Inspection on 10/05/07 for Shandon House

This inspection was carried out on 10th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Shandon House 29/06/10

Shandon House 30/09/09

Shandon House 06/05/09

Shandon House 06/10/08

Shandon House 07/05/08

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Shandon House 20 Crescent Road Birkdale Southport Merseyside PR8 4SR Lead Inspector Daniel Hamilton Unannounced Inspection 10th May 2007 08:05 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shandon House Address 20 Crescent Road Birkdale Southport Merseyside PR8 4SR 01704 564 801 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) SBS Care Homes Limited Mrs Maxine Mason Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to service users of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 20 Date of last inspection 15/09/06 Brief Description of the Service: Shandon House is a care home that is currently registered to provide personal care and support for up to 20 older people. The home is a large detached property situated close to the town centre of Birkdale village and is within easy reach of Southport town centre and all its amenities. Local services such as shops, a post office, bank and public transport are in close proximity to the home. All the 20 bedrooms are for single occupancy and thirteen have en-suite toilets. The home has a pleasant garden and communal areas including a lounge, dining room and conservatory to the side of the building. The building has three floors which are accessible by a passenger lift and the main and side entrance are equipped with ramps to provide disabled access. A small area is provided for off-road parking. The Care Home Fee is £370.00 per week. Shandon House DS0000069402.V339151.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 one day and lasted approximately 10 hours. Fifteen residents were living in the home at the time of the visit. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The Registered Manager, three care staff, a relative and five residents were spoken with during the visit. Satisfaction survey forms “Have Your Say About….” were also distributed to a further five residents prior to the inspection, to obtain additional views / feedback about the home. All the core standards were assessed and action taken in response to previous requirements and recommendations from the last inspection in September 2006 was reviewed. There had been a change of owner since the last visit. The new owner was spoken with during the visit and demonstrated a commitment to addressing the issues raised during the visit and to improving the overall environment and service provided at Shandon House. What the service does well: Feedback received from the people living in the home and / or their relatives was generally positive about the service provided at Shandon House. Residents spoken with confirmed they were satisfied with the standard of care and confirmed they were valued by staff and treated with dignity and respect. A resident said; “I respect them [staff] and I’m sure beyond doubt they [staff] respect me”. Likewise, a relative reported; “The staff are extremely caring and attentive, nothing is too much trouble for them. Each one is kind and considerate in their own way and I wouldn’t hesitate in recommending Shandon House as a great care home where the elderly really do come first”. The home had produced a Statement of Purpose and a Service User Guide in a standard format, to provide people with information on the home. Assessment and Care Planning systems had been established to ensure the needs of residents were identified and planned for. Residents had access to health care service as required and one resident stated; “The manager has always contacted my doctor when I’ve been unwell.” Daily life within the home continued to remain flexible and residents were able to receive visitors and determine their preferred routines and lifestyle. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 6 A range of activities were organised in the home for residents to participate in. Comments from two residents included; “There are activities organised most days and we are encouraged to join in” and “I have no complaints about the home’s activities. I please myself what I do. I went out with my wife for a walk today”. Records showed that there had been no complaints since the last visit and the people living in the home confirmed they were listened to and confident to approach the manager with any issues of concern. For example, a resident reported; “I can’t imagine a situation when I would feel afraid to have a word in complete confidence with Mrs Mason [Manager] or even with a senior carer”. What has improved since the last inspection? What they could do better: Arrangements should be made to ensure Contracts are issued to residents and / or their representatives before they move into the home. This will ensure residents are aware of their rights and obligations. The home’s pre-admission assessment should be updated to ensure the diverse needs of all people accessing social care services are considered as part of a holistic assessment process. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 7 The home had a medication policy but its scope was limited. The policy should be reviewed to ensure it provides guidance to staff on all the key areas of the management of medication. Suitable storage and recording systems for Controlled drugs had not been established. Although the service was not handling controlled drugs at the time of the visit, the home should consider addressing this issue to ensure medication is appropriately managed in the event of a resident being prescribed a controlled drug. Some areas of the home were in need of maintenance / refurbishment. A programme of routine maintenance and refurbishment should be developed to include timescales, to ensure the people living in the home benefit from a well maintained environment. The home had not achieved the target date of 31st December 2005 for 50 of the care staff to achieve a National Vocational Qualification in Care at level 2 or equivalent. Arrangements had been made to ensure the home was working towards the 50 target and this should be kept under review. Although induction records were available for new staff, records showed that staff had not been inducted in accordance with the new ‘Skills for Care’ – Common Induction Standards. Action should be taken to ensure new staff are inducted appropriately, before they are considered safe to work with vulnerable adults. Arrangements should also be made to ensure all staff complete infection control training and refresher training in safe working practice subjects and the manager should complete a National Vocational Qualification in Care at Level 4. This will ensure staff are trained and competent to undertake their roles safely. Risk assessments had not been completed for all Safe Working Practice topics and a number of contraventions detailed in an Environmental Health Officer’s report had not been addressed. Priority should given to address these issues to ensure the health and safety of residents is protected. 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. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, the people who use the service and their representatives have the information needed to choose a home that will meet their needs. Contracts should be issued prior to admission, to ensure people are aware of their rights and obligations. EVIDENCE: Information on the home was available in the form of a Statement of Purpose and Service User Guide. The documents had been developed in a standard format and updated to include the details of the new owner. Files viewed confirmed that residents had been provided with a copy of the documentation, as prospective residents or their representatives had signed a form, to acknowledge receipt of the documents. The manager was advised to also display a copy of the home’s Statement of Purpose in the reception area of the home for visitors to reference. At the time of the visit, the new owner had not issued Contracts to the people living in the home. The owner reported that he was in the process of developing a Contract / Statement of Terms and Conditions and that all the Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 10 residents and / or their representatives would receive a copy within the next two weeks. The files of two residents were viewed during the visit. Each file contained an information sheet and a ‘Pre-Admission Assessment’ that had been completed by the manager before each resident had moved in. Copies of Social Work assessments were not on file however the manager reported that she would always endeavour to obtain a copy for people referred through Care Management arrangements. The home’s assessment documentation was generally well constructed and enabled a detailed assessment of needs to be undertaken. The manager was advised to update the assessment documentation to address equality and diversity issues i.e. ethnicity and gender, to ensure a holistic assessment of needs as previously recommended. Feedback received from residents confirmed that the manager undertook an assessment prior to admission and that they were encouraged to visit the home prior to admission. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that residents receive is based upon their individual needs and the principles of respect, dignity and privacy are put into practice. EVIDENCE: The manager reported that the home developed a plan of care for each resident following an assessment of needs. Two files were examined during the inspection. Files viewed contained a detailed Care Plan that had been signed by residents or their representatives. Care plans identified the needs and support requirements of each resident, together with the desired objectives / outcomes. Records showed that the manager had undertaken a comprehensive review of each care plan on a monthly basis and that significant issues had been recorded. Files also contained a comprehensive range of risk assessments and diary sheets, accident report forms, weight and health care records were available for reference. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 12 Since the last visit, the manager had updated risk assessments to ensure they contained more information on the preventative and control measures for identified risks. Furthermore, personal profiles had been introduced and were in the process of being completed. Health care records viewed provided evidence that residents had attended optician, chiropodist, doctor, and hospital appointments, subject to individual needs. Feedback received from residents and their representatives confirmed the people living in the home had access to medical support / services and that they received the care and support they needed. One resident said; “The manager has always contacted my doctor when I’ve been unwell.” The home continued to use a blister pack system that was dispensed by a local pharmacist as previously noted. Medication was stored in a locked medication trolley, which was bolted to the wall when not in use. A fridge was available to store medication requiring cold storage and a system had been established to record the temperature records of the fridge on a daily basis. Declaration of individual wishes with regard to the administration of medication had been completed and signed by residents and / or their representatives. A record of staff authorised to administer medication together with a system to check the identity of residents prior to administering medication was in place. Previous inspection records detail that staff designated with responsibility for administering medication had completed external medication training and this was confirmed in discussion with the manager and staff. Medication checked was administered, stored and recorded correctly. Systems were in place to record medication received from and returned to the dispensing pharmacist. Staff spoken with demonstrated a satisfactory knowledge of how