Inspection on 10/07/07 for Shaldon House

This inspection was carried out on 10th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shaldon House 27/01/07

Shaldon House 27/06/06

Shaldon House 24/01/06

Shaldon House 10/10/05

Shaldon House 07/12/04

Shaldon House 15/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Shaldon House 77 Shaldon Road Horfield Bristol BS7 9NN Lead Inspector Sandra Gibson Key Unannounced Inspection 10th July 2007 1:15pm Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shaldon House Address 77 Shaldon Road Horfield Bristol BS7 9NN 0117 9518884 0117 9521492 shaldon.house@craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes Ltd 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) Mrs Lisa Marie Cole Care Home 9 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (1) of places Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate one named person with Physical Disability (PD). Will revert to 9 LD when named person leaves. 27th January 2007 Date of last inspection Brief Description of the Service: Shaldon House is registered with the Commission for Social Care Inspection (CSCI) to provide personal care for eight people with learning disabilities who are aged 65 years or younger and one resident with a learning disability who is 65 years and over. There is also a condition of the registration that one named resident who has a learning disability and a physical disability may be accommodated in the home. Parkcare No 2 Ltd, a subsidiary of Craegmoor Healthcare, operates Shaldon House, which is situated in a residential area close to amenities and bus routes. Single bedroom accommodation is arranged over three floors. There are two bedrooms on the ground floor. There is no lift facility available. Disabled access is to the rear of the property. There is a pleasant garden, which is also situated at the rear of the building. This area is reached by steps and has a grassed area and patio with seating. There is currently no appointed registered manager. The fee is £326-£674/week and extra charges are made for chiropody, hairdressing, toiletries etc. This information is provided in the service users’ guide. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place mid week between the hours of 1:15pm and 6pm. The inspector worked with evidence from a whole range of different sources, including: • Information provided by the manager • Monthly reports from the nominate responsible individual • Information from one professional who visits the home • Speaking with residents • Looking at a sample of residents records • Speaking with care staff • Walking round the home • Examination of some of the homes records • Observing some of staff practices and interaction with the residents. The overall analysis is that the home is an adequate place in which to live and to work. What the service does well: Staff have a good awareness of individuals needs and rights and treat the residents in a warm and respectful manner, which means that residents can expect to receive care and support in a secure setting Residents enjoy a range of activities and are supported to live a fulfilling life in and out of the home. Personal relationships with friends and family are encouraged and supported and residents are encouraged to take an active role in promoting and maintaining a healthy well balanced diet. Residents receive sensitive and flexible personal support in the way they prefer by staff trained to maximise residents’ privacy dignity, independence and control over their lives. Residents are well supported to meet their physical and emotional health needs, they are monitored effectively and action is taken promptly when concerns arise so that residents may be confident that their needs will be met. The complaints policy and procedure is satisfactory with some evidence that the service users feel that their views are listened to and acted upon. The measures in place to ensure that residents are protected from abuse are satisfactory The systems in place ensure that the information in place is up to date and that residents are protected from risk of harm at all times. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 6 The relationship between staff and residents is good and creates a warm positive environment to live in. The procedures for the recruitment of staff are satisfactory. The system in place ensures the protection of residents accommodated at Shaldon House. Staff training is satisfactory. The arrangements in place ensure that all residents’ individual needs are met and that staff have an awareness and understanding of equality and diversity. What has improved since the last inspection? Residents’ needs are now fully assessed to ensure the home is suitable to meet individual requirements. Following the last inspection minor improvements have been made to ensure that residents and their representatives (where appropriate) are fully consulted during the process. Residents’ individual needs are satisfactorily met in this home. Following the last inspection residents benefit further from staff being given increased opportunity to receive specialist training to meet individuals’ individual The care planning system in place is satisfactory. Further improvement is starting to take place following the last inspection. The system in place is beginning to ensure that residents’ changing needs continue to be fully identified. The management arrangements in place now ensure that resident rights and best interests are met and staff are aware of who is responsible for day-to-day management of the home. Staffing levels have fluctuated since the last inspection as a result of staff leaving. However, further staff are being recruited and the arrangements in place ensure that residents’ dependency needs are currently met. Following the appointment of a new manager in December 2006 residents are beginning to benefit from the leadership and management approach of a well run home. Residents are also beginning to feel confident that their views are listened in the way that the home is being reviewed developed. Following the last inspection residents rights and best interests are better promoted and protected following the updating of corporate policies and Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 7 procedures to ensure that the management team and staff have the up to date information they need to fulfil their roles and responsibilities 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. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Following the last inspection the information provided to prospective residents and current residents and their representatives is in the process of being reviewed. The information in place needs to be updated to ensure that people have the full information they need to make an informed choice about where to live and that current residents are kept up date with information about the support and services that are provided by the staff. Residents’ needs are now fully assessed to ensure the home is suitable to meet individual requirements. Following the last inspection minor improvements have been made to ensure that residents and their representatives (where appropriate) are fully consulted during the process. Residents’ individual needs are satisfactorily met in this home. Following the last inspection residents benefit further from staff being given increased opportunity to receive specialist training to meet individuals’ individual. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 10 EVIDENCE: The new manager explained that she was in the process of reviewing the statement of purpose and service user as a result of all the changes in the home. She acknowledged that there were gaps in information and that the information in place did not reflect the current aims and objectives of the home. Following the last inspection two residents have moved to other accommodation as a result of their changing needs. These two places have been filled by two residents who lived in another care home belonging to Park Care Limited, which has recently closed down. These residents were transferred with assessments of needs in place which are currently under review by the manager and staff team. The manager explained that she was in the process of reviewing all resident assessments / care plans and had started to contact families where residents were in agreement for their families to be involved. The inspector had the opportunity to meet the two new residents during the inspection. They both appeared to be settling well. This was confirmed by the manager who said the transfer had been helped by the residents already knowing most of the residents in the home as they had met on social occasions. This information was also confirmed by a nurse from the Community Learning Difficulties Team who was visiting one of the residents who had moved in as well as other resident known to him. He also explained that he had been asked to provide training in the home for the staff on working with people with leaning difficulties. This is good practice to use community resources. Evidence also confirmed that other specialist training was provided in the home. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning system in place is satisfactory. Further improvement is starting to take place following the last inspection. The system in place is beginning to ensure that residents’ changing needs continue to be fully identified. Staff have a good awareness of individuals needs and rights and treat the residents in a warm and respectful manner, which means that residents can expect to receive care and support in a secure setting Residents are well supported to take risks in their daily lives within their home and out in the community. However the manager and staff team would benefit from training on how to manage sexual awareness when working with residents with a learning difficulty and residents with pre senile dementia. They would also benefit from training on the implications of the new mental capacity act 2006 so that residents’ best interests and rights are better protected. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 12 EVIDENCE: As already discussed the manager told the inspector that she is in the process of reviewing all resident assessments / care plans and had started to contact families where residents are in agreement for their families to be involved. Residents in this home are aware they have a care plan and that they can be involved in its review and development. During the course of the inspection evidence confirmed through discussions with the manager and through observing the residents interacting with staff that the service recognises the rights of individual’s to take control of their lives and to make their own choices. For example the menu confirmed that residents take it in turns to help choose what they eat on an evening residents. Three residents told the inspector about the choices they had made about bedroom furniture and redecoration. One the day of the inspection one of the residents’ rooms was being decorated in Manchester United Colours by a staff member and another resident showed the inspector the pink furniture she chosen for her bedroom. All staff seen were very aware of individual residents privacy and dignity. However the inspector was informed that one of the residents had moved bedrooms but sometimes returned to his old bedroom at night. An alarm has been installed on this resident’s bedroom door so that the sleep in night staff are aware if this resident moves out of his room in the middle of the night. This is a form of restraint and must be used only where there is no alternative solution. Consultation with the resident concerned and their family / representative must be carried out and written consent obtained. This action must then be reviewed on a regular basis. Evidence confirmed that risk assessments are completed in this home and that residents are supported to take individual risks in their day-to-day lives. However following discussions with the manager about several residents it became apparent that staff would benefit from training on sexual awareness and how to feel comfortable with residents when residents wish to talk about sex, sexuality and relationships. It was pleasing to hear how one resident spoke about her boyfriend and how she felt she could talk to any of the staff about her relationship and that she felt supported. However, it was observed that a couple of residents use openly sexual language and that some of the staff found this behaviour sensitive to manage when other residents and visitors are present. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents enjoy a range of activities and are supported to live a fulfilling life in and out of the home. Personal relationships with friends and family are encouraged and supported and residents are encouraged to take an active role in promoting and maintaining a healthy well balanced diet. EVIDENCE: Daily routines and activities were discussed with several residents, which include attending college and various day centres on weekdays. All residents regularly go out and enjoy the local community amenities by visiting local pubs, restaurants, shops, cinemas and Tenpin Bowling. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 14 This was confirmed by residents and staff who said that following the last two inspections they were now going out more often on an evening (during the week) and also at weekends. Residents spoke about going to play bingo at a local hall and going to watch some a wrestling match. Evidence confirmed that the residents are choosing to go out to eat in cafes /pubs more often. On the day of the inspection two male residents had been to the local pub to play pool and some of the female residents had been shopping. No residents currently choose to attend a place of worship. This was confirmed previously in resident’s files Residents are able to enjoy hobbies such as football, music, watching soap operas and films on TV or DVD. An activities record is maintained and special sessions are arranged for the residents, for example a pampering night, card making, or discussions on road safety or hazard awareness bingo, etc. Some residents attend a local community club. Some residents lead very busy lives and expressed one again that they often enjoy just ‘relaxing on the weekend’. Family and friendship contact is encouraged and supported whereby the residents invite people for tea and some resident’s stay with their families for weekend visits and holidays. Each resident has a list to remind them of important family dates and they send cards to mark these special occasions. Information confirmed that residents meet every Sunday to discuss their chosen menu plan for the week ahead. This system enables the residents to make their own choices and with the support of the staff it was evident from the menus that they have produced a varied healthy diet plan. On the day of the inspection residents enjoyed a communal lunch, which consisted of a choice of sandwiches and dessert of choice. Both hot and cold drinks were available. For the evening meal residents had sausages and mash and peas. Alternatives were also made available and flexibility in meals was also evident. Once again several residents confirmed they enjoyed the food and never felt hungry. Evidence confirmed that staff in the home continue to support residents to eat a healthy diet. The manager told the inspector that she had been introducing residents to new foods such as squash and other different vegetables and fruit and had increased her food budget to provide that choice. Throughout the inspection residents said “I like it here” “I like the staff”. “This is my home”. Evidence confirmed that residents at Shaldon House are involved with the domestic routines of the home; they take responsibility for their own room, menu planning, and assisting with settings the table. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive sensitive and flexible personal support in the way they prefer by staff trained to maximise residents’ privacy dignity, independence and control over their lives. Residents are well supported to meet their physical and emotional health needs, they are monitored effectively and action is taken promptly when concerns arise so that residents may be confident that their needs will be met. EVIDENCE: Evidence confirmed that personal care and intimate care is provided by a member of staff who the resident feels comfortable with. Support and prompting to wash and shave is provided where required during the inspection. The inspector saw residents choosing to have a shower when they returned from going out for the day. Evidence confirmed that times for getting up and going to bed, baths meals and other activities are all flexible. This was confirmed by residents at the time of the inspection and observed during the inspection. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 16 Evidence at the inspection confirmed that residents choose their own clothes, hairstyle and make up and their appearance reflects their personalities. Evidence confirmed that the residents at Shaldon House have access to health care services both within the home and in the local community. The majority of people are able to choose their own GP and attend local dentists opticians and other community services with support from staff. Residents’ health needs are monitored by the staff team and appropriate action taken. This was confirmed by residents records held in the home and the visiting nurse from the Community Learning Difficulties team. Further evidence was seen for example how one resident had been referred to the continence adviser for support with continence needs. The home is generally able to provide the aids and equipment and the manager demonstrated how they were looking at residents changing needs for example one younger resident has a history of falls as a result of a genetic condition and the manger has already started to make enquiries about installing a stair lift if the residents mobility needs deteriorate so that the resident in question does not need to move to a different house. During the course of the inspection a discussion took place with the manager about residents changing needs as they become older and frailer. As discussed earlier in the section on choice of home two older residents has recently been transferred from another home operated by the same provider which has recently closed. The manger spoke about how the staff were meeting these residents complex needs and what changes may need to be made in the future. As discussed previously two residents have been assessed as having pre senile dementia with a result that their personal care needs have increased and staff provide further prompting and support. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints policy and procedure is satisfactory with some evidence that the service users feel that their views are listened to and acted upon. The measures in place to ensure that residents are protected from abuse are satisfactory The systems in place ensure that the information in place is up to date and that residents are protected from risk of harm at all times. EVIDENCE: Residents have information provided in the Service Users Guide on how to make a complaint or voice concerns, this information is also on display in the reception area. Evidence confirmed that it is also available in different formats including pictorial format, audiotape and Braille. Representatives are now informed about the complaints procedure. Evidence confirmed that that this policy and procedure is in the process of being reviewed. . Relatives and representatives are made aware of the procedure, which is sent out to their home addresses. A couple of residents talked about the residents meetings where they are able to discuss any issues and concerns they may have. These meetings are held on a regular basis. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 18 Evidence confirmed there is an Adult Protection policy and procedure in place which complies with the Local Authority Guidance No Secrets in Bristol. No complaints have been made or received by residents or families in the last year. Staff have received training on the protection of vulnerable adults. Staff have also attended training on ‘Non violent crisis intervention’ which is also updated annually. The new manager and new staff are in the process of being put forward for adult protection training Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been some improvements in the health and safety, comfort and cleanliness of Shaldon House since the last inspection. However, further urgent attention is still needed to ensure the health, safety and comfort of residents and staff at all times. EVIDENCE: The front garden ha s improved since the last inspection. However, it is still in need of further attention as a result of building debris being left in the garden following the building and repair work to the steep steps, which are the main access to the front of the house. These steps have been built with non-slip stone on top. There is a rail at one side of the step. The steps have not been completed as the maintenance person is on annual leave. Consequently, the front entrance which is also a fire exit which s currently not in use at the moment. The exit is at the rear of the property where there is disabled access. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 20 A risk assessment was previously carried out for this arrangement. the inspector did not see this risk assessment on this occasion. However, Following the departure of one resident from Shaldon House, three residents have chosen to change rooms. This was confirmed by residents seen at the time of the inspection who all spoke positively about their new rooms. Three residents’ bedrooms were looked at and expressed individual choices in colours, fabrics and layout. Residents had accessorised their rooms with football memorabilia, soft toys, photographs and ornaments. Residents have televisions, stereos and such like to enable them to spend quality time alone. The samples of bedrooms seen were comfortable and homely. Following the admission of one of the two new residents the inspector was informed that there had been concerns about one of the residents accessing during the night as previously he had slept on the first floor. A stair gate had been used on the stairs when this person was first admitted to stop the resident going up stairs. There had been no risk assessment in place. The inspector advised that this was a form of restraint. It was also a risk for residents and the sleep in member of staff who sleep on the first and second floor particularly in a fire. This stair gate was removed three weeks prior to the inspection according to the manager who confirmed it would not be used again. The inspector was informed that the majority of residents would not use a call alarm but would call out or locate the member of staff on duty if they needed help. The inspector was informed that there is currently only one member of staff who carries out sleep in duties. A tour was made of the toilet / bath and shower facilities for residents. All bathrooms, toilets were clean, tidy and smelt fresh. However the bathroom on the second floor was found to be very worn and in need of attention. There has been a new water heater and water tank installed in this home since the last inspection. The water temperature on all floors was found to be satisfactory during this inspection. All minor repairs are reported to the maintenance section and evidence confirmed that appropriate action was taken in reasonable timescales. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32,33,34 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The relationship between staff and residents is good and creates a warm positive environment to live in. The management arrangements in place now ensure that resident rights and best interests are met and staff are aware of who is responsible for day-to-day management of the home. Staffing levels have fluctuated since the last inspection as a result of staff leaving. However further staff are being recruited and the arrangements in place ensure that residents’ dependency needs are currently met. The procedures for the recruitment of staff are satisfactory. The system in place ensures the protection of residents accommodated at Shaldon House. Staff training is satisfactory. The arrangements in place ensure that all residents’ individual needs are met and that staff have an awareness and understanding of equality and diversity. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 22 EVIDENCE: A new manager has recently been appointed and started working in the home on 16th December 2006. There is also a deputy manager. Several staff have left the home during the last few months but the new manager has been recruiting new staff. There is currently a 29-hour post vacant. Staff seen at the time of the inspection were clear about the management arrangements and who to contact at night in an emergency. There is an on call list in place. The staffing levels at the time of the inspection were satisfactory. Staff are no longer working excessive hours. Evidence confirmed that senior management from Craegmoor monitor staffing levels at all times to ensure that there is no contravention of The European Working Time Directive. Following the recent departure of one resident who had high personal care needs the staffing arrangements at night have returned to one sleep in member of staff who sleeps in a bedroom on the middle floor. The manager told the inspector that this situation is under constant review as a result of residents’ dependency levels. Information confirmed that the two new residents who had transferred from another care operated by Park Care limited were settling into life at Shaldon House very well. The manager explained that these residents had been used to a member of staff being awake at night, but they were aware that the member of staff at Shaldon did sleep in duties and knew what to do if they needed assistance at night. Information confirmed that the manager of Shaldon House follows a robust recruitment policy and procedure. Staff training records showed that staff receives mandatory training on food hygiene, POVA, fire, first aid, health and safety and manual handling. Specialist training takes place in this home as discussed earlier in the report. Staff had been doing well with NVQ training in this home. Some of these staff members have now left the home and the manager recognises that NVQ training will need to be offered to new members of staff in order that this standard can be fully met. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Following the appointment of a new manager in December 2006 residents are beginning to benefit from the leadership and management approach of a well run home. Residents are also beginning to feel confident that their views are listened in the way that the home is being reviewed developed. Following the last inspection residents rights and best interests are better promoted and protected following the updating of corporate policies and procedures to ensure that the management team and staff have the up to date information they need to fulfil their roles and responsibilities Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 24 EVIDENCE: Evidence confirmed that the new manager has the necessary experience to run the home. Prior to the inspection the manager completed “ the fit persons” process with The Commission for Social care Inspection during this process she demonstrated her experience and competence to manage the home. She has now been registered as manager of Shaldon House. Throughout the inspection the manager demonstrated her awareness of and how she is working towards the national minimum standards. The manager is aware need to keep up to date with practice and continuously develop management skills. The manager confirmed that she has enrolled onto the Registered Managers award training to start in September 2007 and following that training she plans to complete NV4 in Management. She also confirmed that she has completed First Aid training since her appointment and evidence confirmed that she had organised to update her skills and knowledge in manual handling, infection control and protection of vulnerable adults in the next few weeks. Following the departure of the previous manager in May 2006 and the start of the new manager in December 2006 several members of staff have left Shaldon House. Evidence confirmed that the manager is in the process of recruiting new staff. Through the inspection she demonstrate that she is starting to develop new and current staff to care for the people who live at Shaldon House in a more service user focused way to take account of equality and diversity issues particularly as residents needs are changing as they get older. The manager told the inspector that residents / relatives questionnaires have recently been sent to residents and their families and she was awaiting the findings. Residents confirmed that regular residents meetings take place in the home. Evidence confirmed that she is working in partnership with families of people who live at Shaldon House and professionals who are responsible for residents’ health acre. This information was confirmed by recent letters sent out to relatives by the manager asking them to arrange a time to visit so that reviews can be carried out as discussed previously. The visiting health professional also conformed that communication with the home was good. Evidence confirmed that the manager with support from the nominated responsible individual is improving and developing the systems in place that monitor the care provided at Shaldon House and ensure that staff comply with the homes policies and procedures. This is was confirmed in the Regulation 26 monthly reports sent to The Commission for Social Care inspection. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 25 A quality Audit has also recently been conducted by Craegmoor Health care who are responsible for Park Care Homes Limited. A high number of recommendations have been made in this report but the manager demonstrated that she is working towards meeting these recommendations. The manger demonstrated that she was aware that the home was under financial pressure last year and that she is aware of the need to plan the business activity of the home and manage the finances and resources to deliver the business plan. However as discussed earlier she also demonstrated that she was aware of residents needs and would use the budget to meet these needs for example as discussed earlier in the section on daily living she has increased spending on extra fruit and fresh vegetable to improve the diet for residents. This is good practice. Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 3 3 3 3 3 3 Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 27 yes 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 YA24 Regulation 23(2) Requirement The main entrance to the home must be put back into action by raising the step. Until that time the fire risk assessment and the fire safety procedures must reflect this temporary situation Timescale for action 31/08/07 2 YA1 6 3 YA9 18(1) 4 YA7 12 This is an on going made at the last inspection 267/01/07 The statement of purpose and 30/09/07 service users guide must be reviewed to ensue that it meets the aims and objectives of the home The manager and staff would 31/10/07 benefit from training on how to manage sexual awareness when working with residents with learning difficulties and residents with pre senile dementia. Also training on the implications of the new Mental Capacity Act 2006 Written consent must be 31/07/07 obtained for the use of the alarm in consultation with the resident and his family/representative where appropriate and the use of this alarm must be regularly reviewed. DS0000026554.V345799.R01.S.doc Version 5.2 Page 28 Shaldon House 5 YA24 23(2)(d) The bathroom on the second floor is in need of attention as a result of wear and tear. A programme of when this refurbishment is to take place must be drawn up and sent to The Commission for Social Care Inspection. 31/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Shaldon House DS0000026554.V345799.R01.S.doc Version 5.2 Page 30 - 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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