Inspection on 06/05/09 for Shandon House

This inspection was carried out on 6th May 2009.

CQC found this care home to be providing an Adequate service.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shandon House 29/06/10

Shandon House 30/09/09

Shandon House 06/10/08

Shandon House 07/05/08

Shandon House 10/05/07

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 07/08/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Shandon House 20 Crescent Road Birkdale Southport Merseyside PR8 4SR     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Daniel Hamilton     Date: 0 6 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 33 Information about the care home Name of care home: Address: Shandon House 20 Crescent Road Birkdale Southport Merseyside PR8 4SR 01704564801 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): SBS Care Homes Limited Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 20 Number of places (if applicable): Under 65 Over 65 20 old age, not falling within any other category Additional conditions: 0 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 Brief description of the care home 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. Care Homes for Older People Page 4 of 33 0 6 1 0 2 0 0 8 Brief description of the care 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 fees range from £379.90 to £410.00 per week. Care Homes for Older People Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means that the people who use the service experience adequate quality outcomes. This unannounced inspection took place over one day and lasted approximately 10 hours. A partial tour of the premises took place and observations were made. Six care files and a selection of staff and service records were also examined and the new acting manager, three care staff, the chef and eight residents were spoken with during the visit. Reference was also made to an Annual Quality Assurance Assessment which was completed by the previous acting manager on behalf of the Registered Provider. This Care Homes for Older People Page 6 of 33 document enables a Registered Provider to undertake a self-assessment on the service prior to an inspection. It should be noted that there has been ongoing changes to the management of Shandon House since the last visit. A new acting manager commenced employment at Shandon House during April 2009 and this should be taken into consideration when reading this report. What the care home does well: What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide should be updated to include the correct details of the acting managers qualifications, details of the Care Quality Commission and more information on the assessment criteria and fire policy and procedures. This will ensure residents and their representatives have access to key information on the service. The needs of prospective and current residents living at Shandon House must be assessed and kept under review. This will enable the service to identify needs and determine whether it is able to meet the needs of people considering living in Shandon House. A plan of care must be completed and kept under review for all the residents. This will provide assurance to the people living in the home that their care needs will be met and provide guidance to staff on how to deliver person-centred care. Care plans should be updated to include information on how the routine health care needs of residents are to be met and the frequency of appointments. This will help to maintain a proactive approach to health care and ensure residents have access to all their entitlements to NHS services. Care Homes for Older People Page 8 of 33 Risk assessments must be undertaken and kept under review to safeguard the welfare of all the people living in Shandon House. This will help to ensure that unnecessary risks to the health and safety of residents are identified and so far as possible eliminated.Risk assessments should also be updated to include detailed information on the control mechanisms. This will enable staff to understand how to control and respond to potential risks. Management systems should be developed to ensure activities are coordinated on a daily basis and records of the date, activity, participants and facilitator should be maintained. This will help to provide evidence that the people using the service engage in meaningful person-centred activities. The programme of activities should also be reviewed in consultation with residents and be updated to include opportunities for community based activities. Records of complaints, concerns and allegations should be improved to ensure the date, name and contact details of complainant, details of complaint, action taken and outcomes are clearly recorded. This will help to provide a clear audit trail and evidence that the views of the people using the service and their representatives are listened to and acted upon. The manager and all staff should complete training in the Protection of Vulnerable Adults periodically and evidence of the training should be maintained for reference. This will help to provide evidence that staff have completed and understand their duty of care to protect vulnerable adults from abuse. A copy of the local authoritys safeguarding adults procedure should also be obtained for staff to reference. The areas identified to the acting manager as requiring maintenance and refurbishment should be rectified as a matter of priority, to ensure the environment is comfortable, attractive and homely for residents. Control of Substances Hazardous to Health (COSHH) data sheets should also be obtained and available for staff to reference, to safeguard health and safety. Staff must not commence employment in Shandon House until two satisfactory references and a Protection of Vulnerable Adult or a Criminal Record Bureau Check have been received. This will help to protect the welfare of vulnerable adults. All records and documents listed in Schedule 2 of the Care Home Regulations 2001 must also be obtained for all new and existing staff, to provide evidence that staff have been correctly recruited. Documentary evidence of induction and ongoing training must be maintained and available for inspection. This will provide evidence that staff are trained and competent to undertake their role and responsibilities effectively. An up-to-date training matrix should also be developed to provide an overview of training completed by staff and the date the training