Inspection on 11/12/07 for Shamrock House

This inspection was carried out on 11th December 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shamrock House 17/02/09

Shamrock House 22/08/06

Shamrock House 06/12/05

Shamrock House 05/07/05

Shamrock House 26/10/04

Shamrock House 20/05/04

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

CARE HOME ADULTS 18-65 Shamrock House 69 Hook Road Goole East Yorkshire DN14 5JN Lead Inspector David White Unannounced Inspection 11th December 2007 09:00 Shamrock House DS0000019723.V355506.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 Shamrock House DS0000019723.V355506.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. Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shamrock House Address 69 Hook Road Goole East Yorkshire DN14 5JN 01405 766217 F/P01405 766217 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 Lila Chaudhary Mrs Marcia Dorothy Nicholls Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The category MD (E) refers to only five (5) named individuals already resident within the home. 22nd August 2006 Date of last inspection Brief Description of the Service: Shamrock House is a care home that is registered to provide accommodation and care services for up to twelve people who have mental health problems. Bedroom accommodation is mostly in shared rooms. People have the opportunity to mix in the communal areas, which currently consists of a lounge and a dining room. Work is underway to extend the building on the ground floor. This will create additional bedrooms and more communal space. The garden area is accessible to wheelchair users, although the homes two bathrooms are situated upstairs and therefore the accommodation is limited for those with mobility problems. However, the planned alterations to the building include installing bathroom and shower facilities on the ground floor. The location of the home close to the centre of Goole, ensures that there is good access to local bus and train services for both people living at the home and their visitors. Current information about the care and services provided at Shamrock House in the form of a statement of purpose, service user guide and the most recent inspection report published by the Commission for Social Care Inspection (CSCI) are available by contacting the home. The current fees at the time of the site visit on 11th December 2007 ranged from £245 to £399 per week and do not include costs for hairdressing, chiropody, toiletries and activities. Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. More information about the inspection process can be found on our website www.csci.org.uk We went to the home without telling them that we were going to visit. This report follows the visit that took place on the 11th December 2007. The visit lasted for 7 hours. The purpose of the visit was to make sure that the home was operating and being managed in the best interests of people living there. Information has been used from different sources for this report. These sources include: • • • Reviewing information that has been received about the home since the last inspection. Information provided by the manager on an Annual Quality Assurance Assessment questionnaire. Comment cards returned from seven people who live at the home, six care professionals and six members of staff who have contact with the home. During the visit time was spent talking to three people who live at the home, three members of the care staff, the administrator and the manager. Documentation and records were also looked at as part of the site visit and time was spent observing the interaction between people at the home and staff. This all helped in gaining an insight into what life is like for people living in the home. The manager was available throughout the site visit and the findings were discussed with her at the end of the inspection. What the service does well: The people who live at the home say “staff are kind, helpful and respectful”. One person said, “I am happy and well cared for”. Another commented, “the staff are an excellent team and treat you with the utmost care”. People said, “the food at the home is good and there are always choices”. This helps in making sure people receive nutritious food that they enjoy. Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 6 Other services that are involved with the home say that the home is good at keeping them informed and act on any concerns. One care professional commented, “this is one of the home’s strengths”. This helps in making sure that people get the right kind of support they need quickly. People who live in the home describe it as “homely”. One person said, “it is a great place to live”. The home has a sufficient number of staff who work hard to provide the care that people need. People feel that their concerns are listened to and properly acted on by the manager. This helps people to feel reassured and safe. What has improved since the last inspection? What they could do better: People’s needs could be documented when they are being assessed for admission to the home, so that staff have written information about what these needs are and how they can be best met. People’s care plans could include more information about potential risks to people and ways of managing these risks so that people are at less risk of harm. They could also be more person centred so that all aspects of each person’s life can be considered. The broken lock in a shared bedroom could be repaired so that the room is more secure and private for the people who use it. Some extractor fans could be cleaned to provide better ventilation in the home and in one toilet the lighting could be better. This will make the home more comfortable and safer for people who live there. Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 7 Staff training could be updated in some areas so that people who live at the home can feel confident that staff have up to date training and skills to provide care in a safe way. Action could be taken to make sure people are comfortable and safe. The sink hot water temperatures need adjusting to make them safe. Some work needs to be undertaken to make sure that any outstanding issues from the last inspection of the electrical wiring systems have been satisfactorily addressed. This will help in making sure that people are kept safe. The owner of the home could keep a record of her findings from her visits to the home and actions taken from these. This will help in identifying what the home is doing well and actions she is taking to improve the care and services on offer. 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. Shamrock House DS0000019723.V355506.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 Shamrock House DS0000019723.V355506.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): 2 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Overall the pre-admission arrangements are followed to make sure that only suitable people are admitted to the home. Written information needs to be made available to staff when people move into the house in an emergency so that they are clear about the person’s needs and how these are to be met. EVIDENCE: People who are thinking about moving into the home are given information about the care and services on offer and are able to visit the home before making any decisions about moving in there. The manager carries out the preadmission assessments and information is collected from sources such as GP’s and the placing authority as part of the assessment process. This is so that the home can make a decision about whether they are able to meet someone’s needs. Since the previous inspection one person has been admitted as an emergency. The manager said that prior to the admission she had discussed the person’s needs with their care manager to make sure the home could meet the person’s needs. However this information had not been recorded. This meant that Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 10 information about the person could only be passed on verbally. The quality of this information is dependent on good communication and could have led to important information being missed. Since that time written information had been obtained about the person from their placing authority. One person said that they wanted to consider living elsewhere and a care review meeting had been arranged with the person’s care manager to discuss this matter. A survey returned by a care professional said, “The home was very good at providing extra support when one of my clients moved in there”. Since the previous inspection visit staff have received some training that is specific to the needs of people with mental health problems to develop their skills and knowledge in this area. This enables them to have a better understanding about how people’s needs are to be best met. Shamrock House DS0000019723.V355506.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 and 9 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are encouraged to live their daily lives as they choose. This is partly supported through improvements in the care planning documentation although these need to be improved further to show how people are involved in decision-making about their care. EVIDENCE: Each person has a care plan that provides staff with information about what help and support is required to meet people’s needs. The care plans have improved in that they provide more information about the personal support that each person requires. However, information in the care plans tend to focus on people’s physical needs and needs to be more person centred to take into account other aspects of their lives that are important to them. Whilst there is some evidence that attempts have been made to include people more Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 12 in the planning of their care, further work is needed so that people can be supported in the way they prefer. The home has a key worker system that enables people to receive individual support and have one to one time with staff. Care plans are evaluated and reviewed, with changes made as needed. People did say that they could choose their daily routines and could go out whenever they wanted to. Some people enjoyed taking part in activities in and outside of the home but were not pressurised to participate in these. Menu planning was discussed with people before food was bought. Risk assessments have been carried out on aspects of daily living to help maintain the independence and safety of people living in the home. Where limitations are in place, there is some evidence that this has been agreed with the individual but this does not always happen as in the case of one person who wanted a key for his bedroom. Whilst assessments in general identify risks, the information about how risk is managed is basic and does not provide enough guidance to staff about what actions to take to minimise the risk of people coming to harm. Daily records were up to date and reflected the cares being given. Verbal handovers take place between shifts to make sure that relevant information is shared between staff. Shamrock House DS0000019723.V355506.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): 12, 13, 15, 16 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are given opportunities to engage in recreational activities and be involved in the local community. EVIDENCE: People have the opportunity to participate in a number of activities. Some attend adult education, leisure centres and other local resources. One person said that they enjoy attending arts and craft sessions at a local day service and another person liked gardening at another local facility. In the house people said that they sometimes played dominoes in an evening or have bingo sessions. Prior to the current building work that is being undertaken to extend the home, the home had a conservatory where people enjoyed a game of darts. The manager said that more in-house activities would be available again once the refurbishment work had been completed. People said they go to the Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 14 local shops and pubs and have been on trips to the coast. Some people had also chosen to go on a holiday abroad earlier on the year. The home has arranged for transport to be provided