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Inspection on 25/05/06 for Shalom Residential Home

Also see our care home review for Shalom Residential Home for more information

This inspection was carried out on 25th May 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service provides a comfortable and attractive home for the service users who have pleasant rooms and a variety of communal space to sit in. Equipment in the home is good except for the lift (see below). The home is fresh and clean and the atmosphere is friendly. Service users can use their rooms as they like and the service is good and provided in a flexible way. The service users feel in charge of their routines and their care. Staff are well recruited and have initial training to see that they work appropriately. They are properly supervised. There is good communication between the staff and manager which ensures that the service users are looked after properly. There is good liaison with health professionals and service users have appropriate access to them. Service users like the staff and feel they are kind and sensitive. They feel listened to and that staff look after them properly. The meals are good and the menus varied. The medication is dealt with properly and only trained senior staff administer it. Relatives are very pleased with the home and their comments include "staff are friendly and caring", "residents are well looked after", "nothing is too much trouble" and "everybody is very pleasant and kind". They all felt welcomed and were kept informed about their relative. This is a ringing endorsement of the home.

What has improved since the last inspection?

There have been numerous improvements since the last inspection where some requirements for change were made. Staff now have a chance to meet regularly with the manager or deputy to discuss how they are working. Staff practice has also been changed in relation to how service users are spoken to and how continence is promoted. This does more to protect service users` dignity. Wheelchairs are now more safely used with footrests in place. The menus are now displayed in the dining room and breakfast choices are also displayed in service users` rooms to ensure that everyone knows what they can have and the choices available. All complaints including low level complaints from the service users are recorded including the actions taken to remedy the situation. This demonstrates more clearly how staff are listening to service users. There is more information in the care records to help the staff to assist appropriately. Some progress has been made on a system for reviewing what the home does and receiving comments from service users and their relatives, though more work is still needed on this.

What the care home could do better:

Since the last inspection some discussions have been carried out about the plan for alterations in the home but progress is not as far forward as the Commission hoped. The lack of a shaft lift continues to give concern to the Commission though the provider has said that work is to begin in the near future. The Commission continues to monitor this situation and restrictions remain on who can be accommodated on the first floor. Some health and safety issues delayed because of the expected extension work really need to be attended to. Despite being required at the last inspection, they have not been attended to. The garden could be developed to be more accessible for the service users. Staff training needs to be more available and a training strategy developed. The provider has been giving some attention to a system for checking the quality of the home but this still needs to be refined.

