Inspection on 06/12/05 for Shamrock House

This inspection was carried out on 6th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 10 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 11/12/07

Shamrock House 22/08/06

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 Rob Padwick Unannounced Inspection 6th December 2005 12:00 Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 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.V268044.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 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.V268044.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shamrock House Address 69 Hook Road Goole East Yorkshire DN14 5JN 01405 766217 01405 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.V268044.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The category MD(E) refers to only five (5) named individuals already resident within the home. 5th July 2005 Date of last inspection Brief Description of the Service: Shamrock House is a care home, which provides twelve placements for male and female service users with mental health problems, and aims to enable them towards independent living. Bedroom accommodation is mostly in shared rooms. Service users have the opportunity to mix in the communal areas, which consists of a lounge, conservatory and a dining room. 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. The location of the home close to the centre of Goole ensures that there is good access to the local bus and train services for both service users and their visitors. Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and lasted from 12.00 pm until 5.00 pm. The inspection included a tour of the premises and talking with the service users and observing their daily lives. Further time was spent checking the progress towards meeting the requirements and recommendations from previous inspections; talking with staff and reading care plans and other documentation that is maintained within the home. What the service does well: What has improved since the last inspection? What they could do better: The practice of documenting in the service user case files needs developing in order to show that residents are in agreement with what is written about them. The recording of risk assessments and care plans needs to be strengthened. Service users’ monies held by the home must be properly accounted for. Staff must be properly checked before starting work in the home, in order to protect the service users and better staff training is required. The home’s systems for checking that it is providing a good service should be strengthened and some certificates for the servicing of equipment obtained. A number of issues Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 6 relating to the management of the home remain outstanding and must be addressed. 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. Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 7 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.V268044.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 Service users had been supplied with information to help them make an informed choice about what to expect from the home. EVIDENCE: Discussion with residents and examination of a sample of their files confirmed that they had been given information about the home in order to help make an informed choice about what to expect from it. A statement of purpose had been developed together with a service user guide, which detailed the services provided by the home and outlined its philosophy, aims and objectives. The residents continued to praise the caring nature of the staff and indicated that the home was meeting their needs appropriately. Staff confirmed that they had received training to help them do their jobs, but from examination of their files and discussion with the manager, this had not yet included specialist mental health training, which the manager stated she was endeavouring to access. The case files examined contained evidence that registered provider had issued residents with an individual contract or statement of their terms and conditions since the last inspection. An examination of these documents confirmed that these had been satisfactorily developed and that individual residents had signed them to signify their agreement with them. Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 Service users’ needs and choices were supported but care plans and documentation of risk needed development. EVIDENCE: Most of the residents spoken to were aware of their individual plans of care and indicated that staff consulted them about these. Residents said that staff “looked after them” and confirmed that they regularly participated in reviews of their care. Care plans had been developed since the last inspection and were now signed by individual residents to demonstrate that they were in agreement with them. Case files examined contained evidence of daily recordings, monthly summaries of any progress or significant developments, together with assessments of known risks and agreed multi disciplinary strategies of intervention for these as appropriate. A recommendation was made that care plans continue to be developed in order to show a clear picture of the individual residents’ needs, together with information to staff about how they are to meet them. The residents confirmed they were supported to be as independent as possible and gave examples about how staff supported them in this respect. Staff indicated a good working knowledge of the individual residents’ strengths and Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 10 needs and the case files inspected contained assessments of known areas of risk and management strategies for dealing with these. However, it was strongly recommended that risk assessment strategies are agreed and signed by residents or their representatives in order to demonstrate agreement to any restrictions on choice that might be implemented. Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Service users were enabled to participate in the community and supported to make appropriate lifestyle choices according to individual need. EVIDENCE: Residents confirmed that they were able to take part in peer and culturally appropriate activities and that some followed their own hobbies and interests. One resident enjoyed going to classes at a local college, whilst another attended a local MIND group. Staff indicated that residents participated in the life of the community and used the facilities of the local leisure centre, clubs and pubs and went shopping on a regular basis. Residents told the inspector of an outing to Bridlington they had been on during the summer. The home had various policies and procedures that enabled residents to maintain appropriate personal relationships. Staff indicated that the home operated an open visiting policy and residents spoke of visits from relatives and friends. One resident had invited a friend to come for Christmas, whilst others stated that that they were going away for the holiday period with their relatives. Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 12 Observation of the care practices in the home indicated that the residents’ rights were respected. Relationships between staff and residents were positive and friendly with individual residents wishes for privacy being appropriately maintained. The home had a flexible regime and staff indicated that they encouraged residents to make their own choices and decisions about their daily lives. Residents were enthusiastic about the food served and indicated that they were able to have input into planning the home’s menus. Inspection of these confirmed that a balanced diet was provided but staff stated that these were not always rigidly adhered to, and depended on residents expressed wishes on a given day. The food stores were being appropriately maintained and recording in the case files samples demonstrated that residents were monitored for weight and that special diets could be accommodated. Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The service users’ personal and health care needs were being met. EVIDENCE: Residents described the care they received as being “the best” and confirmed that any personal support they received was given in the way that they preferred and required and that their physical and emotional needs were being met. Care plans demonstrated that this aspect of practice to be satisfactory and staff spoken to were knowledgeable of the residents individual needs. Evidence was seen of good multi disciplinary working, with recording of visits from healthcare professionals and appropriate referrals being made where necessary. Observation of interactions within the home indicated staff to be attentive and sensitive to the residents’ wishes. A recommendation is made however, that the registered person should consider addressing the gender imbalance of the staff team, in order to ensure that the (all) male residents needs are appropriately met. Residents indicated they did not want to take control of their own medication and had passed this responsibility on to staff. Inspection of the home’s records confirmed that staff had received training in the safe use and handling of medication. The home used the “Monitored Dosage System” for the dispensing of drugs to residents and a random check of this indicated that it was being satisfactorily maintained. Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Better recording systems were needed in respect of service users’ finances in order to ensure that service users are protected from abuse. EVIDENCE: Residents stated that staff supported them with their finances. However, inspection of the home’s system for the documentation of their personal allowances revealed a number of receipts that were out of date and it was therefore not possible to account for them accurately. Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 30 The service users’ environment was comfortable. EVIDENCE: The residents lived in a homely environment, which was clean, bright, comfortable and tidy. The home had an ongoing programme of repairs, which indicated that, the previous requirement that the conservatory guttering be repaired had been implemented. The residents’ individual needs continued to be adequately met by the homes provision of lockable bathrooms and toilets. Inspection of these indicated that the previous recommendation had been implemented and that the downstairs toilet cistern was now more securely fitted to the wall. Staff indicated that the home complied with the requirements of the Environmental Health Department and recent fire inspection certificates were on display in the home’s corridor. Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 The home’s recruitment and staff training practices needed to be further developed in order to ensure that the service user’s welfare is safeguarded. Staff supervision was satisfactory. EVIDENCE: Discussion with staff and examination of a sample of their files indicated that they had received some training to help them do their jobs. A staff member spoken to said that she had two units to complete her NVQ level 2 training and the manager stated that 4 others had received induction training for this and were due to begin working on this award in the weeks following this inspection. However, more work is still needed to ensure that the target that 50 of the staff team hold this level of qualification. The home had a recruitment policy and procedure to ensure that residents were protected and supported, but examination of staff files indicated that this was not being followed appropriately. The files of the two most recently appointed staff indicated that they had started employment in the home before up to date Criminal Records Bureau checks had been received. Residents were very positive about the caring nature of the staff and observation of the care practices in the home indicated that these were being delivered in accordance with the residents’ needs. Staff files inspected contained evidence of mandatory training and evidence was seen of some Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 17 refresher courses being sought, but more of these were needed to ensure that these were in line with the Sector Skills council workforce training targets. A recommendation is made that an individual staff training development needs analysis is undertaken and the results of this implemented. Discussion with staff and examination of their files confirmed that the registered person had implemented a programme of staff supervision in order to ensure that residents were supported. A sample of staff files contained evidence of this with regular 2 monthly supervision meetings and annual appraisals of staff performance being documented. Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42, The overall management of the service needed strengthening in order to ensure the welfare of the service users. EVIDENCE: Residents continued to indicate that they felt the home was well run. The home has a registered manager who has worked in the care sector for a considerable number of years, but hoping to step down from her current responsibilities in the near future. Discussion with the home’s administrator indicated that she was in the process of undertaking the Registered Managers Award with a view to being considered for this position. Residents confirmed that they were consulted about decisions concerning the home and inspection of resident meeting minutes confirmed this. Questionnaires had been developed and circulated to residents and their relatives since the last inspection, in order to obtain their views on the home. A recommendation is made that the quality assurance system is further Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 19 developed in order that it is possible to measure the home’s success in achieving its aims, objectives and its statement of purpose. The home had developed its policies and procedures in the light of previous requirements and recommendations in order to ensure that the residents’ rights and best interests were met. Inspection of a range of these documents indicated that they were satisfactory. The standard of record keeping and documentation had been developed since the last inspection, in order to demonstrate that the rights and best interest of the residents were safeguarded. However, further work was still needed to ensure that risk assessments were up to date and agreed with the residents concerned and more work was required to ensure that care plans were developed holistically and that staff have guidance in giving the appropriate type of support. Recommendations were made in these matters. Discussion with the manager indicated that the Registered Person still needed to compile monthly reports of her unannounced visits to the home, in accordance with her responsibilities under Regulation 26 of the Care Homes Regulations 2001. Residents confirmed that they believed that their health and safety was being promoted. A range of certificates relating to the servicing of the home’s equipment was seen, however those relating to gas and electricity were not up to date, however the home’s administrator confirmed that these systems had recently been professionally checked. The registered person must ensure that up to date certificates for the gas and electricity systems are obtained. Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X 1 X 3 Standard No 22 23 Score X 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 1 X 1 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shamrock House Score 2 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 3 1 1 X DS0000019723.V268044.R01.S.doc Version 5.0 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA3YA3 Regulation 12 Requirement The Registered Person must ensure that staff specialist training and development to equip them with the skills and experience to meet the needs of the service users. (Previous timescales of 27/3/04 and 1/10/05 not met) The Registered Person must ensure that a robust system for the documentation of service users money is developed with accurate records kept. (Previous timescale of 1/9/05 not met) The Registered Person must ensure that staff have the competencies and qualities required to meet the Sector Skills Council workforce strategy targets within the required timescales. (Previous timescale of 27/3/04 and 1/10/05 not met). The Registered Person must ensure that staff are not deployed in the home until confirmation is received that they have had an up to date Protection of Vulnerable Adults check. DS0000019723.V268044.R01.S.doc Timescale for action 01/04/06 2. YA23YA23 16, 20 06/12/05 3. YA32YA32 18 01/04/06 4. YA34YA34 19 06/12/05 Shamrock House Version 5.0 Page 22 5. YA41 26 6. YA42 23 (2) (c) The Registered Person must ensure that she compiles a monthly report of her unannounced visits to the home in accordance with her responsibilities under the Care Homes Regulations 2001. (Previous timescale of 27/4/04 and 1/09/05 not met). The registered person must ensure that up to date certificates are obtained for the servicing of the home gas and electricity systems 06/03/06 06/02/06 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. Refer to Standard YA6YA6 Good Practice Recommendations The Registered Person should ensure that care plans are developed holistically and that they demonstrate that service users are in agreement with what is recorded in them. The Registered Person should ensure that risk management strategies are drawn up and agreed with the service user (or their representative) The registered person should take steps to address the staff team gender imbalance in order to ensure that the (all) male service users needs are appropriately met. The registered person should ensure that an individual staff training development needs analysis is undertaken and the results of this implemented. The Registered Person should continue her efforts to appoint a new manager for the home who is suitably qualified. The Registered Person should ensure that the quality assurance system for the home is further developed in order that it is possible to measure the homes success in achieving its aims, objectives and its statement of purpose. 2 3 4 5 6 YA9YA9 YA18YA18 YA35YA35 YA37YA37 YA39 Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Shamrock House DS0000019723.V268044.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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