to enable people to attend church and other local community services. A lot of people prefer to spend their time watching television in the lounge and some people have their own television in their bedroom. People were looking forward to a Christmas party that was taking place at the home later in the week. The home receives information about local events throughout the year and this information is passed on to people in the home and their families, who are also invited to attend these. Visiting arrangements are flexible and people can visit whenever they wish. Some people go and visit their families or maintain contact with them by telephone. People living at the home felt that their rights were protected and described staff as “respectful”. Staff addressed people by their preferred names and people said that staff knocked on their bedroom doors before entering their bedroom. People said they liked the food on offer. One person said, “the food is of very good quality and there is plenty of it”. The menus were on display and these were varied and nutritionally balanced. One person said that they did not eat some meat but that there was “always an alternative meal available”. People can have drinks and snacks between meals if they wish. Shamrock House DS0000019723.V355506.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 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. EVIDENCE: Each person has a care plan that details how support is to be given. People who need personal support said that this was given in the way they preferred. One person said “I am happy and well cared for” and another, “the staff are an excellent team and treat you with the uppermost care”. A care professional did say that meeting with people could be difficult if the person is sharing a bedroom and the manager should consider ways of overcoming this. People who live at the home have a General Practitioner (GP) and have access to dental, optical and chiropody services. The home has close links with the local mental health service teams and other specialist health teams. Referrals to health teams are made when needed in a timely fashion so that any health Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 16 problems can be addressed at an early stage. A survey returned by a health care professional stated “advice is always sought when concerns are raised about people living at the home. This is one of the strengths of the service”. All the other surveys returned by care professionals who have involvement with the home indicated that people are well cared for. Staff support people to attend health care appointments where appropriate and outcomes from appointments are well documented so that staff are aware of any actions that they need to take from these. None of the people at the home are currently administering their own medication. The administration of medication was observed and this was carried out appropriately. Medication records were up to date and corresponded with the drugs that were being given. All staff that administer medication have received the appropriate training. Shamrock House DS0000019723.V355506.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 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People feel confident that their concerns would be listened to and acted on. Improvements in staff training have helped in making sure that people are safeguarded from potential abuse. EVIDENCE: The complaints procedure is on display in the home. Each person living at the home receives a copy of the complaints procedure and the manager sends a second copy to relatives. People who use the service said that they would talk to staff or the manager if they were unhappy with anything. They also had confidence that the manager would take proper action in acting on their concerns. No complaints have been made to the home or have been received by the Commission for Social Care Inspection (CSCI) since the previous inspection visit. Since the previous inspection visit staff have undertaken some training in how to safeguard people from harm and information about abuse forms part of the induction programme for new staff. Staff were able to describe different types of abuse and what action they would take if they suspected abuse or had an allegation made to them. Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 18 The manager is in the process of arranging for staff to attend some training to improve their knowledge and skills in managing aggressive behaviour. This will help staff to deal with difficult situations in a safe way. Shamrock House DS0000019723.V355506.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, 26 and 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is generally clean. The refurbishment work has had an impact on the comfort of people living at the home and some aspects of the environment need improving so that the home is more pleasant and safer for people living there. EVIDENCE: The home is undergoing some major refurbishment work to create additional bedrooms, communal space, a new laundry and refurbishment of the kitchen. A bathroom area is also going to be built where there will be a walk in shower facility to make it easier for people with mobility problems. The work was originally due to be completed around January 2008 but due to unforeseen circumstances the planned completion date has been put back to March 2008. Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 20 The problems in completing the work within the original timescale were not identified until a late stage by which time the home’s conservatory and laundry area had been knocked down. This has left the home with reduced amounts of space and storage areas and the manager is trying to manage this situation in the best possible way within her limitations. A door has been fitted to the area that previously led from the kitchen area to the conservatory and now goes outside. This door would now enable people to leave the building. However, it has been boarded up to stop intruders from entering the premises. This was discussed with the manager and following this discussion the manager spoke to the local fire authority and arranged for a fire officer to visit the premises to check and offer advice about these arrangements. Following this visit the home provided written confirmation that the fire officer had visited the premises and had no issues with the present arrangements. Since the previous inspection visit some improvements have been made to the environment. Some communal areas had been re-decorated along with some bedrooms. New carpets and curtains have been fitted to some parts of the home and a new television has been bought. The kitchen also has a new cooker and water boiler. Improvements have been made to care practices so that chemical substances are now safely stored so that they are not accessible to people living in the home. The home was generally clean and people who live there describe it as “homely”. The home has individual and shared bedrooms that are personalised. One person who is sharing a bedroom said that they would prefer their own bedroom. The manager said that this would be arranged once a single bedroom became available. During a tour of the environment it was observed that some issues needed addressing. The lock to the door of a shared bedroom was broken and needed repairing in order to make the bedroom more secure and private for people in there. A number of extractor fans needed cleaning in bathroom and toilet areas and there was insufficient lighting in the toilet area on the first floor of the home so that people may be at risk from falling. Water temperatures from the sinks in washrooms, were found to be too hot and potentially put people at risk from scalding. This was brought to the attention of the manager who put measures in place to reduce any immediate risk to people at the home and arranged for a plumber to visit to make the water temperatures safe. Whilst regular monitoring of hot water temperatures from baths was carried out and recorded, checks of the sinks in toilet and bedroom areas had not been done and the manager said that this would be implemented at once. Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 21 A discussion took place with the manager about the use of bed rails for one person who was at risk from falling out of bed at night. Whilst the home do have guidance about this, there is no specific policy in place to identify when it is appropriate to use bed rails. Also, the care records did not clearly show who had decided to use the rails and no risk assessment had been carried out on the use of bed rails for this particular person. Since the conservatory was knocked down as part of the refurbishment, people have been asked to smoke outside the building. However it was observed that one person was smoking in the lounge area of the home where other people who didn’t smoke were sat and where some people ate their meals. The manager discussed this with the person and asked them not to smoke in this area. She also said that the builders were delivering a portakabin where people would be able to smoke as a temporary measure until the building work is completed. This would mean people not having to sit outside in cold weather to smoke. Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 22 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): 32, 34 and 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People feel well cared for by the staff team who are employed in sufficient numbers to meet their needs. Improvements have been made to recruitment practices to protect people from possible harm. EVIDENCE: People who live at the home and staff who work there all felt that staffing levels were sufficient and this was supported by information from the duty rosters. During the day there are usually three care staff on duty as well as the manager and the administrator. People said that staff are “kind, helpful and respectful” and one person said that the home is a “lovely place to live”. Staff are committed to providing good care for people at the home and work hard to achieve this. All new staff have induction that covers a number of aspects of care including equality and diversity and these are covered in the staff workbook that is based on the Skills for Care Induction Workbook. Since the previous inspection visit staff have attended training on how to safeguard people from harm, fire Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 23 safety and infection control training. The manager has arranged for some moving and handling training for those staff who need updating with this. Specialist mental health training has been provided to all the staff to develop their knowledge and skills in meeting the needs of the people using the service. Most of the staff have either completed or are doing the National Vocational Qualification (NVQ) at Level 2 in care. Recruitment procedures have improved so that all the necessary checks are undertaken before new workers start working at the home. The home continues to have difficulty in attracting male applicants to vacant posts. Staff feel that they have a good team and they are well supported by management. They said that they receive supervision from the manager and staff meetings are held monthly. Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 24 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, 39 and 42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is managed in the best interests of people who live there although more attention to some health and safety matters is needed to protect their safety. EVIDENCE: The registered manager is experienced in running the home having worked there for a number of years. She is extremely committed to acting in the best interests of people who live at the home and in enabling them to enjoy a good quality of life. One person living at the home said, “she is great and can’t do Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 25 enough for you”, whilst others were also complimentary. Staff particularly felt comforted that “the manager keeps what you say in confidence, private”. Systems are in place so that people living in the home and others who have contact with the home are able to have a say in how the home is run. House meetings are held between people