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Inspection on 31/07/07 for Shamu

Also see our care home review for Shamu for more information

This inspection was carried out on 31st July 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.

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 financial arrangements for the people using the service are safe and robust. Receipts are obtained for all purchases and the staff and residents sign against each transaction. The people using the service are able to choose how they spend their day. All of the people using the service are independent and able to access the community on their own. The residents use the local bus service and have a bus pass. The people using the service also have access to two seven-seater people carriers. Regular meetings are held with the people using the service both in groups and individual sessions. Care plans and risk assessments are developed for all of the people using the service, which are regularly reviewed. The people using the service are encouraged to be as independent as possible. Each person has their own bedroom and they are encouraged to personalise them. Most of the people using the service have keys to the house and their bedroom. Health needs are closely monitored and the people using the service are supported to access the appropriate health professionals. Staff receive regular supervision and team meetings are held monthly. Regular mandatory training is provided on a regular basis and staff confirm that it is of a high standard. The staff are trained to support the people using the service with their mental health needs. Staff recruitment procedures are robust and protect the people using the service. Protection of Vulnerable Adults and Criminal Records Bureau checks are carried out for all prospective staff members. There have been no complaints made about the service at Shamu to the Commission for Social Care Inspection.

What has improved since the last inspection?

The complaints procedure has been developed in pictorial format to help the people using the service better understand it. The organisation has recently introduced the Person Centred Plan approach to care planning, which should further ensure individual needs and wishes are established and addressed. Goals and objectives have been identified and set. The organisation is setting up a service user forum, which one of the residents is going to join. The bathroom suite has been replaced and the room decorated. Staff have had medication and infection control training.

What the care home could do better:

The acting manager must apply to be registered with the Commission for Social Care Inspection. The organisation must ensure that all items not included in the cost of fees are clearly listed in the contracts and Service Users` Guide. This will ensure that the people using the service have the correct information about what they may be expected to pay. Staff members and the people using the service must be included in the fire drills to ensure that they know what to do in the event of a fire. Individual evacuation procedures need to be developed for each person using the service. A risk assessment needs to be developed, which supports the person administering his or her own medication. It is advised that the general practitioner be asked to sign the `as required` medication protocols. Care plans and health records need to be kept up to date to ensure that the staff have access to current information about the people using the service. The recording of complaints must be improved, to include timescales, the action taken and the outcome. Cleaning products should be kept locked away when not in use. The manager needs to obtain the new Local Authority Safeguarding Adults policy, to ensure that all staff know what to do in the event of an allegation or suspicion of an abusive situation. The organisation must demonstrate that they regularly review the staffing levels to reflect the needs of the people using the service. There is only one member of staff on duty, which means that individual or impromptu excursions with staff are difficult to facilitate. The organisation needs to formalise their Quality Assurance arrangements to ensure that the views of people using the service, staff and stakeholders are gathered, the results collated and a report as to any action required available. Up to date the people using the service have been very reluctant to discuss death and any after death wishes they may have. The organisation has commited to continue working in this area, to ensure that individual wishes are known and followed at this very difficult time. Work is still required to improve the environment and the management need to consider redecoration and refurbishment of the Home as outlined in thisreport, to ensure that the people using the service live in more pleasant surroundings. Systems should be in place to control the risk of infection and consideration given to providing paper towels in the communal bathrooms, toilets, kitchen and laundry and washable flooring in the bathrooms and toilets.

