Inspection on 13/06/06 for Shakespeare House

This inspection was carried out on 13th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 10/05/07

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 Dragan Cvejic Unannounced Inspection 13th June 2006 09:00 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.V299458.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.V299458.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 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.V299458.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2005 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.. Access to the building from the garden to the rear was restricted for those with mobility problems. 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 £420-450. Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the yearly key inspection where all key, or major standards were inspected. The proprietor’s reports and other reported events from the home were used in the planning process. The site visit to the home was used to clarify and confirm some of the standards and to inspect the rest of key standards. The findings of the inspection are presented in this report with emphasis on the outcomes for service users. The main methodology on the site visit was case tracking, where three service users were followed to determine the quality of the services and provisions for service users. They provided their comments, the staff also expressed their views and the manager provided comments on inspected standards. The care was observed during the site visit. The home had responded to the requirements from the previous inspection and improved services and provisions. What the service does well: What has improved since the last inspection? The home improved pre-admission assessments to ensure that they could meet users’ needs when offering a place. The home recently employed an activity co-ordinator and improved activities for service users. Outings were now planned on a weekly basis and service users were delighted with the opportunity to go out more. A service user stated: “We discussed having a picnic at our meeting.” Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shakespeare House DS0000014965.V299458.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.V299458.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needed to up-date the statement of purpose and users’ guide to provide accurate up to date information to potential service users. The home properly assessed service users to ensure their needs would be met when admitted. EVIDENCE: The statement of purpose needed another review to accurately present details about the home. The Service users’ guide also needed to be up dated. The contract was drawn up with a blank line on which to record the fee, as the fee was not presented in any other document. The contract stated what was covered by the fee. Checked users files contained improved assessment forms. Since the last admission, the manager expanded admission assessment forms adding sections for skin care and detailed nutritional assessments for those whose needs were identified as higher in these areas. Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 9 Two service users spoken to commented: “Yes, they can meet all our needs. They are very good. The manager is open and always listens and then staff meet our needs.” Shakespeare House DS0000014965.V299458.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users’ healthcare was ensured by a stable staff team that knew users well and, although records were inconsistent, service users were well looked after. However, the medication process needed several actions to ensure full safety of service users. EVIDENCE: Three service users’ files were inspected and there was inconsistency in the quality and quantity of information recorded. Two files did not contain users’ photographs. The manager stated that some users refused to be photographed, but there were no records of that. One file contained confusing information about family contact for a service user who, actually, did not have contact with his family. Evaluation sheets contained dates of care plan reviews, but the dates showed only recent consolidation of regular, monthly reviews, while previous reviews were not done monthly. Staff stated that care plans were an essential source of information for new staff. The observation showed that verbal communication among staff related to service users was Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 11 carried out very well and ensured that all staff knew all current issues for each individual service user. The home used a written description of assessed needs in care plans and clearly instructed staff on how to meet these needs. Service users confirmed: “We are involved in care planning. Staff discuss care plans with us.” Health care needs were recorded in detail and demonstrated that these needs were met. A separate record of professional visits to individuals was kept in files. Weight charts contained inaccurate figures in one file, but the other two recorded users’ weight and the tendency of losing weight was appropriately addressed in the care plan with suggested action to address this potential problem. Skin care was also well recorded. Medication issues inspected were recorded on a pharmacy triggers tool and attached to this record. Medication was recently inspected by the pharmacist, but there were issues that needed action taking on: controlled drugs were kept in a loose metal box. The home did not have a medication fridge and medication was stored in a trolley, as the home did not have a clinical room. An alternative hygienic procedure was in place. The temperature of where medication was kept was not monitored. Records showed that one of the case tracked service users did not receive his prescribed medication, as the stock had run out and the new supply was not to be delivered for a number of days. Staff signatures against their initials used for recording administration did not exist. The arrangements for receiving personal care ensured that privacy and dignity were respected. Four service users spoken to confirmed that their privacy was fully respected. One user explained in more detail: “I get my mail unopened. I can refuse to take medication if I want to.” Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoyed organised, structured, but flexible daily life in the home and they contributed to this routine either through their meetings or speaking directly to the home’s staff. EVIDENCE: The home had a displayed and well developed activity plan and programme. The results of employing an activity co-ordinator were evident not only in relation to the increased activity programme but also to the variety and quality of activities organised in the home. The favourite activity for the majority was still outings and the home fully met users needs in this area. The records showed almost regular outings at weekends, too. The home was open to visitors, relatives and friends. The visitors book confirmed a number of visitors visited the home regularly. The home facilitated contact for service users through the Dutch Embassy for a user to get the chance to speak her mother tongue with, a now regular, monthly visitor. The majority of service users relied on their families for support with their finances, as they preferred. A service user that preferred the home to support her stated that she “could manage her money with help from the manager”. The records contained receipts and were signed by two staff members. Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 13 However there was no evidence that users or their representatives took part in the general auditing process for the balances. The users and families should be asked to sign when balances in accounts are audited. “The food is excellent”, commented a service user. The menu was discussed on users’ meetings. The menu did not show fruit served as a snack throughout the day, but the fruit was in bowls in the dining room, available whenever users wished. Nutrition, variety and special dietary needs were checked against the Nutrition triggers tool, attached. The home did not record extra orders, outside the set menu, but both users and the cook confirmed that all required was provided. Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had an effective complaints procedure and users were confident that their voice would be heard, and they were protected with robust protection procedures. EVIDENCE: The home had not received any complaints since the last inspection. The records of previous complaints were kept in a special complaints register book. Service users stated that they knew how to complain and were confident that they would do so if they had any complaints. Some service users took part in postal voting, some were taken to poll stations by their families, but some decided not to take part in elections. By engaging families to help service users with their finances and other robust protection procedures, the home ensured service users were protected from potential abuse. Service users confirmed that they felt protected. Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment allowed service users to fully enjoy the benefits of the care setting, to feel comfortable and to be protected by good organisation of hygienic procedures. EVIDENCE: The home’s location was in an old Bedford street, where several other residential homes were positioned. The home did not have a planned maintenance programme, but all faults and renewals were carried out when the need was identified. The home recently replaced several beds, a washing machine, a tumble drier, new flooring in the kitchen and some carpets. Furnishing was domestic in style. Service users were allowed to bring in their own possessions and two users spoken were pleased with this provision that allowed them to make their rooms personalised. A new seating scale was bought since the last inspection. Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 16 Adaptations in the home were appropriate for service users’ needs. The bedrooms were fitted with locks and new lockable drawers were also bought following the requirements set previously. New washing machine and a tumble drier were part of the plan to improve hygiene and general cleanliness. The home was clean and cleaners worked their hours spread throughout the day to ensure that cleanliness was constantly of an appropriate standard. Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29.30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensured that a stable, skilled and committed staff team carefully planned to work according to users’ needs and provided effective care to service users. EVIDENCE: Staff rota showed 3 staff worked in the morning, 3 in the afternoon and 2 at night. Both staff and service users stated that the staffing was appropriate for service users, needs. However, the manager admitted that she worked care shifts to cover for staff absences and not as supernumery, as required by standards. An activity co-ordinator worked three days a week and ensured the stable and organised daily routine met users expectations and needs. Domestic staff worked to meet the needs of the home, sometimes split shift, but ensured that the home was clean and hygienic at all times. Seven staff members of thirteen held NVQ qualifications. The home exceeded this standard and continued to encourage all staff to gain this qualification. The recruitment procedure was appropriate. Two references, CRB and POVA disclosures were obtained prior to starting work. All three staff files were consistent and contained application forms, contracts and elements related to employment matters. Training records showed only two training courses in this year, but the training record demonstrated that all mandatory training ran in principle when the majority of staff were due for refresher training. Two training sessions were booked for the forthcoming period. An induction form was present in one of the Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 18 files and showed that a proper induction was carried out for all new, or recently appointed staff. Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home promoted and ensured that service users health and safety and welfare were emphasised and respected but the records were not up to date to demonstrate the real quality of the services and provisions. EVIDENCE: The manager had just completed her RMA. She effectively managed the home, but was still covering some extra care shifts and did not always work as supernumery. Staff emphasised that the manager encouraged them to talk and staff sought the manager’s attention twice during the site visit for support. The atmosphere was open and inclusive. The home respected equal opportunities and the service users benefited from a staffing composition that promoted equality and diversity. Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 20 The home purchased and adapted a system for quality assurance. The manager stated that the action plan was slightly behind the time schedule. The provider’s business plan was out of date, but the manager stated that she would derive an action plan that would be incorporated into the overall business plan for the service. Service users finances were protected by the system in place that only required users or their representatives’ signatures against the audited balances. A service user commented: “I can control my money with the manager’s help.” Staff supervision records showed improvements in regularity since April and the plan for future sessions demonstrated the manager’s commitment to provide this support to staff on a regular basis. Records, including some users’ files were slightly behind schedule and the manager was aware of the need to improve timing in record keeping procedures. The home promoted the health, safety and welfare of service users. New health and safety policy was introduced. Staff received regular refresher training when their certificates were about to expire for all mandatory training. The home had recently been inspected by environmental health and other external regulatory authorities, such as the fire service. Accident/incident records were up to date and kept in each individual user’s file. Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 21 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 3 1 3 Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 6 Requirement The statement of purpose and service user’s guide must be updated and reviewed regularly. The reviewed copy must be sent to the CSCI. The care plans and other documents in users’ files must be accurate to avoid potential confusion. This relates to contact with family, to weight records, to list of personal properties and to dates of reviews. The home must have a medication fridge to safely store medication that requires refrigerating. Then, the temperature records for this must be set and maintained. A metal box for storing controlled drugs must be fixed to a hard surface. The home must ensure that medication is ordered in advance to prevent running out for a number of prescribed terms. The sample of staff signatures against their initials must be available to allow identification of who signed the administering of DS0000014965.V299458.R01.S.doc Timescale for action 30/07/06 2 OP7 15 30/07/06 3. OP9 13 30/08/06 4. 5. OP9 OP9 13 13 30/08/06 30/07/06 Shakespeare House Version 5.2 Page 23 6. OP14 12,13 7. OP19 23(2b) 8. OP37 17 medication. Signatures must be obtained from service users or their relatives and representatives on records of their possessions and against balances checked on the records of the service users’ money held in the home. There must be a planned maintenance programme for the home.(Previous timescale of 30.09.04 and 31.04.05 had not been met) Records kept in the home must be accurate, regularly updated, reviewed and appropriately signed. 30/07/06 30/08/06 30/08/06 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 OP33 Good Practice Recommendations The home should bring the quality assurance process up to date and when the action plan is produced, the copy should be sent to the CSCI office. Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Shakespeare House DS0000014965.V299458.R01.S.doc Version 5.2 Page 25 - 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. 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