CARE HOMES FOR OLDER PEOPLE Shalom Residential Home 147 Yarmouth Road Norwich Norfolk NR7 0SA Lead Inspector Mrs Dorothy Binns Unannounced Inspection 25th May 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shalom Residential Home DS0000046100.V297554.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. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 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) 01603 432050 01603 432576 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.V297554.R01.S.doc Version 5.2 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. 19th January 2006 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. Current fees range from £314 - £400. There are extra charges for hairdressing and chiropody. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection of the Home and lasted six and a half hours. Discussions took place with the manager and provider about how the home was progressing and records and policies were examined. Three staff were interviewed in private and three service users were seen in their rooms. One relative was also spoken to. Observations were made throughout the day in the lounges and dining room and some of the building was inspected. In addition the Commission sends out survey forms to service users and their relatives and to health professionals who know the home. Twelve service users, nine relatives and three health professionals responded. Their views have been incorporated into the report. Information on the Commissions own record received since the last inspection has also been taken into account. What the service does well: The service provides a comfortable and attractive home for the service users who have pleasant rooms and a variety of communal space to sit in. Equipment in the home is good except for the lift (see below). The home is fresh and clean and the atmosphere is friendly. Service users can use their rooms as they like and the service is good and provided in a flexible way. The service users feel in charge of their routines and their care. Staff are well recruited and have initial training to see that they work appropriately. They are properly supervised. There is good communication between the staff and manager which ensures that the service users are looked after properly. There is good liaison with health professionals and service users have appropriate access to them. Service users like the staff and feel they are kind and sensitive. They feel listened to and that staff look after them properly. The meals are good and the menus varied. The medication is dealt with properly and only trained senior staff administer it. Relatives are very pleased with the home and their comments include “staff are friendly and caring”, “residents are well looked after”, “nothing is too much trouble” and “everybody is very pleasant and kind”. They all felt welcomed and were kept informed about their relative. This is a ringing endorsement of the home. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Since the last inspection some discussions have been carried out about the plan for alterations in the home but progress is not as far forward as the Commission hoped. The lack of a shaft lift continues to give concern to the Commission though the provider has said that work is to begin in the near future. The Commission continues to monitor this situation and restrictions remain on who can be accommodated on the first floor. Some health and safety issues delayed because of the expected extension work really need to be attended to. Despite being required at the last inspection, they have not been attended to. The garden could be developed to be more accessible for the service users. Staff training needs to be more available and a training strategy developed. The provider has been giving some attention to a system for checking the quality of the home but this still needs to be refined. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 7 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.V297554.R01.S.doc Version 5.2 Page 8 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.V297554.R01.S.doc Version 5.2 Page 9 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): 3 The quality of this outcome area is good. Service users do have their needs assessed before coming into the home and though the assessment documentation could be better it does give staff the information they need to care for people properly. EVIDENCE: Three care records were examined. All had a short assessment of the service user’s needs and information from the social worker or hospital who had been involved in the admission. The assessment document gave details of special diets, sleep patterns, mobility and other aspects of health and this led on to a care plan detailing how staff would need to assist. Care records are not as organised as they could be but are doing the job for which they are intended. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The quality of this outcome area is good. The health and personal needs of the service users are set out in the care plan and staff work well in seeing that they provide the right assistance. There are good systems in place for seeing that service users’ health is monitored and that the medication is given out correctly. Service users feel treated with respect and their privacy is upheld. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 11 EVIDENCE: Care plans seen gave instructions to staff on how they are to assist the service users. Three care plans seen were quite brief though had been added to when needs changed. There were clear instructions about caring for particular needs such as continence and very full reports to prevent for instance the risk of falling. The care plans were reviewed monthly. Staff wrote daily reports on the progress of the service users. Ten out of twelve of the service users surveyed said they “always “ received the care and support they need. One relative seen at the inspection felt his service user was very well looked after and was very happy in the home. Staff told the inspector that they had handover meetings between shifts so that they were aware of how each service user was progressing. They felt there was good communication between staff and the manager, which helped them to ensure that the job was done well. There was plenty of evidence in the care records that the service users’ health was monitored. Doctors and district nurses visits were recorded separately on each file and there was evidence that continence advice had been sought. Risk assessments were in place for risks of falling, not eating and using the lift. Very detailed instructions were seen regarding one service user who was prone to falls. Fluid charts were in place for specific service users and staff confirmed they assisted some service users to drink. Weight charts were seen and opticians’ visits were also noted. Ten out of twelve service users said they “always “ received the medical support they needed. It was also noticed that service users were wearing clean glasses which showed staff paying attention to detail. Two of the district nurses and the GP of the home responded to the Commission’s survey and said that they were satisfied with the overall care provided in the home and thought staff demonstrated a clear understanding of the care needs of the service users. The Home uses a monitored dosage system where the medication is pre packed by the pharmacist. The system was maintained satisfactorily. The records were completed appropriately and only trained staff give out medication. A locked cupboard was used. Controlled drugs are signed for by two staff and the amount recorded. Stock control is recorded and medication returned to the pharmacy in a timely way. The staff member who showed the inspector the medication was very confident in the process and understood the need for safety. One area for improvement is that some service users have help with their eye drops. The manager reports that staff have been trained by Boots on how to administer eye drops but there was no recording in the staff training file. This needs to be remedied with the training of named staff verified by the nurse trainer and documented. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 12 Service users are assisted in private in their own rooms and those talked to during the inspection were quite happy with the way they were treated. They found staff kind and sensitive and mindful of their privacy and dignity. At the last inspection, mention had been made of staff being patronising in the way they spoke, but this has been dealt with and this time there was no mention of this. Staff confirmed that they had been instructed about speaking respectfully to service users. Service users also confirmed they could see their visitors in private and stay in their rooms as they wished. Some had all their meals in private. The provider reported that five service users have their own keys to their rooms which is good practice. Shalom Residential Home DS0000046100.V297554.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality of this outcome area is good. Overall routines are flexible and service users felt they were able to exercise choice and have some control over what happened to them in the home. The meals were well received and generally service users and their relatives felt they had a good quality of life in the home. Activities are improving. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 14 EVIDENCE: Service users felt they did have a say in their routines and that staff left them to make the choices. One person said she went to bed at 10pm as she liked to sit and watch television, another said she liked to be in bed very early. One person said the staff do not disturb her in the morning until she has rung the call bell which is good practice. All service users are offered a bath twice a week though staff said they would help with more if required. Service users are free to spend time in their rooms or be sociable in the lounges. There are activities provided by the home and these have improved over the months. Service users were able to describe visiting entertainers and craft work is on display which service users have done. One person is reported to have made their own blanket and another does tapestry work. A person comes into the home on a regular basis to provide stimulation and one member of staff specialises in social care. A list of activities offered in the home is displayed in service users bedrooms but without dates. One service user thought the activities were not provided despite the list. The Commission did receive a complaint about the lack of activities in the home and there is still work to be done. The development of a key worker system and the recording of a service users interests in the care plan could be developed further to ensure individual attention is given, together with time for staff to take service users out for a walk and better use of the garden. Service users confirmed they could see their visitors in private and that relatives are welcomed in the home. One relative was seen in the lounge and he confirmed he came as often as he liked. Relatives responding to the survey all reported that staff and managers welcomed them in the home and they could see their relative in private. The home does not handle service users’ personal money, all service users either looking after it themselves or with the help of a relative. Service users are able to bring personal possessions with them to make their rooms cosy. Should a service user need an advocate the manager would discuss with the social worker. Overall service users are able to exercise control over their own lives. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 15 Menus are displayed in the dining room with the breakfast menu showing a range of choices including cereals, prunes, bacon and sausages. This menu was also posted up in service users rooms so that those who breakfasted in their rooms could see what was available. This was a big improvement from the last inspection where service users had been unsure what they could have. At the beginning of the day the menu for the previous day’s main meal was also displayed showing that roast chicken had been served with apricots and custard to follow. Later in the day, the main meal was seen being served – corned beef, chips and salad. The manager had had to step in with the cooking as the cook was off sick. There is no choice of menu but the manager was seen asking a service user if they would prefer boiled potatoes to chips. The meal went down well with the service users. Sauce and salad dressing were also provided when service users asked. Staff reported that for tea, they go round and ask everyone what they would like so they are able to have a choice. Those service users seen in private were quite happy with the food and one said she had all her meals in her room and they were always served hot. She also appreciated that staff ensured she was getting enough fluids. Twelve service users completed the survey sent out by the Commission and eleven said they “always” liked the food in the home. The twelfth person said they “usually” liked it. In the survey of relatives’ opinions about the home, a third gave extra comments about how good the food was. Although a choice in the main meal is still something the manager should consider, overall the food is going down well in this home. Currently there are no special diets to cater for. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality of this outcome area is good. The procedures are in place to ensure service users are listened to when they complain and to protect them from abuse. Service users can be assured that they will be taken seriously. EVIDENCE: The complaints procedure is available in the service users guide which is given to all service users. It contains the address of the Commission should service users feel they have to refer the matter on. A complaints record is kept and low level complaints from service users are now recorded following the last inspection, with the actions that the home took to remedy the situation. All twelve of the service users responding to the survey said they knew how to make a complaint if they had to. One service user seen said she was confident that she would be listened to if she had a concern and was quite sure that things would get done. Service users are protected from abuse by the home’s policies which include referring any suspicions of abuse to the local Adult Protection Unit in line with government policy. Staff confirmed that they had been trained about abuse and understood that they could be reported if there were any suspicions. There is also a whistle blowing policy and a gifts policy ensuring that service users are protected from financial abuse. Shalom Residential Home DS0000046100.V297554.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The quality of this outcome area is adequate. The building is attractive but is in need of some attention including a shaft lift, currently delayed because of planned extensive building work. The main garden is also inaccessible. Laundry facilities though small are good and the home is clean and free from offensive odours. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 18 EVIDENCE: This is a comfortable and well furnished home in a good location on the outskirts of Norwich and looking towards the river Yare. Many of the rooms have en suite facilities and communal space is comfortable. The home is built on an incline making the current very spacious front garden inaccessible to all but the most mobile service users. There is a small secured garden area in the middle of the home which is accessible. The programme of routine maintenance is in place but more extensive maintenance has been postponed due to the planned building of an extension though internally it is bright and attractive. The environmental health officer has recently attended and fire prevention measures are up to date. The main difficulty in the home is the lack of a shaft lift and there are restrictions on admissions of service users who use wheelchairs on the first floor. Three service users who use wheelchairs and have lived in the home for some time, remain on the first floor but no new admissions have been made. Other adaptations for older users such as adapted baths, are in place. The concern of the Commission is that the extension has been considerably delayed and improvements to the building have therefore not been done. Should there be further delay then the Commission would have to consider what actions to take in relation to the lift and access to the first floor. Although the laundry facilities are quite small and will be improved under the new building works, the home deals very well with the laundry. The Home is always odour free and staff have strict hand washing procedures and infection control measures in place. Shalom Residential Home DS0000046100.V297554.