was last completed. This will help to monitor the training needs of staff and in the planning of future training. The acting manager should refer to guidance issued by the department of health, to ensure the dependency levels of the people using the service are monitored and the resultant staffing levels in the home are adequate at all times. Care Homes for Older People Page 9 of 33 The registered provider must ensure that the Care Quality Commission is notified without delay of the occurrence of death, illness and other events. This will ensure compliance with Regulation 37 of the Care Home Regulations 2001. The Registered Provider should ensure the acting manager submits an application to register with the Care Quality Commission as the manager of Shandon House, to ensure compliance with the relevant regulations. The fire risk assessment should be kept under review and updated following the installation of the new fire alarm system, to ensure it meets the requirements of the fire authority. Night staff should also receive fire instruction refresher training every three months and day staff every six months as recommended by the fire service. This will ensure staff fully understand the fire procedures in the event of an emergency. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 33 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 33 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents do not consistently have their needs assessed before deciding to move into Shandon House. Unless an assessment is undertaken before admission, there is no assurance that care needs will be met. Evidence: A Statement of Purpose and Service User Guide had been developed in a standard format to provide information to current and prospective residents on the service provided at Shandon House. The acting manager was advised to update the documents to include the correct details of the acting managers qualifications, details of the Care Quality Commission and more information on the assessment criteria and fire policy and procedures. Discussion with residents and examination of files confirmed that residents had been provided with a copy of the documentation, as prospective residents or their Care Homes for Older People Page 12 of 33 Evidence: representatives had signed a form, to acknowledge receipt of the documents. A copy of the Statement of Purpose was also displayed in the reception area of Shandon House for people to reference and a colour brochure had been developed. The Annual Quality Assurance Assessment (AQAA) detailed that there had been 5 permanent and 1 short-term care admission in the past 12 months. It was not possible to accurately determine admissions and discharges as the admission register had not been kept up-to-date and records viewed provided conflicting information. The files of two permanent residents and four people who had used the service for respite care were requested to view. Two respite care files could not be located and the files for the two permanent residents did not contain assessment information. Only two respite care file viewed contained an assessment, one of which had been completed by a health care professional following admission. A senior member of staff spoken with reported that the previous acting manager had not routinely completed pre-admission assessments, despite a requirement being issued following a random inspection during October 2008. Care Homes for Older People Page 13 of 33 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service does not operate a consistent approach to care planning. Unless the needs of residents are appropriately planned for and periodically reviewed there is a possibility that the health and personal care needs of residents will not be met. Evidence: The Annual Quality Assurance Assessment (AQAA) for Shandon House detailed that the home had a policy on Individual Planning and Review and the Control, Storage, Disposal, Recording and Administration of Medicines. The files of two permanent residents and four people who had used the service for respite care were requested to view. Only one permanent resident had a care plan on file which had been kept under monthly review, however the standard of the review process was not as detailed as noted at the last key inspection. The other permanent resident had a care plan on file although this had not been completed until the resident had lived in Shandon House for over four months. Furthermore, two respite care files could not be located, one did not have a care plan and another had a care plan which Care Homes for Older People Page 14 of 33 Evidence: had been completed by the previous registered manager, however it had not been updated or reviewed since June 2007. A senior member of staff spoken with reported that the previous acting manager had not routinely completed care plans, despite a requirement being issued to address this issue following a random inspection during October 2008. Only three of the six files viewed contained evidence of risk assessments. The service continued to use a tick box approach to assessing risks and hazards and many of the risk assessments viewed did not contain adequate information on the control mechanisms. Daily record sheets were available for three residents however only one file contained a completed personal profile and weight records were not being monitored or updated on a regular basis. Discussion with residents and examination of health care records available for reference confirmed the people using the service had accessed a range of health care services subject to individual need. Records of general practitioner, chiropodist, hospital and / or physiotherapy appointments were recorded on files viewed. The acting manager was advised to include information in care plans on how the routine health care needs of residents were to met and the frequency of appointments, as no evidence of dental or optician services was available for the residents case tracked. The home continued to use a blister pack system that was dispensed by a local pharmacist. Medication was stored in a locked medication trolley, which was bolted to the wall when not in use and a fridge was available to store medication requiring cold storage. A controlled drugs register and cabinet was available to store controlled drugs and advice was given to the acting manager regarding the storage of Diazepam. The acting manager reported that no residents were self-administering medication at the time of the visit however files viewed did not contain a signed declaration of individual wishes with regard to the administration of medication. 