Inspection on 27/05/08 for Shakespeare House

This inspection was carried out on 27th May 2008.

CSCI found this care home to be providing an Adequate service.

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 10/05/07

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Shakespeare House 19 Shakespeare Road Bedford Bedfordshire MK40 2DZ Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 11:45 27th May 2008 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.V360762.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.V360762.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.V360762.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2007 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 £430 - £450. Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 27/05/08 over 7 hours 20 minutes by Pursotamraj Hirekar. Sarah Bartholomew, methodology manager, has shadowed the inspection process, as part of the Inspecting for Better Lives – Walkthrough project. The registered manager coordinated the inspection through out. The method of inspection included study of care plans, risk assessments, staff recruitment records, staff deployment duty rota, relevant care delivery documents, discussions with manager, staffs on duty, 3 visitors of people using the service, conversation with people using the service and partial tour of the building. The pre – inspection survey of people who use this service, responses were not received as on the day of writing this report. Therefore, the feedback has not been included in the preparation for inspection, analysis of evidence gathered, and writing of this report. The annual quality assurance assessment (AQAA) – provider’s self-assessment and in response to the inspection feedback session, the documentary evidence sent in by the registered manager, post this inspection is included for analysis and preparation of this report as well. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: The home had maintained good outcomes for people who use the service. The registered manager and staffs have maintained good working relations with the people who use the service and their family members, and relevant professionals who had been useful for appropriate care delivery. It was observed during the interaction with the people who use the service on this inspection that, they were neatly dressed and appeared clean. During the inspection we spoke to 3 visitors to the home. One told ‘my family and my mother have nothing but praise for the way the home is running. Our mother, in particular is always full of praise for the service’. One person living at the home since September 2007, her daughter visit twice a week and said ‘my mother came in for respite and continued to stay here as she cannot look after herself’ ‘I am pleased my mother is here, place is good, neat, clean, staff take care of her well, very happy, her bedroom is good’. Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 6 The premises were clean and tidy throughout and all of the people who use this service appeared to enjoy the variety of meals and activities provided. 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.V360762.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.V360762.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 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments were completed to assess the care needs of people considering using the service. EVIDENCE: The Statement of Purpose and Service Users Guide had been updated and the registered manager confirmed that these documents were kept under review. Following the observation in the previous inspection report that, there was no mention of the fees payable, this has been now included in the revised documentation. On this inspection, 4 people who use the service were case tracked, of which one person was new and was admitted on the 18/03/08. Prior to admission, the registered manager, had carried out the assessment, this admission Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 9 assessment had been completed in sufficient detail to ensure that an informed decision could be made as to whether the staff team could meet the needs of the person. The people living in the home have diverse needs and diagnoses, and staff training information records seen showed that the staff team had the necessary skills and qualifications to meet their needs. A contract had been prepared for each of the service users. However, 2 out of 4 people case tracked, their contracts were not signed. The registered manager confirmed that she was chasing up. Intermediate care was not provided in the home at the time of this inspection. Shakespeare House DS0000014965.V360762.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 good. This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments had been written in sufficient detail to ensure that the care needs of the people at the home would be met in a consistent and safe way. The staff and the people using the service have a good working relationship. EVIDENCE: Of the 4 people who use the service, their care plans were tracked; all of them had care plans that clearly identified the care need, which included behaviour, environmental and physical condition, sleep, hobbies, social skills, general health conditions, personal care, communication, mobility, continence, diet, medication, social skills, nutritional assessments, guide for safe working and health care professionals appointments. The plans had been written in Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 11 sufficient detail to ensure that anyone working at the home could provide the necessary care. The care plans have been regularly reviewed and updated to reflect the changing needs of the people who use the service. However, there were areas that needed improvement. For example, the home used scoring system, for the assessment of abilities of people using the service, regarding their personal care, communication, mobility, feeding etc and it was not clear, how these various scores have been used in the preparation of the care plans. This was discussed with the registered manager during the inspection feedback session, the registered manager, confirmed in writing to the commission that, all the care staff would be informed how to use scoring for assessment of abilities and how to record this as part of preparation of peoples care plan. The care plan documents included a number of assessments and the associated risk assessments for areas such as moving and handling and nutrition. It was also noted that, the people were weighed every month and BMI recorded, nutritional assessment are carried out and used for diet planning. 