Inspection on 19/01/06 for Shalom Residential Home

This inspection was carried out on 19th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Shalom Residential Home 15/07/08

Shalom Residential Home 01/08/07

Shalom Residential Home 25/05/06

Shalom Residential Home 22/07/05

Shalom Residential Home 31/01/05

Shalom Residential Home 18/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Shalom Residential Home 147 Yarmouth Road Norwich Norfolk NR7 0SA Lead Inspector Mrs Dorothy Binns Announced Inspection 19th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shalom Residential Home Address 147 Yarmouth Road Norwich Norfolk NR7 0SA 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) 07974 979644 Medicare Corporation Ltd Mrs Lorraine Walkinshaw Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Old age, not falling within any other category (24) persons. Care Home only. No new admissions of service users who are wheelchair users to be accommodated on the first floor until the registered person ensures the establishment complies with regulation 23(2)(n). All service users accommodated on the first floor must have written risk assessments regarding the use of the stair lift. 22nd July 2005 4. Date of last inspection Brief Description of the Service: Shalom is a large period residence located well back from the road, on the outskirts of Norwich and overlooking the Yare valley. The house has been carefully extended and adapted to provide residential accommodation to a maximum of 24 older people. There are 20 single and 2 double rooms. Two of the single rooms within the extension offer a bed sit type accommodation and the majority of rooms are spacious. Both the double rooms and 12 of the single rooms have en suite facilities. The care home stands in attractive grounds, surrounded by mature trees. There is a bungalow to the rear of the main building which provides accommodation for the supporting night care worker who sleeps in. There is currently no passenger lift in the Home. A stair lift has been provided but until a new passenger lift is installed, there are restrictions on admitting service users who use wheelchairs to the first floor. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine announced inspection of the home lasting all day. Discussions took place with the manager and provider about how the home was progressing and records and policies were examined. Three staff were interviewed and five service users were seen in their rooms. Survey forms had been sent out to the home to be given out to service users but none were returned to the Commission. Two health service professionals surveyed by the Commission returned their forms. The environmental health officer also conferred with the Commission. What the service does well: What has improved since the last inspection? What they could do better: The provision of a shaft lift needs to be remedied as soon as possible. Although there is a stair lift it remains difficult for service users to move easily between floors and makes extra burdens for staff. The home needs to be more formal about a code of practice for staff to ensure that care is delivered in the best possible way. This is not to lose the friendliness of the staff but to ensure that they understand current standards. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 6 It would help if service users were consulted more about life in the home. A quality assurance system is being devised but not yet in place. Some health and safety matters need to be attended to such as checks on the gas and electrical systems, food hygiene training and how the staff use the wheelchairs. The responsibility for health and safety and the procedures to be followed need to be localised to the home so that everyone is clear about their responsibilities. 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. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 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 Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 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 and 3 Prospective service users are provided with a guide to the home to help them make their mind up about staying. Each service user is issued with a contract describing the conditions of residence. Service users are all assessed before being admitted to the home. EVIDENCE: The service users guide was seen which is given out to all service users. It contains a short version of the statement of purpose and a list of the facilities in the home. The complaints procedure and terms and conditions of residence are also included. It was also mentioned that the shaft lift is out of action and that a stair lift is currently being used reflecting correctly the situation in the home. Three contracts were seen and they were all signed by the service users reflecting the fact that service users were given the information about the terms and conditions in the home. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 9 Three files were selected at random. All had a short assessment of need. Some of the information could have been more detailed especially in the areas of personal care and mobility but it was used to form the basis of a care plan. Where the service users had been referred by social services or been admitted from hospital, information was provided by those agencies. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 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, 9 and 10 Care plans are in place and show what assistance the staff have to give the service users. Some minor improvements are needed. The medicines for the service users are administered satisfactorily and staff abide by the policies and procedures in the home. Service users feel their right to privacy is upheld and that in the main they are treated with respect. Some staff talk down to them however and they don’t like that. EVIDENCE: Three care plans were examined. They are simply written but spell out the care required from staff based on the assessment. Care plans are reviewed every two months. A daily reports varied some having more information than others Some information that should have been recorded was not done so. Staff still would benefit from further guidance on this. Risk assessments were in place for use of the stair lift and for falling for instance. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 11 The medicines system was briefly checked. A monitored dosage system is used. Medication was appropriately stored in a locked cabinet and the daily administration record was correctly completed. Staff confirmed they had received medication training and described correctly how they gave out the drugs. Two staff sign the record when controlled drugs are involved. All service users have help with their medication. In terms of privacy and dignity, service users confirmed that they were attended to in the privacy of their room and given individual care depending on their needs. Two service users seen had their meals in their rooms and others had their breakfast or their tea in private. They could see their visitors in private and several of them had their own telephone. They were provided with a key safe in their room though none of the service users seen had been given a key. They felt their clothes were well looked after by the staff and there was no problem is receiving their mail. Two service users did describe staff being patronising in how they spoke to them. One said “(staff talk) in silly voices – talk to you as if to a kid”. Another said they called you “darling and dear”. This needs to be addressed with staff. Lack of dignity was also apparent in the use of continence sheets draped on every seat in the conservatory. This advertised a problem of continence that was not mindful of how service users might feel. This does not reflect an individualised approach to a person’s care needs. The sheets were taken off straightaway and it is hoped that the practice will cease. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 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): 14 and 15 Overall service users can still make their own decisions about their lives. Service users have mixed views about the food though the menus looked good. More choice is recommended. EVIDENCE: In terms of autonomy and choice, service users are in control of their own affairs, the Home having no part in the service users’ finances for instance. Service users said they could keep to their own routines and stay in their rooms all the time if they wished. They are able to bring into the home their own possessions and their rooms were individual and contained some familiar things. One service user had a classical record on and was working on his computer indicating he was free to be himself in his room. Some lack of choice is caused by the frailty of the service users and their dependence on staff but care records showed that a choice was given in the daily routines. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 13 The menus for the home were seen and looked varied and nutritious. There is not a choice of food at the main meal though the home is hoping to offer this in the near future. The cook did say that an alternative would be offered if a service user did not like what was on the menu. The menu is displayed in the dining room. Views about the food varied with the service users. Comments included the food was “simple” and “breakfast was just toast and cereals”– no juice, prunes or grapefruit; the food was “very good” and you “could have what you want”; “the food was more or less OK” and “if you don’t like it you don’t eat it” (implying that there was no alternative). Two had recently complained about the food though it was not clear whether staff had reported this to the manager (see complaints section). All liked their early morning cup of tea and one said if she woke in the night, staff would make her a cup of tea. These comments were not to the inspector a ringing endorsement of the food offered in the home and some discussion would seem to be desirable. Some of the service users seen at the inspection eat in their rooms and it may be that the service to them because they are not in the main dining room is offering less choice. The manager gave examples where individual choices were catered for but a recommendation is made to look into the matter. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 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 and 18 The Home rarely receives a complaint, nor is it reported to the Commission. It has a complaints procedure but the recording of low level complaints and actions taken would be better recorded. Abuse procedures are in place and service users are protected. EVIDENCE: The complaints procedure is in the service user guide and it also contains the address of the Commission. The home keeps a record of complaints though none were recorded since 2004. There have been no complaints to the Commission. It would be good practice to record the low level complaints made by service users to show what actions were taken by the home and to show that complaints are listened to. One service user told the inspector about a complaint made about the food the previous week and another mentioned a complaint about the food the previous day. Neither of these were recorded. An abuse policy was in place though did not record how a referral could be made to the Adult Protection Unit. This needs to be added to the procedure. The manager was aware however of the procedures to be taken if there was any suspicion of abuse. Staff seen at the inspection confirmed that they had been trained on the matter. There is also a whistle blowing policy to protect staff who report any suspicions. The home also has a gifts policy which staff must comply with. This protects the service users from financial abuse. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 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): 22 Service users have some specialist equipment to maximise their independence but the main problem is the lack of a shaft lift. EVIDENCE: The provision of a shaft lift has again been delayed due to difficulties in the proposed extension plans. The stair lift is the only way to come downstairs and has caused limitations on the home as it is too difficult for those who are frail and need a wheelchair. No new admissions can be made to the upstairs rooms of service users who need a wheelchair. There are however three people upstairs who need wheelchairs and some difficulties were seen during the inspection not only for the service users but for the staff as well. The stair lift was also out of action the day before the inspection and service users had to remain in their upstairs rooms including being provided with meals. Other aids are provided with grab rails in the corridors and aids in bathrooms and toilets. There is an assisted bath on each floor. Call bells are provided and a test was made during the inspection. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 16 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): 29 and 30 The recruitment procedure is rigorous protecting the service users. Staff are receiving initial training for their job. EVIDENCE: Three staff files were examined to see what the recruitment procedure was. All contained two references, identity checks and criminal record checks. A format for the interview is used. All staff receive contracts and a disciplinary code. Induction workbooks were seen on all three staff files sampled. One induction was not yet complete as it was a very new staff but both the others were completed. One showed foundation training as well. This is a big improvement on the last inspection when a requirement had been made for more rigorous training. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 17 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): 33, 35 and 38 A more developed quality assurance system is required to ensure that the home is run in the best interests of the service users. Residents look after their own money with no involvement by the home. On balance the health and safety of the staff and service users are protected but a more organised approach is required. EVIDENCE: The home does not have a comprehensive quality assurance system though the provider is working on this and presented a checklist. More development is required to enable service users and relatives to feedback their views and for an action plan to be written showing the response to the findings. Some of the inspection findings would be discovered by the home themselves if a consultative process was in place. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 18 The home has no involvement at all in the finances of the service users. It collects no benefits nor does it look after money for anyone. All service users have safes in their room. The health and safety procedures and training were examined. Staff confirmed that they received moving and handling training and this was kept up to date with retraining every year. Some staff have received emergency aid and food hygiene training though one of the cooks had not and this should be remedied. Staff were also very clear about infection control procedures and confirmed that gloves and aprons were available and there were appropriate disposal facilities. Policies were in place regarding COSHH and hand washing. There was no documentation for the regular servicing of boilers nor for electrical testing though the owner said these had been carried out. There was no evidence that water temperatures were tested. More evidence of these checks is required. The Home has a health and safety policy but this is an imported one and needs to be made relevant to the home. The fire system was up to date with the records showing that appropriate tests and drills were carried out on a regular basis. The accident record was also kept. Service reports were seen for the hoist and lift. It was observed during the inspection that none of the wheelchairs used or stored had footrests on them. This can be a dangerous practice for the service users and must cease. Also one wheelchair user who is able to use the stair lift, has her own wheelchair carried by staff up or down the stairs as she uses it to sit in, both in her room and in the lounge. There is no shaft lift to avoid this situation. It is the provider’s responsibility to ensure that staff are safe in this practice and that their training is up to date. Any specific procedures should be recorded in the health and safety policy. Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 19 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 3 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 x x x 2 x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 3 x x 1 Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP22 Regulation 23(2)(n) Requirement A shaft lift must be installed to allow greater mobility for the service users. This has not been attended to and remains a requirement The way care is delivered must be in a manner which respects the dignity of the service users. A system for maintaining, reviewing and improving the quality of care in the home should be in place. The provider must ensure that staff receive training appropriate to their work, in this instance, the cook must receive food hygiene training. A health and safety policy for the home must be devised identifying any risk areas, what training and procedures are provided to staff and the checks and services of equipment to be carried out and at what frequencies. Unnecessary risks to the service users are identified and eliminated. In this case footrests on wheelchairs must be used. DS0000046100.V273078.R01.S.doc Timescale for action 30/06/06 2. 3 OP10 OP33 12(4) 24 15/02/06 30/04/06 4 OP38 18(1)(c) 31/03/06 5 OP38 4 31/03/06 6 OP38 4 15/02/06 Shalom Residential Home Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3OP7 OP15 OP16 Good Practice Recommendations The care and assessment records though much improved still need some work to make them more comprehensive. It is recommended that an anonymous survey is conducted with the service users about the food. It is recommended that all concerns from service users or their relatives are recorded in the complaints book with the actions taken to show that service users are listened to. The adult protection procedure needs to contain the local procedure for reporting any suspicion of abuse. 4 OP18 Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Shalom Residential Home DS0000046100.V273078.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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