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 and subject to review. Previous records confirmed that staff designated with responsibility for administering medication had completed external medication training and a basic a system had been established to monitor the competence of staff responsible for the administration of medication as previously recommended. Advice was given to the manager on how the assessment tool should be further developed. Medication administration records (MAR) viewed had generally been completed to a satisfactory standard however the following issues were noted. Firstly, variable Care Homes for Older People Page 15 of 33 Evidence: dosages for the administration of paracetamol had not been recorded for one resident and the date that medication had been received into Shandon House had not been recorded on MAR. Furthermore, a handwritten MAR had not been countersigned by a suitably trained member of staff to verify that the prescribed instructions were correct. Policies and procedures had been developed to provide guidance to staff on the values of privacy, dignity, choice, rights and independence. Staff spoken with demonstrated a satisfactory understanding of the principles of good care practice and were observed to treat people with respect and dignity during the visit. Residents spoken with during the inspection confirmed they were satisfied with the standard of care provided. Comments included: Staff are all very helpful; All the carers are nice and Im getting looked after. Care Homes for Older People Page 16 of 33 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social and community-based activities have not been provided on a regular basis and this has resulted in residents not having opportunities to participate in stimulating and meaningful activities of their choice. Evidence: A basic weekly programme of activities had been developed by the acting manager which was displayed in the reception area of Shandon House. Additional external entertainment was also sometimes arranged and details were advertised on the reception notice board. The acting manager reported that activities were available each afternoon and included; Reminiscence on a Monday, Sing-a-long on a Tuesday, Quiz on a Wednesday, Hairdressing, Beauty and Foot massages on a Thursday, Arm Chair exercises on Friday, Games on Saturday and Bingo on a Sunday. Information on each residents preferred activities was limited as some care plans and personal profiles were not available or up-to-date and there was no evidence of community-based activities. Some residents spoken with reported that there had been Care Homes for Older People Page 17 of 33 Evidence: a period when the home had offered very few activities and activity records viewed did not provide a clear audit trail for the period June 2008 to March 2009. A minister from a local Church of England church continued to visit two residents at Shandon House each month. Residents spoken with confirmed they were encouraged to maintain contact with their family and friends and to maintain as much independence as possible. The lifestyle experienced by residents appeared relaxed and flexible and residents confirmed they could follow their preferred routines. One resident reported They make visitors welcome. Shandon House had a four-week rolling menu as previously noted. Discussion with the chef confirmed there had been no change to the menus since the last visit however the menus were subject to review in consultation with the residents. The chef reported that the service would cater for all the health, religious or cultural dietary needs of residents. The menu provided evidence that residents received a satisfactory diet and additional drinks were served throughout the day. Daily meals and alternatives were recorded on the menu board in the dining room and records of meals served were maintained for dinner and tea time meals. The chef was advised to also record information on dietary intake for breakfasts. Meals were served in the homes dining room at set times, however residents could choose to eat their meals in their rooms if they preferred. Dining tables were equipped with tablecloths, napkins, flowers and condiments. Staff were observed to be available to offer support to residents during mealtimes as required and feedback received from residents was generally positive about the standard of catering. Comments included The food is very good and I have no grumbles about the meals. One resident reported There could be a better choice for tea-time meals and this should be reviewed in consultation with residents. Care Homes for Older People Page 18 of 33 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management systems for recording and responding to complaints, concerns and allegations need to be developed to provide evidence that the views of residents and their representatives are taken seriously and acted upon. Evidence: Shandon House had a complaints procedure in place, which detailed that complaints would be responded to within 28 days. The procedure was in need of review as the contact details of the Care Quality Commission needed to be included. The Annual Quality Assurance Assessment (AQAA) for the service detailed that five complaints and two safeguarding incidents had been received by the service since in the last 12 months. It was not possible to accurately determine the nature of the complaints or the outcomes as the standard of record keeping in the home was poor. Since the last inspection the following concerns, complaints and allegations have been brought to the attention of the Care Quality Commission. Concerns were raised on two occasions by a relative which concerned staffing levels, limited range of activities, missing clothing and poor personal care. Three anonymous complaints were also received since the last visit. The first concerned the conduct of a previous acting manager. The second also concerned the conduct of a previous acting Care Homes for Older People Page 19 of 33 Evidence: manager and staffing levels, the absence of cleaning staff and poor recruitment procedures. These issues were referred to the Registered Provider to investigate and action was take to address the issues. The third anonymous complaint concerned the absence of assessment, care planning