly reviewed. Accurate records of service users personal monies must be kept and audited at least monthly by the manager to ensure that there are no discrepancies. The home must have a copy of the local adult protection policy and this document must DS0000014965.V334559.R01.S.doc 3. OP8 12,13 01/08/07 4. OP14 OP18 12,13 01/06/07 5 OP18 12 01/08/07 Shakespeare House Version 5.2 Page 26 6 OP30 12,18 7 OP33 24 8. OP37 17 influence the home’s POVA policy. Staff training should be 01/08/07 structured to a programme to ensure all staff keep their training updated. The home must have a system in 01/08/07 place that ensures the standards of the home are reviewed by all stakeholders regularly. Records kept in the home must 30/08/07 be accurate, regularly updated, reviewed and appropriately signed. This includes polices and procedures which need to be reviewed regularly. 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 Refer to Standard OP1 OP7 OP12 OP14 OP36 Good Practice Recommendations The Service Users Guide must provide information about he fees and the method of payment. There should be plans to involve service users, or their representatives, in the care planning process. Service users interests should be recorded and an activity plan developed that is regularly reviewed and updated. Service users should be provided to make choices in a way that reflects an awareness of their diagnosis of dementia. All staff must receive a minimum of six supervision sessions a year. Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Shakespeare House DS0000014965.V334559.R01.S.doc Version 5.2 Page 28 - 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. 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