to record, handle and administer medication in the home however the scope of the home’s medication policy was limited. A copy of guidelines issued by the Royal Pharmaceutical Society of Great Britain was available for reference. The manager was advised to update the home’s medication policy to ensure it fully addressed all the key areas of the management of medication. No controlled drugs were being stored in the home at the time of the visit. A controlled drug register and a suitable storage facility for controlled drugs had not been purchased as previously recommended. The new owner was advised to address this issue to ensure appropriate storage and recording of controlled drugs, should a resident be prescribed with controlled medication in the future. Records showed that a risk assessment had been developed since the last visit for a resident who was self-administering medication. Advice was given to the manager on how the assessment and review process could be further developed. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 13 Policies and procedures had been developed to provide guidance to staff on the principles of good care practice. Feedback received from residents and their representatives via Care Home Survey forms and discussion confirmed the people living in the home were treated with privacy and dignity and that they were satisfied with the standard of care provided. Staff spoken with during the visit were able to give good examples of how they promoted the principles of respect, privacy and dignity in their day-to-day practice and were observed to be attentive and sensitive to the needs of the residents. One resident reported via a care home survey; “I respect them [staff] and I’m sure beyond doubt they [staff] respect me”. Likewise, a relative reported; “The staff are extremely caring and attentive, nothing is too much trouble for them. Each one is kind and considerate in their own way and I wouldn’t hesitate in recommending Shandon House as a great care home where the elderly really do come first”. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily life, activities and meals were flexible and varied to meet the preferred routines, expectations and preferences of the people living in the home. EVIDENCE: Records showed that a range of activities were organised for residents. The majority of the activities were provided inside the home. A programme of activities had not been developed as the people living in the home were asked about their preferred activities on a daily basis. Staff recorded details of activities and the participants on ‘Daily activity record’ sheets. Records viewed detailed that residents had participated in a range of recreational activities. Regular activities included; bingo, skittles, cards, armchair exercises, quiz, music and dance, hand massage, board games, dominoes and hairdressing. Representatives from a local Church of England church visited two of the residents on a monthly basis, in accordance with their religious beliefs. Feedback from residents via Care Home Surveys and discussion confirmed the people living in the home were generally satisfied with the range of activities provided. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 15 Comments received included; “There are activities organised most days and we are encouraged to join in” and “I have no complaints about the home’s activities. I please myself what I do. I went out with my wife for a walk today”. Residents and a relative spoken with during the visit confirmed that the people living in the home could receive visitors at any reasonable time. A relative spoken with said; “I generally visit twice a week and I have always been given a warm welcome.” The people living in the home confirmed that Shandon House was a relaxed place to live and that the lifestyle experienced in the home was determined by their needs and preferences. A relative spoken with said; “The care is second to none.” Staff spoken with demonstrated a commitment to supporting residents to maintain their independence and acknowledged the right of residents to have choice and control over their lives. The manager reported that the home had recently introduced a revised fourweek rolling menu in consultation with residents. The new menu included details of the tea-time menu as recommended at the last visit and confirmed a choice of wholesome and nutritious meals were provided at each sitting. Daily meals were recorded on the menu board in the dining room and a copy of the daily menu had been laminated and displayed on each table for residents to view. Meals were served in the home’s dining room at set times, however residents could choose to eat their meals in their rooms if they preferred. Additional drinks were served throughout the day. Dining tables were equipped with tablecloths, napkins, flowers and condiments. The manager reported that the home was providing puree meals for a resident and able to cater for the religious and / or cultural dietary needs of any prospective resident referred to the home. Feedback received from residents regarding the meals and mealtimes included; “The food is good” and “The meals are fine. They are always nicely presented and we get a choice of alternative meals”. A relative reported; “The food is homemade and excellent”. Staff were observed to be available to offer support to residents during mealtimes as required. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service are able to express their concerns via a complaints procedure and are protected from abuse to ensure their welfare is safeguarded. EVIDENCE: Shandon House had a complaints procedure in place, which detailed that the home would respond to complaints within 28 days. The procedure had been updated since the last visit to include details of the Commission for Social Care Inspection. Records showed that the home had received no complaints since the last visit and no complaints had been referred to the Commission for Social Care Inspection. Residents confirmed via care home surveys and through discussion that they felt listened to and were aware of who to speak to if they were not happy and how to make a complaint. One resident reported; “I can’t imagine a situation when I would feel afraid to have a word in complete confidence with Mrs Mason [Manager] or even with a senior carer”. Policies and procedures had been developed to provide guidance to staff on how to respond to suspicion or evidence of abuse. Training records showed that 15 out of 17 staff had completed training in the Protection of Vulnerable Adults from Abuse. Staff spoken with demonstrated a good understanding of the different types of abuse and their duty of care to safeguard the welfare of the people using the service. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 17 Pre-inspection records detailed that there had been no adult protection referrals or investigations since the last visit. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the home are in need of maintenance and refurbishment, to provide residents with a safe, well-maintained and comfortable environment. EVIDENCE: The home employed a part-time handyman who was responsible for the maintenance of the home and the grounds. A maintenance book was in place for staff to record jobs in need of attention. Pre-inspection records detailed that there had been no changes to the environment since the last visit. Some of the home’s furnishings and fabric was showing signs of wear and tear as previously noted. For example, the carpet on the staircase in the main entrance was damaged and the dining chairs and conservatory furniture was showing signs of wear. Other maintenance and refurbishment issues were discussed with the new owner and manager. The new owner demonstrated a commitment to improving the environment and was able to provide evidence that he had obtained quotations for some Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 19 priority maintenance work. The owner was recommended to develop a maintenance and refurbishment plan, to ensure the environment is improved for the benefit of the people using the service. This had not been completed by the previous owner, as recommended at the last visit. The home continued to employ a part-time domestic. Areas viewed during the visit were clean and fresh. Infection Control polices and procedures and Control of Substances Hazardous to Health data sheets were available for staff to reference. Pre-inspection records detailed that there had been no progress in supporting staff to complete infection control training. Training records showed that only three staff had completed the training. Feedback received from residents and their representatives via survey forms and discussion confirmed the home was kept fresh and clean. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by staff who are correctly recruited however some staff have not completed the necessary training, to confirm they are competent to undertake their roles effectively. EVIDENCE: Fifteen people were living in the home at the time of the visit. Inspection of rotas, direct observation and discussion with the manager confirmed that three care staff were on duty from 7.00 am to 9.00 pm. During the night, two waking night staff were on duty. The manager worked Monday to Friday each week or as required by the service. Since the last visit, the service had withdrawn the sleep-in duty each night. Feedback received from residents and their representatives confirmed the people living in the home received the care and support they required and that staff were available when needed. Staff were observed spending time chatting with residents and offering support as required throughout the day. Records detailed that the home employed 12 care staff. Training records showed that only four staff (33.33 ) had completed a National Vocational Qualification (NVQ) at level 2 or above in Care. The manager reported that a further six staff (49.99 ) were working towards the qualification. Once the outstanding staff have completed the award, ten staff (83.33 ) will have completed a National Vocational Qualification in Care. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 21 Previous inspection records confirm that the home had a recruitment policy. The manager reported that three staff (a new cook and two senior care staff) had commenced employment at the home since the last visit. The recruitment files for the new staff were viewed. Files viewed contained evidence that the necessary records required under Schedule 2 of the Care Home Regulations 2001 had been obtained. Files also contained evidence that the manager had taken staff through a brief in-house induction. The induction programme did not comply with the ‘Skills for Care’ - Common Induction Standards. Advice was given to the Owner and Manager on how to obtain information and documentation related to the new standards. The manager reported that ‘Moving and Handling’, ‘First Aid’, ‘Food Hygiene’, ‘Induction’, ‘Health and Safety’, ‘Infection Control’ and ‘Needs of Service User’ training had been scheduled for staff to attend however the training courses were cancelled by the training provider as they did not receive training from the previous owner. The home’s training matrix showed that the majority of the staff team required training in infection control and some gaps were noted for moving and handling (1); first aid (2); food hygiene (2); fire safety (2) and health and safety (4). Records showed that only one staff member had completed training in the principles of care. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of training and some key records is need of attention, to confirm the health, safety and welfare of the people using the service is fully protected. EVIDENCE: The Manager of the home (Mrs Maxine Mason) was registered with the Commission for Social Care Inspection and had managed the home for over two years. Prior to her appointment, the manager had been employed as the deputy manager of the home. Training records showed that the manager had attained the City and Guilds Advanced Management for Care 325/3 course and completed a range of Safe Working Practice and performance appraisal, risk assessment, palliative care, medication and abuse training. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 23 Records showed that the manager had not completed Infection Control training and / or a National Vocational Qualification level 4 in Care as recommended at the last visit. The home continued to commission an external consultant to undertake an annual quality assurance assessment. This was last completed during March 2007. Records showed that the manager had also recently distributed a brief questionnaire to residents and / or their representatives. The format of the questionnaire remained the same as at the last visit and the results (scores) had been displayed in the reception area of the home for people to view. A suggestions box was sited in the reception area of the home, to enable residents and their representatives to contribute their views anonymously. No resident meetings had taken place since the last visit as recommended at the last visit. Furthermore, the previous owner had not completed Regulation 26 reports each month. This issue was discussed with the manager and the new owner during the visit, who agreed to ensure compliance with the Regulation. Pre-inspection records detailed that the manager did not act as an appointee for any of the residents and that no residents’ finances were handled by the home. The manager reported that she had been requested to hold some money for one resident. A record of the money received had been completed and signed by the resident and manager. The manager was advised to establish a financial transaction sheet should this happen again. The new owner reported that he was responsible for processing and distributing invoices for residents or their representatives for fees and any additional costs e.g. (chiropody, hair dressing, papers etc). Previous inspection records confirm that the home had a policy on ‘Health and Safety’ in place. Pre-inspection records detailed that services and equipment within the home was regularly serviced. A selection of records were viewed. Since the last visit the home had obtained an electrical wiring certificate, however a gas safety certificate was not in place. The manager confirmed that the gas system had been recently serviced and the home was waiting to receive a certificate. This was confirmed in discussion with the contractor. Fire records were also viewed. These detailed that the fire alarm system had been tested on a weekly basis and the emergency lights and fire extinguishers had been inspected on a monthly basis. Records also showed that the majority of the staff team had completed fire evacuation and drill debrief training during Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 24 March 2007. The manager was advised to ensure that night staff receive refresher training every three months and day staff every six months. The home’s fire risk assessment was not available for reference and risk assessments had not been completed to address all safe working practice topics. Furthermore, a number of contraventions identified by the Environmental Health Department following an inspection in October 2006 had not been addressed. Some staff had not completed training in all Safe Working Practice topics as identified in Standard 30. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP2 Good Practice Recommendations Contracts / Statement of Terms and Conditions of Residency should be given to all residents or their representatives, to ensure they are aware of their rights and obligations. The home’s pre-admission assessment should be updated, to ensure equality and diversity issues are taken into consideration as part of the assessment and care planning process. The home’s medication policy should be updated, to provide more detailed information for staff to reference. Suitable storage and recording systems for controlled medication should be established to ensure medication is appropriately managed in the event of a resident being prescribed a controlled drug. The home should explore opportunities for community based activities in consultation with residents, to ensure people have access to their local community / social DS0000069402.V339151.R01.S.doc Version 5.2 Page 27 2 OP3 3 4 OP9 OP9 5 OP12 Shandon House 6 OP19 7 OP28 8 OP30 9 10 OP31 OP33 11 OP38 12 13 OP38 OP38 events. A programme of routine maintenance and refurbishment (to include timescales) should be developed and made available for future inspections, to ensure the home receives ongoing investment and is well maintained, 50 of the home’s care staff should have completed a National Vocational Qualification in Care at level 2 or equivalent by 31st December 2005, to comply with National Training Targets. The home’s induction programme should be updated in accordance with the ‘Skills for Care’ specification, to ensure staff are inducted in accordance with Common Induction Standards. The manager should complete a National Vocational Qualification in Care at Level 4, to ensure she has the necessary qualifications for her management role. The Registered Provider should make arrangements for the home to be visited at least once a month and the person carrying out the visit should produce a report on the conduct of the care home, to ensure compliance with Regulation 26. Priority should be given to address the Contraventions detailed in the Environmental Health Officer’s report of 20/10/06, to ensure the health of residents is safeguarded. Risk assessments should be completed for all Safe Working Practice topics to assess and control potential risks. All staff should complete training in Infection Control and all Safe Working Practice topics, to ensure they understand how to safeguard Heath and Safety. Shandon House DS0000069402.V339151.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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. 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