who live at the home and staff, where people are asked to contribute towards the running of the home and have the opportunity to raise any concerns. Questionnaires have been recently sent out to people at the home and a number of these were looked at and comments were positive. Similar methods have also been used so that care professionals who visit the home can also provide feedback and again the comments from these were positive. The manager is in regular discussion with relatives who are also invited to care plan reviews so that they can also offer their views and comments about the home. Whilst the manager said the registered person was making regular visits to the home and monitoring the quality and performance of the service, no records were available to show the findings from the visits and any actions that have been taken from this. A sample of health certificates were looked at and were mainly satisfactory and up to date. However, the last inspection of the electrical wiring systems was found to be unsatisfactory and a number of recommendations had been made. Whilst some of these had been addressed other issues remained outstanding. This was discussed with the registered provider by telephone at the time of the site visit who understood that the necessary work had been undertaken. There was no updated electrical wiring certificate available though to show that the work had been completed to a satisfactory standard. The manager said that she would be contacting the relevant people to make sure that any outstanding work is carried out and will forward a copy of the up to date electrical wiring certificate to CSCI on satisfactory completion of the work. Regular fire safety checks are undertaken and staff have all attended fire training. A fire risk assessment has been carried out on the premises. Some aspects of health and safety need addressing. A number of staff have not done any first aid training and some are in need of updated moving and handling training. As previously mentioned under the heading of Environment, action needs to be taken to make excessive hot water temperatures safe, and advice needs to be taken from the fire authority about blocked access to a door leading to the outside of the building from outside the kitchen area. A risk assessment and review also needs to be carried out on the use of bedrails for one person to protect their interests and safety. Shamrock House DS0000019723.V355506.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 X 2 2 3 X 4 X 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 X 26 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 1 X Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 27 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 YA2 Regulation 17 (1) (a) Schedule 3 (1) (a) Requirement The registered provider must make sure that they complete a written assessment of people’s needs, so that care staff have a record of what care is needed for people who are admitted to the home. Timescale for action 11/12/07 2. YA24 12 (4) Arrangements must be put in 11/01/08 place to address the problem with the bedroom lock in a shared bedroom as discussed at the time of the site visit. This will make the bedroom more secure and private for the people living in there. Risk assessments must be carried out in all cases where bed safety rails are to be used. This will help in making sure that bed safety rails are only used when needed and have been assessed as safe and suitable in meeting people’s individual needs The registered person must make a report of her unannounced visits to the home DS0000019723.V355506.R01.S.doc 3. YA26 13 18/12/07 4. YA39 26 11/01/08 Shamrock House Version 5.2 Page 28 5. YA42 13 providing information about her findings and actions taken from these to improve the overall service. (Previous timescale of 22/11/06 not met). A risk assessment must be 11/03/08 completed to check what level of first aid training is required by staff at the home so that people can be assured that they will be given the proper first aid attention in emergencies. This risk assessment should consider: • • • The needs of people using the service. How likely it is that first aid will be needed. What kind of first aid is likely to be needed. 6. YA42 13 (4) (a) 7. YA42 23 Where a risk assessment is not completed, there must be a qualified first aider on the premises at all times. 11/12/07 • The registered manager must assess the risk to people using the service from excessive water temperatures from the sinks in the toilet areas and other parts of the home (as identified at the time of the site visit) and take necessary actions to minimise any identified risk so that people are kept safe. • Arrangements must be put in place for better monitoring of water temperatures so that that any problems can be identified and acted on at an early stage. • The registered provider 11/01/08 must take action to address any issues that DS0000019723.V355506.R01.S.doc Version 5.2 Page 29 Shamrock House remain outstanding from the last inspection of the home’s electrical wiring systems. This will help to maintain people’s safety. • The registered provider must submit a copy of the up to date electrical wiring certificate on satisfactory completion of the necessary work. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 Good Practice Recommendations Care plans could be more person centred so that people have more involvement in how they are to be supported in meeting their needs and goals. Risk assessment information could be more detailed to show how risk is to be managed and how decisions have been made and agreed where actions have been taken that might place restrictions on people. Extractor fans could be kept clean and free from dust in order to make sure that they work properly. Lighting could be improved in the toilet area on the first floor of the home. Staff could receive updated moving and handling training so that they have up to date knowledge and skills to provid care in a safe way. YA9 3. 4. 5. YA24 YA24 YA42 Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Shamrock House DS0000019723.V355506.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!