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 4 people using the service, case tracked indicated that there were no gaps and ‘as required’ medications were used appropriately. We were able to reconcile the medications, including the controlled drugs. However, it was not clear from the MAR charts, the staff initials used to sign the MAR charts that it could be identified that had been responsible for the administration of the medication. The staffs that were giving medication had been trained to do so. Throughout the inspection, we noted that staff treated people living and visiting the home with respect. Personal care was carried out in people’s own bedrooms and all staff knocked before entering a person’s private space. None of the people were self-medicating at the time of the inspection. 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. However, one of the controlled drugs was stored with the rest of the medicine in a locked trolley. This was brought to the attention of the registered manager, who said that, this time the pharmacy has supplied in a monitored dosage system, instead of a container. The registered manager immediately has transferred the control drugs into the control drugs cupboard. Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 12 All of the 4 people case tracked, indicated that they had seen various health care professionals such as doctors and community nurses were used appropriately including optician, chiropodist, and a dentist, since the previous inspection. The home had made appropriate arrangements to implement, following the advice of the health care professionals appointments; for example one person using the service had a fall and was referred to the hospital, before her return from the hospital, cot sides were placed on her bed. Also, following the nutritional assessment, one person using the service was given fluid diet and has been monitored regularly. Another person was assessed as requiring a recliner type armchair and a recliner type armchair has been provided. It was noted that the people were dressed in their own clothes and that they were treated as individuals. Throughout the inspection staff were seen talking to people and treating them with dignity; this was particularly noticeable at mealtimes, leisure activity and medication times. The people using the service had a good rapport with the staff and the relationship between staff and the people appeared to be that of a large family. Shakespeare House DS0000014965.V360762.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): 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. The service is committed to and promotes good relationships with people who use this service, and enable them to participate in wide range of activities that enhances their quality of life. The menu was varied with a number of choices including a healthy option. Staffs are sensitive to the needs of those people who find it difficult to eat and give assistance with feeding. EVIDENCE: 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. On the day of the inspection, the activity coordinator had organised wide range of activities, which were specific to individual and groups needs. The activity coordinator appeared to have the appropriate skills to involve people who Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 14 found it difficult to concentrate in something that stimulated them, both mentally and physically. The people using the services were actively engaged and appeared to have enjoyed the activities throughout. People using the service had the opportunity to meet with their visitors in the lounge or in their own rooms. Visitors reported that they were welcomed into the home, could come and go as they pleased and felt part of the home. It was noted that a tray of coffee was made for the visitors of people using the service as soon as they arrived. During the inspection 3 visitors (families) were spoken to. One person living at the home since September 2007, her daughter visit twice a week and said ‘my mother came in for respite ad continued to stay here as she cannot look after herself’ ‘I am pleased my mother is here, place is good, neat, clean, staff take care of her well, very happy, her bedroom is good’. The other two visitors have echoed the same feeling and satisfaction as well. People were able to make choices about, when they got up and what they ate. Staff confirmed that religious services were bought into the home and other community groups visited as well. Observation of the lunchtime meal showed it to be unrushed and enjoyed by the people using the service. Nutritional risk assessments were seen within the people’s care records. The menu plan appeared to provide people with a balance nutritious diet, drinks were served with the meal, and people were encouraged to eat in the dining room and lounge as well. Staffs are sensitive to the needs of those people who find it difficult to eat and give assistance with feeding. The people expressed satisfaction with the quality, quantity, and presentation. For example one person, who was unable to eat her regular meal, was offered an alternative meal followed by a cup of tea, to suit her dietary needs. Another person using the service spoken to, have said that ‘lunch has been always good, staff are polite and feed the people who cannot eat on their own’. Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 15 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 service had an open culture, people using the service and staff said that they are happy with the service provided, feel safe and well supported. A complaint’s investigation, outcome, and actions were not being properly logged. EVIDENCE: The service had a complaints procedure. It gave simple guidance on how to make a complaint and gave timescales in which the home would respond to a complainant. People using the service spoken to knew how to put across a view or a concern to staff. One person using the service said, “I am happy here, staff are good”. Another person said ‘I have not experienced any problems or had any concerns about living at the home’. Staff demonstrated a good awareness of their role, responsibility, and procedures they are required to follow in relation to any allegation or suspicion of abuse. Staff training records also showed that staff at the home had received training in this area. Staff were confident to whistle-blow on bad practice and confirmed that the manager or the provider is available at all Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 16 times should any concerns arise. The registered manager also through discussion demonstrated a good understanding in this area and was aware of the local guidance in reporting procedures. The manager stated that the home had not received any complaints since the last inspection. The commission had received an anonymous complaint regarding low levels of staff deployment during weekends. The commission had written to the provider, to investigate and report. However, the commission had not received any response yet, and the registered manager had said that, she was not aware of this correspondence. The staff deployment duty rota indicated that the morning and afternoon shifts had 3 staff members and night shift had 2 walking staff on weekends as well. However, staff reporting in and going out record was not always upto date, to determine the actual staff deployed on a weekend shift. Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 17 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, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service was clean, tidy, and free of any offensive odours. The environment is well maintained for the people who use the service to live in. EVIDENCE: A tour of the premises was undertaken all the communal areas were found to be clean, tidy, and free of any offensive odours. The people using the service, their rooms that were seen contained personal items, photographs, pictures, and furniture. Grab rails were also in place to assist with their mobility. The rooms were clean and tidy and no odours were detected. For example, one visitor spoken to on this inspection, have confirmed that the bedroom of her mother is good and well maintained. Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 18 The laundry room was situated close to the lounge, and the laundry room key was kept, at an accessible point to people using the service. It was observed that a person using the service had accessed the laundry room key, and went inside, a staff member noticed just in time, and asked the person polity to come out of the laundry room. When visiting the laundry, by opening one cupboard were able to have access to cleaning fluids, which could be harmful to the people living at the home with a diagnosis of dementia. This was discussed with the registered manager during the inspection feedback session. The registered manager had confirmed in writing to the commission, post this inspection that the staffs on duty are now carrying the laundry keys on their individual sets of keys. Information received from the registered manager prior to the inspection stated that the home has a rolling programme of maintenance and decoration of the bedrooms and communal areas. The exterior and interior of the premises, lounge, and kitchen has been decorated in the last 12 months. The service has now built a new conservatory in addition to the existing communal space provided for the people who use the service, and it’s completion work was in progress. Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 19 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 poor. This judgement has been made using available evidence including a visit to this service. The service has a poor recruitment procedure with shortfalls in record keeping and process being evident. Staffs are appointed and start working without appropriate references or other important documentation being received to protect people using the service. Between them, the staff had the necessary training and experience to meet the assessed needs of the service users. EVIDENCE: The staffs are deployed to satisfactory levels and the staff rota reflected this. The interaction of staff with the service users was good, showed there was a good rapport both verbal and non-verbal communication used and a good understanding. On this inspection 9 staff members’ records were seen and found that, the home’s recruitment procedure was inadequate. For example few staff members working at the service, their references did not match with the references provided in their application form. Few staff members, Criminal Records Bureau (CRB) check carried out were few years old, and by the previous Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 20 employer, not by the current employer. Also 2 staff members that were working at the home, their records did not evidence, that they were eligible to work in the country. These findings were discussed with the registered manager during the inspection feed back session. The registered manager appeared to have not been aware of the some of the recruitment procedures and their relevant record keeping. The registered manager, on a proactive measure, telephoned both the staff members, of which, one staff member brought with him copy of the documentation, and was able to provide the evidence to work in the country, the registered manager was arranging for copies to be kept for records at the service. But, another staff member was not able to provide any evidence. The registered manager had confirmed in writing with the commission, post this inspection that, she would give the individual staff member time to produce evidence, back track information and notify Home Office if necessary. Regarding the CRB checks by the current employer and references, the registered manager confirmed in writing with the commission post this inspection that, she would back track in attempt to get reference from last employer (for more recent staff). Also, she would provide evidence in individual staff records, of where attempts have been made to contact referee and why alternative referees has been sought. Regarding the CRB checks, she confirmed in writing to the commission that, she would ensure that staff complete new CRB application by the current employer and POVA first to be fast tracked by umbrella body. The information received from the manager before this inspection stated; of the total 15 staff members, 8 staff members have attained National Vocational Qualification (NVQ) level 2 and 4 continue to work for NVQ2 qualification. Staff training records showed that staffs have attended a variety of courses and workshops, 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. Staff through interviewing described other training that they had undertaken including the National Vocational Qualification in Care. Staff confirmed that the manager supported, and indeed encouraged them, to attend training courses. Training courses were available both externally and in-house. Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 21 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, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is not aware of current developments both nationally and by CSCI to plan the service accordingly. The registered manager and staff have good working relationship with the people who use this service and key stakeholders that promote the quality of life of people using this service. EVIDENCE: It was apparent that the staff team worked well together and respected the registered manager. Staff supervision was regular, the minutes of the staff Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 22 team meeting was available and showed how information is shared with staff, concerns raised by staff are addressed in the best possible way, which benefits the people who use this service. Staff said that in addition to supervision sessions they could speak to the registered manager at any time. The registered manager has not maintained her knowledge of the requirement for carrying statutory checks, including CRB checks and maintaining appropriate records, prior to the appointment of staff (please refer staffing outcome group of this report for detailed information). Thereby placing the people using the service at potential risk of harm. Discussion with the registered manager evidenced that she has been on a learning curve, on this matter. Guidance and advice regarding regulatory matters are published on the commission’s website and consideration needs to be given by the registered manager, to reviewing the site on a regular basis to keep updated. The registered manager informed that, she does not access to Internet. The home had an internal quality assurance system and procedure, to ensure that the quality of care provision and delivery is of always-high standard and the people who use this service; their quality of life goals are addressed. The service had also sought the views of people who use this service and their relatives, and other key stakeholders as well. The results are yet to be analysed, on how the service, then use these views to influence and further improve the care provision and delivery. This was discussed in the inspection feedback session with the registered manager. The registered manager, confirmed in writing with the commission, post this inspection that, she had now scheduled to develop an action plan from the results of this audit. The moving and handling techniques observed during the inspection were good, with appropriate use of slings, and the use of footrests on wheelchairs to avoid injury to staff and people who use the service. People, who use the service, can choose to manage their own money, if they are able to do so. The manager described the process for recording and handling people’s money, which ensures the people’s money, is protected. The registered manager had access to the money, and in the absence of the registered manager, the deputy manager operates the money of people using this service. On this inspection, a sample of 4 people using the service, their money management record, and the balance money was checked and found satisfactory. The information received from the registered manager before the inspection confirmed, there is a programme of servicing and testing of equipment, maintenance, and fire detection and emergency equipment. Risk assessments are in place for the home, people who use the service, and staff. Documents pertaining to the management of Fire, environmental Health and internal safety checks were seen. Staff and their training records confirmed that they Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 23 had been trained in a variety of Health and Safety areas including moving and handling and food hygiene. The hot water temperatures checks were regularly carried out once a month only at, few random outlets. In response, to the inspection feedback the registered manager has confirmed in writing with the commission that, new documentation would be in place, and all individual hot water outlets would be temperature checked on a fortnightly basis. The people, who use the service spoken to, reported that they found the staffs and the manager to be a very good listener and all felt that they were very easy to talk to and that they trusted them. Staff said that they found the provider and the manager to be very committed to the care of the people using the service and are approachable. One person’s family member said ‘my family and my mother have nothing but praise for the way the home is running. Our mother in particular is always full of praise for the service’. Shakespeare House DS0000014965.V360762.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 3 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 25 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 OP29 Regulation 19 (4) Requirement The registered manager must ensure that satisfactory statutory checks have been carried out prior to the employment of any potential and existing staff member. The registered provider must ensure that complaints are investigated; outcome and actions were being properly logged. Timescale for action 30/06/08 2. OP18 13 (6) 30/06/08 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. Refer to Standard OP7 OP9 Good Practice Recommendations The registered manager should ensure that people using service or their representatives were part of care planning and review process. The registered manager should ensure the name of the DS0000014965.V360762.R01.S.doc Version 5.2 Page 26 Shakespeare House 3. 4. 5. 6. OP9 OP2 OP25 OP31 staff member and their initials are recorded to identify who had been responsible for the administration of the medication. The registered manager should ensure that the controlled drugs are stored only in the controlled drugs cupboard and right temperature is maintained. The registered manager should ensure that each person using the service has a written signed contract in place. The registered manager should ensure that the people living at the service are free from accessing any harmful objects. The registered manager must update her knowledge of the requirement for carrying statutory checks, including CRB checks and maintaining appropriate records, prior to the appointment of staff to protect people using the service from potential risk of harm. The registered manager should ensure that all the hot water temperature outlets are regularly checked and recorded. 7. OP38 Shakespeare House DS0000014965.V360762.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection 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. 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