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality of this outcome area is adequate. The amount of staffing and the care put into the recruitment procedures ensure that service users are in safe hands and are properly cared for. These aspects of the service are good. There does need to be improvement in the training of staff however and a training plan for the staff group would highlight where that training should be prioritised. EVIDENCE: A rota was available showing that three staff are always on duty with the manager during the day and two staff are on duty in the evenings. Catering and cleaning staff are extra. The provider is also often on the premises. This is considered to be sufficient staffing for the number of service users. At night one waking staff is on duty with one person asleep and on call on the premises. A volunteer also comes in weekly to provide activities for the service users. Currently service users needs are met by such staffing though social activities could be increased. Only two staff have completed their NVQ certificate and two more are currently studying for it. The home has unfortunately lost some trained staff recently, currently the home is not meeting the standard (50 ). Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 20 Two staff files were examined and were found to contain a criminal records check, identity documents and references. Staff interviewed confirmed that they went through the recruitment procedure including an interview. They also have a contract and knew their terms and conditions. All three staff seen confirmed they received induction training when they first started work and workbooks signed off by the deputy manager were seen in staff files. It was not clear from the records whether staff received three paid training days a year as there was no evidence of further training. The information provided by the provider indicated that some extra training had been given to some staff but this is not recorded in a systematic way. Nor was there a staff development plan or training analysis. This is something that should be completed. Shalom Residential Home DS0000046100.V297554.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 The quality of this outcome area is adequate. The manager is very experienced in the delivery of care and service users live in a home where the manager takes her responsibilities seriously. Staff are appropriately supervised which is a good aspect of the home. However some systems regarding quality assurance and health and safety need more attention to ensure that the home is run in the best interests of the service users and their safety is promoted. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager has been running the home for many years and used to be the owner. She is therefore very experienced in residential care though has no qualifications. She is very familiar with the conditions associated with the client group and works well with other agencies. She has an instinctive feel for people which helps her to provide a good standard of care. She is supported by the current owner who is on site for much of the time and who carries out much of the administrative duties in the home. Relatives in the survey were very supportive of the manager saying “the manager and staff are all so helpful” and “home is very well managed” and “well managed and staff work together to provide a very good team spirit.” There are now efforts being made into creating a quality assurance system to enable the service to be judged against the aims and objectives of the home. The registered provider says that questionnaires have been devised and sent out to service users, relatives, and other professionals to seek their views. Samples of these were seen. This shows some progress from the last inspection. Some completed questionnaires were provided to the Commission from the home. However they were not felt to be objective enough due to the lack of anonymity and the service users having been assisted to complete them by the provider. The need for a more objective approach and for a set of standards by which to judge the quality of the home was discussed. In addition the questionnaires will need to be analysed once returned and an action plan drawn up to show where improvements are to be made. None of the service users have their money looked after by the home. All look after their own affairs or have the help of a relative. All staff are now receiving one to one supervision with a manager, and records are kept of these meetings. Staff seen at the inspection confirmed this was the case. This is a great improvement on the last inspection. Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 23 Policies and procedures were seen to be in place for safe working practices in the home. Hand hygiene, infection control, coshh, and fire procedures were all in evidence. Staff also confirmed that they were up to date with moving and handling training and records showed that they had also received training in emergency aid and fire procedures. The main cook has also received food hygiene training though because all staff make the evening meal, food hygiene training should be generally offered. The fire record showed that fire instruction was regularly provided and alarms and emergency lighting checked regularly. There was no documentation for the regular servicing of boilers nor for electrical testing despite this being required as part of a health and safety policy at the last inspection. There was no evidence that water temperatures were checked though baths are reported by the manager to have thermostatic valves. It is accepted that the provider is waiting for extensive building work to commence on a new extension and some building maintenance has been delayed as a result. However to avoid any compromise in the safety of service users appropriate checks should be part of a health and safety strategy. There are risk assessments in place for safe working practices for individual service users and the way wheelchairs are used has been changed since the last inspection. All staff reported that they ensure the footrests are in place. Accident records are in place. Shalom Residential Home DS0000046100.V297554.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 x x 2 x x N/a 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x N/a 3 x 2 Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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. Previous timescale 30/06/06 REPEATED REQUIREMENT The registered person shall ensure that external grounds are suitable for and safe for use by service users. The provider must ensure that staff receive training appropriate to their work including time off for the purpose of obtaining further qualifications. A training analysis will help with priorities. A system for maintaining, reviewing and improving the quality of care in the home should be in place. Previous timescale 30/04/06 REPEATED REQUIREMENT Timescale for action 31/12/06 2. OP19 23(2)(O) 31/12/06 3. OP28 OP30 18(1)©I and ii 30/09/06 4. OP33 24 31/08/06 Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 26 5. OP38 13(4) The registered person must ensure that unnecessary risks to the health and safety of the service users are identified and eliminated. In this instance the servicing of gas and electrical installations should be carried out. 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP12 OP38 Good Practice Recommendations The training of staff to carry out eye drops should be verified by the nurse who trained them and recorded on the staff file. It is recommended that the promotion of activities continues and that staff are more involved in individual outings and activities. It is recommended that all staff who prepare food (even care staff who prepare the tea) are given training in food hygiene Shalom Residential Home DS0000046100.V297554.R01.S.doc Version 5.2 Page 27 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.V297554.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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