CARE HOME ADULTS 18-65 Shamu 126 Regent Road Hanley Stoke on Trent Staffordshire ST1 3AY Lead Inspector Sue Jordan Key Unannounced Inspection 31st July 2007 10:30 Shamu DS0000064026.V341854.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 Shamu DS0000064026.V341854.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. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shamu Address 126 Regent Road Hanley Stoke on Trent Staffordshire ST1 3AY 01782 284520 01782 269187 stoke.enquiry@caretech-uk.com 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) Delam Care Ltd vacant post Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th June 2006 Brief Description of the Service: Shamu is a residential care home, which provides to six service users who have a learning disability and who may also experience mental health difficulties. It is owned by Delam Care, a company that owns five similar care homes in the vicinity. Delam Care is owned by Care Tech. People using the service have their own bedrooms, four of which are on the ground floor. There a lounge, separate dining room, kitchen and a laundry shared with the adjacent care home. The home has a small garden area at the front and a larger area at the rear with a grassed area and trees and flower borders. There are facilities for the people using the service to sit in the garden. There is a shower room downstairs and a bathroom upstairs. The home is located close to Hanley centre, with access to some local shops and a 20-minute walk to the main shopping area. Some of the people using the service attend a local college and they are all able to access the community independently. The aim of the home is to promote the independence of the service users and to support and encourage them to develop their life skills. The acting manager, Nina Sheik has recently been formally employed as the manager and she has yet to apply for registration with the Commission for Social Care Inspection. The current fee level is £333- £503.62 per week. The people using the service have to pay for their own holidays, contribute to the use of the minibus and buy their own toiletries. The organisation has been asked to look at this area and ensure that all parties are fully aware of what is and is not included in the fees. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four hours. This was a ‘key inspection’ and the core standards were assessed. The methodologies used were: A day of preparation before the inspection, including scrutiny of the Commission for Social Care Inspection Annual Quality Assurance Assessment completed and returned by the acting manager. During the visit, the inspector met and spoke to five of the people living in the home, one in more detail and discussions were held with the staff member on duty and the area manager. Observations were made of some staff and service user interaction and nonpersonal care tasks. The medication systems were checked and a walk round the home taken. One set of care records was checked. The service users financial records were also checked. The training matrix was examined. A random selection of the Health and Safety and maintenance records were examined. A Random Inspection was carried out in January 2007 to check compliance with the requirements made at the Key Inspection in June 2006 Six requirements and nine recommendations have been made as a result of this inspection. Two requirements have been carried over from previous inspections. What the service does well: The financial arrangements for the people using the service are safe and robust. Receipts are obtained for all purchases and the staff and residents sign against each transaction. The people using the service are able to choose how they spend their day. All of the people using the service are independent and able to access the community on their own. The residents use the local bus service and have a bus pass. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 6 The people using the service also have access to two seven-seater people carriers. Regular meetings are held with the people using the service both in groups and individual sessions. Care plans and risk assessments are developed for all of the people using the service, which are regularly reviewed. The people using the service are encouraged to be as independent as possible. Each person has their own bedroom and they are encouraged to personalise them. Most of the people using the service have keys to the house and their bedroom. Health needs are closely monitored and the people using the service are supported to access the appropriate health professionals. Staff receive regular supervision and team meetings are held monthly. Regular mandatory training is provided on a regular basis and staff confirm that it is of a high standard. The staff are trained to support the people using the service with their mental health needs. Staff recruitment procedures are robust and protect the people using the service. Protection of Vulnerable Adults and Criminal Records Bureau checks are carried out for all prospective staff members. There have been no complaints made about the service at Shamu to the Commission for Social Care Inspection. What has improved since the last inspection? The complaints procedure has been developed in pictorial format to help the people using the service better understand it. The organisation has recently introduced the Person Centred Plan approach to care planning, which should further ensure individual needs and wishes are established and addressed. Goals and objectives have been identified and set. The organisation is setting up a service user forum, which one of the residents is going to join. The bathroom suite has been replaced and the room decorated. Staff have had medication and infection control training. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 7 What they could do better: The acting manager must apply to be registered with the Commission for Social Care Inspection. The organisation must ensure that all items not included in the cost of fees are clearly listed in the contracts and Service Users Guide. This will ensure that the people using the service have the correct information about what they may be expected to pay. Staff members and the people using the service must be included in the fire drills to ensure that they know what to do in the event of a fire. Individual evacuation procedures need to be developed for each person using the service. A risk assessment needs to be developed, which supports the person administering his or her own medication. It is advised that the general practitioner be asked to sign the ‘as required’ medication protocols. Care plans and health records need to be kept up to date to ensure that the staff have access to current information about the people using the service. The recording of complaints must be improved, to include timescales, the action taken and the outcome. Cleaning products should be kept locked away when not in use. The manager needs to obtain the new Local Authority Safeguarding Adults policy, to ensure that all staff know what to do in the event of an allegation or suspicion of an abusive situation. The organisation must demonstrate that they regularly review the staffing levels to reflect the needs of the people using the service. There is only one member of staff on duty, which means that individual or impromptu excursions with staff are difficult to facilitate. The organisation needs to formalise their Quality Assurance arrangements to ensure that the views of people using the service, staff and stakeholders are gathered, the results collated and a report as to any action required available. Up to date the people using the service have been very reluctant to discuss death and any after death wishes they may have. The organisation has commited to continue working in this area, to ensure that individual wishes are known and followed at this very difficult time. Work is still required to improve the environment and the management need to consider redecoration and refurbishment of the Home as outlined in this Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 8 report, to ensure that the people using the service live in more pleasant surroundings. Systems should be in place to control the risk of infection and consideration given to providing paper towels in the communal bathrooms, toilets, kitchen and laundry and washable flooring in the bathrooms and toilets. 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. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 9 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 Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the Home, the service provided and the expectations and responsibilities of all parties is available to the people using the service in a standard format. Staff have the necessary skills and abilities to care for the people using the service. EVIDENCE: The Home’s Statement of Purpose was reviewed and amended at the beginning of 2007. The organisation has plans to develop the Statement of Purpose and Service Users Guide into more accessible formats for the people using the service. This was agreed as being useful to ensure that all of the people using the service are able to understand their rights and responsibilities. However, regular meetings are held with the people using the service where they discuss issues such as the complaints procedure and the running of the Home. Some of the people living in Shamu have found the new person centred planning formats patronising and the organisation will need to bear this in mind when offering them alternative formats. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 11 The Statement of Purpose lists the services included in the fees and those not covered. However, the manager needs to revisit these lists to ensure that all items are included. For example, the people using the service pay for their holidays and for the accommodation used by the accompanying staff. This is not listed. This information should also be included in the contracts. Some items have been included, for example the residents’ contribution to the running of the minibus. The organisation is aware that the present contract also need amending to reflect the fact that Caretech now owns the Home. The Admission procedure states that before people are admitted into the Home, their needs are carefully assessed and the Home receives the required information from the referring agencies to ensure that they can meet the person’s needs. The present residents have lived at Shamu for many years. The people using the service predominately have mental health and/or a learning disability Organisational training is available in mental health awareness and the staff are completing Learning Disability Awards Framework qualifications. One of the people using the service is diabetic and has a sugar free diet. The care plans contain comprehensive details about the individual mental health difficulties, including information for staff as to how the people using the service are to be assisted and supported, however these need to be kept up to date to ensure that staff have access to current information about the people using the service. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 12 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, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home has systems in place that allow the people using the service the opportunity to make their views known and join in any decision-making. Information is available for staff regarding the needs of the people using the service, however it is not always kept up to date. EVIDENCE: The care records for one person using the service were checked. Care plans and risk assessments are in place for all aspects of the person’s life. However, it was noted that recent developments had not been recorded clearly, meaning that staff may not know how to meet the current needs of the person using the service. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 13 It is recommended that the files be reorganised and streamlined to ensure that the staff can easily access the information to meet the present needs of the people using the service. The organisation has just introduced Person Centred Planning. The people living in Shamu have started to develop their person centred plan and objectives and goals have been set and in some cases achieved. The plans will be reviewed at least six-monthly, although in some cases this may need to be done more regularly to enable people using the service to move forward at a pace appropriate to them personally. Regular meetings are held with the people using the service at which they discuss a variety of topics. This was confirmed during a chat with one of the people using the service. Each person using the service has a monthly one to one session with a member of staff, where they can discuss any concerns or just discuss day-today issues. It was evident during this visit that people using the service are able to choose how to spend their day. The people living in Shamu are very independent and are able to access the community without staff support. Most of the people using the service are assisted to manage their finances and the level of support depends on the person’s ability. Each person is offered a key to the house and their own bedroom, although some choose not to have them. The menus are devised with the people using the service. The organisation is setting up a service user forum to which, one of the people living at Shamu will attend. Eventually it is hoped that the people using the service will run the forum themselves. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 14 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, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The organisational ethos promotes independence and the right to live in a flexible environment where the residents’ choice of routines are acknowledged and respected. The people using the service are able to access the community independently. EVIDENCE: Five of the six people living at Shamu are going on holiday in August. One of the people living in Shamu attends various local churches and all regularly access Hanley town centre, which is close by. Some people go to college, whilst others attend local day centres. One person plays football and has represented the country. Most of the people living in Shamu are actively involved in keeping their home clean. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 15 The organisation has the use of two 7 seater people carriers and each person has a bus pass. All people using the service are on the electoral register and have the opportunity should they so wish, to cast their votes in local and national elections. Nearly all residents have regular contact with their family. Friendships and relationships have formed in the Home and with some of the residents in the other Homes. Each person using the service has their own bedroom if they wish to spend time alone. People are able to get up and go to bed when they wish. One person said that they help to make snacks and make their own drinks but that the staff normally prepare the main meal. Staff confirmed that the budget allows them to buy good guality food. The people using the service accompany staff to any of the local supermarkets. One person has a diabetic diet. Staff receive food and hygiene training. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 16 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, 20, 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use services have access to healthcare and remedial services and staff assist them to attend appointments and visit local health care services. The health records need to be kept up to date to ensure that the staff have access to current information about the people using the service. If possible people using the service are enabled to administer their own medication, although the records do not tell staff of any risks or support required. EVIDENCE: The people living at Shamu do not require ‘hands on’ support with their personal care but some require encouragement and prompting. This is indicated within the care plans. There is ample recorded evidence that the health of people using the service is monitored and the appropriate medical, professional services accessed. All of the people using the service are registered with a general practitioner Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 17 and are they supported in making appointments and if necessary attending those appointments. All have six monthly medication reviews. All of the people using the service are encouraged and supported to attend dental, chiropody and optician appointments for check ups and treatments. Some attend practice nurse appointments for vaccinations and one the diabetes clinic. The people using the service are supported to attend outpatients specialist appointments including psychiatry, psychology and mental health services. The health records must be kept up to date, to ensure that the staff know of the most recent developments and what action is required to support the people using the service. The medication systems and procedures were checked. Medication is appropriately stored and stock control is monitored. Records are kept of all medication brought into the Home or returned to the pharmacist. The administration records are well maintained and no errors or gaps were seen during this inspection. Protocols have been developed for all PRN medication and explanations as to the reason and effects of medication are available for staff. These have not however been signed by the general practitioner. The staff at Shamu have received ‘in-house’ medication training and their continuing competency will be checked every six months. The acting manager and assistant manager have undertaken the indepth ‘Safe Handling of Medicines’ course. It is hoped that all staff will receive this training. One of the people using the service administers their own medication. A risk assessment is needed, which details the support needed by staff if any, and the systems in place to maintain the person’s safety. Up to date the people using the service have been very reluctant to discuss death and any after death wishes they may have. The organisation has commited to continue working in this area, to ensure that individual wishes are known and followed at this very difficult time. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the people using the service have opportunities to express their concerns the records are incomplete with timescales, outcomes and actions not being properly logged. The procedures followed in the Home protect the people using the service and training is being planned, which will show the staff how to recognise and respond to potentially abusive situations. EVIDENCE: A new complaints procedure in pictorial format has been developed and this is on display in the hallway. A complaint had been received and the records were checked. The incident leading up to the complaint has been recorded, although the acting manager must ensure that the terminology used is not derogatory to the people using the service. Although action had been taken to address the complaint, this and the overall outcome have not been recorded. The people using the service have opportunity to express their concerns during regular meetings or within their monthly one to one sessions with staff. The Home has access to the Local Authority Adult Protection policy but needs to obtain the new ‘Safe Guarding’ policies. Some staff have been trained in Adult Abuse and the procedures to follow in the event of an allegation or suspicion of an abusive situation. More training is being planned. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 19 The organisation undertakes Protection of Vulnerable Adults and Criminal Records Bureau checks on all prospective staff. The financial procedures were checked and the records and monies tallied. The people using the service and the staff member sign all transactions and receipts are obtained. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 20 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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is comfortable but some areas have not been decorated for many years. The staff and residents keep the Home clean, however this is made difficult by the dated decoration and furnishings. EVIDENCE: Shamu is a large Victorian house, close to Hanley city centre. All of the people using the service have their own bedroom, although none have en-suite facilities. Each has a wash hand basin. The people using the service are encouraged to personalise their rooms, all of which are lockable. There is an upstairs bathroom and separate toilet and a downstairs shower room. An additional separate toilet is situated close to the downstairs bedrooms. A small office/staff ‘sleeping in’ room is provided on the first floor. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 21 The people using the service have the use of a communal lounge, a dining room and there is a small ‘domestic’ kitchen. Shamu share a laundry facility with an adjacent Home belonging to the same organisation. The Home is comfortable and domestic in style but does need redecoration and refurbishment in areas. Some of the decoration and furnishings are very dated. The hallway downstairs has been repainted and a new carpet fitted. The upstairs bathroom suite has been replaced, the walls repainted and new flooring fitted. New dining room furniture has been purchased. The downstairs shower room is in desperate need of refurbishment and redecoration. The shower cubicle is unsafe to use and impossible to clean. Staff say that the people using the service refuse to use it, which means that they have no choice but to have a bath even if they prefer a shower. The kitchen needs upgrading. The staff and residents do a good job in maintaining cleanliness in the Home, although it is recommended that together with the liquid soap, paper towels are provided in the communal bathrooms, kitchen and laundry to maintain infection control. Staff have recently received infection control training. The Fire Safety Officer visited the Home in April 2006 and the organisation was required to make a number of improvements. He visited again in November and confirmed that they had been completed. The environmental health officer has not visited the Home recently. The organisation recognises the improvements needed to the environment and have developed an action plan for 2007. Shamu DS0000064026.V341854.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, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people using the service benefit from being supported by staff that are well recruited and supervised and trained to meet their needs. The low staffing levels are adequate for group activities but would not allow for individual or spontaneous pursuits. EVIDENCE: There was one person on duty during this inspection, which is the normal ratio provided. The area manager visited the Home for the duration of the Commission for Social Care Inspection visit. The people using the service are very independent and are able to assist the staff to undertake domestic tasks, meal preparation and the laundry. Concerns have been expressed about the low staffing levels at previous Commission for Social Care Inspection visits, although the people living at Shamu are very independent and able to access the community on their own. The organisation will need to demonstrate that they review the staffing levels on a regular basis to ensure that they still meet the residents’ needs. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 23 Four staff are employed at the home, two of which have National Vocational Qualification 2 or above. The Home does not use agency staff and the staff attend monthly team meetings and receive monthly supervision. As an organisation, Caretech provides a range of training courses and the staff also attend some arranged by the Local Authority. The training records of the staff employed at Shamu were checked and mandatory training is mainly up to date. They have also been trained in mental health awareness. The staff member on duty said that the training is very good. The organisation has introduced the Learning Disability Awards Framework award as part of the staff induction. It was not possible to check the staff files because the acting manager was on holiday. However two recent Commission for Social Care Inspection visits to ‘sister’ homes provided evidence that the organisation undertakes the appropriate checks and gathers the required information before employing staff. Shamu DS0000064026.V341854.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, 42, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An experienced and qualified manager has been employed to fill the vacant post. However she must now register with the Commission for Social Care Inspection. Health and Safety procedures, including fire safety must be improved to ensure that the people using the service are kept safe. The organisation is improving and developing systems that monitor practice and compliance. EVIDENCE: The acting manager, Nina Sheikh has completed the National Vocational Qualification 4/Registered Managers Award. She is also the manager of Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 25 another home in close proximity. The area manager informed the Commission for Social Care Inspection that the acting manager has only recently been interviewed and offered the post of manager. A requirement was made at the last inspection for a manager to be recruited and an application sent to Commission for Social Care Inspection for registration. A timescale of 30/04/07 was given, which has not been complied with. This must now be completed as a matter of urgency. The Fire Safety Officer visited the Home in April 2006 and the organisation was required to make a number of improvements. He visited again in November and confirmed that they had been completed. The environmental health officer has not visited the Home recently. A random selection of the maintenance records were checked, which confirmed that electric and gas provision are afforded the appropriate priority. However, there is no evidence that staff are involved in regular fire drills. It is also recommended that the residents’ names be added to the list of people involved in a fire drill, if applicable. Individual fire evacuation procedures need to be completed for the people using the service. Control of Substances Hazardous to Health items are still on show in the kitchen area. They should be locked away when not in use. The area manager visits the Home on a monthly basis to monitor the quality of the service provided. The people using the service regularly meet as a group and in one-to-one sessions with the staff. The organisation does not use surveys or questionnaires to gather people’s views and this is recommended. They should include service users, staff, families and stakeholders and the results of these should be evaluated and a report available. Daily checks are made to check the cleanliness of the Home. Staff receive regular supervision and attend monthly meetings. Caretech had implemented a quality audit system and Shamu had two audits in 2006. There has not been an audit in 2007. The organisation is planning to implement a new Quality Assurance system in the next twelve months. There are plans to initiate a forum for the people using the services in Hanley. A resident of Shamu has agreed to attend. Caretech has the Investors in People award. Shamu DS0000064026.V341854.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 3 2 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 2 1 X 2 X X 2 X Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5 (1b) Requirement The manager must ensure that all items not included in the cost of fees are clearly listed in the contracts and Service Users Guide. This will ensure that the people using the service have the correct information about what they may be expected to pay. A risk assessment is needed for the person administering their own medication. It should detail the support needed by staff, if any and the systems in place to maintain the person’s safety. Timescale for action 01/10/07 2. YA20 13 (2) 01/09/07 3. YA22 22 (3, 4, 8) 4. YA24 23(2)(d) The recording of complaints 01/09/07 must include timescales, the action taken and the outcome. This will give the people using the service confidence that their concerns are taken seriously. The ground floor shower room 01/10/07 must be refurbished to provide a more suitable and safe environment for the people using the service. Previous timescale not met, (30/03/07) Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 28 5. YA37 9 The registered person must submit an application to register the acting manager to the Commission for Social Care Inspection. Previous timescale not met, (30/04/07) 01/09/07 6. YA39 24 7. YA42 23 (4e) 13 (4) The organisation needs to 10/10/07 formalise their Quality Assurance arrangements to ensure that the views of people using the service, staff and stakeholders are gathered, the results collated and a report as to any action required available. Health and Safety procedures, 01/09/07 including fire safety must be improved to ensure that the people using the service are kept safe. Staff and residents must know what to do in the event of a fire so that they are kept safe. 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 YA6 Good Practice Recommendations It is recommended that the care records be streamlined and reorganised to ensure that the staff have easier access to the information required to meet the current needs of the people using the service. Care plans should be amended when changes occur to ensure that the staff have access to current information about the people using the service. The people using the service should be offered the opportunity to enjoy spontaneous, individual activities. Information regarding health must be up to date to ensure that the staff have the information required to meet the DS0000064026.V341854.R01.S.doc Version 5.2 Page 29 2. 3. 4. YA6 YA14 YA19 Shamu 5. 6. YA20 YA21 7. 8. YA24 YA30 9. YA33 current needs of the people using the service. It is recommended that the protocols for ‘as required’ medication be signed by the prescriber. To consider the subject of ageing, death and dying and establish individual wishes. This will ensure that the people using the service and/or their families’ wishes are followed in this event. To consider total redecoration and refurbishment of the Home to ensure that the people using the service live in more pleasant surroundings. Systems should be in place to control the risk of infection, including paper towels in the communal bathrooms, toilets, kitchen and laundry and washable flooring in the bathrooms and toilets. The organisation should demonstrate that they regularly review the staffing levels to reflect the needs of the people using the service. Shamu DS0000064026.V341854.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House, 45-56 Stephenson Street, Birmingham, B2 4UZ 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 Shamu DS0000064026.V341854.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. 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