and risk assessment processes, food stocks, the absence of a cook, recruitment procedures and the conduct of the previous acting manager. These issues were investigated by the Commission as part of a Random Inspection during October 2008. Shortfalls with assessment, care planning and risk assessment processes were noted and requirements issued. No improvement was noted during this inspection. Two anonymous allegations were also received. One concerned the conduct of an employee working at Shandon House and the other concerned the welfare of a resident. Due to the nature of the allegations the incidents were referred to the local authority safeguarding unit. No further action was taken by social services in regard to the first allegation as the issues could not be substantiated. The second incident was investigated by the Registered Provider and acting manager. Following the investigation the Registered Provider agreed to establish a training programme on dementia and de-escalation for all staff to attend. Feedback received from residents confirmed the people living in the home were aware of who to speak to if they had any concerns and that they felt the staff team generally listened and acted upon what they said. On the day of the visit a copy of the City of Liverpool and Borough of Sefton Safeguarding Adults procedure could not be located however policies and procedures had been developed to provide guidance to staff on whistle blowing and how to respond to suspicion or evidence of abuse. The homes training matrix was also missing therefore it was not possible to determine how many staff had completed or required training in the Protection of Vulnerable Adults from Abuse. The acting manager was advised to obtain a copy of the local authority procedures and to familiarise herself with the content, as she was not clear as to the referral process on the day of the visit. Care Homes for Older People Page 20 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home remains in need of ongoing maintenance and refurbishment, to provide residents with a safe, well-maintained and comfortable environment in which to live. Evidence: Since the last visit, a 15 hour per week maintenance person had commenced employment at Shandon House, who was responsible for maintaining the grounds and the home. Contractors were used for specialised maintenance work as required. A maintenance log was in place to record work in need of attention however a maintenance and refurbishment programme could not be located and many areas viewed remained in need of maintenance and refurbishment as previously noted. For example, the dining tables and chairs were scuffed and not been replaced as previously advised and some bedrooms were in need of redecoration and refurbishment. Furthermore, a number of basic maintenance and cleaning tasks were noted including the absence of a toilet roll holder in two toilets, a dirty toilet brush found on the floor of a toilet, poorly fitted carpet in a bathroom, inappropriate bin used to store used pads, two bathrooms full of clutter and a dirty carpet in a toilet. Similar issues were noted at the last inspection. Care Homes for Older People Page 21 of 33 Evidence: In the last 12 months, the hall stairs and landing had been redecorated, one bedroom had been refurbished and another redecorated. Records showed that an Environmental Health inspection had been carried out during October 2008 and that there was one contravention which had since been addressed. The home continued to employ a part-time domestic. Overall, areas viewed during the visit were generally tidy and feedback received from residents confirmed the home was generally kept fresh and clean. Infection Control polices and procedures were available for reference however the acting manager was unable to locate Control of Substances Hazardous to Health data sheets for staff to reference. Care Homes for Older People Page 22 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems for the recruitment, induction and training of staff are not robust and require prompt action to safeguard the welfare of vulnerable adults. Evidence: Eleven people were living in the home on the day of the visit. The acting manager reported that the staffing levels had changed since the last inspection to reflect a decrease in occupancy. Discussion with the manager and examination of rotas confirmed there were three staff on duty from 7.30 am until 5.00 pm and two staff from 5.00 pm until 9.00 pm. From 9.00pm until 7.30 am two waking night staff were on duty. The manager worked Monday to Friday each week or as required by the service. It was noted that the service did not have a suitable system in place to monitor the dependency levels of the people using the service and the resultant staffing levels. Advice was given to the acting manager on where to access guidance from the department of health. At the time of the visit the evening care staff were also responsible for preparing evening meals, leaving only one carer available to respond to the needs of residents. The acting manager agreed to ensure that two care staff were available to support Care Homes for Older People Page 23 of 33 Evidence: residents during the preparation of evening meals. Staff were observed to be attentive to the needs of residents during the visit and feedback received from residents confirmed they were satisfied with the standard of care they received. At the time of the visit 13 care staff were employed to work at Shandon House. Records showed that seven staff (46.15 ) had completed a National Vocational Qualification (NVQ) at level 2 or above in Care. The acting manager reported that another member of staff had also completed the award and was waiting to receive a certificate and an additional staff member was working towards the award. The Annual Quality Assurance Assessment (AQAA) detailed that the home had a policy on recruitment, as noted at the last inspection. The acting manager reported that seven care staff, a cleaner, chef and handyman had commenced employment at the home since the last visit. The recruitment files for seven care staff were viewed. The start date of employment had not been recorded on any files. Records showed that staff recruited by the previous acting manager had not been correctly recruited despite a requirement being issued during a random inspection in October 2008. Protection of Vulnerable Adult Checks and Criminal Record Bureau checks had been completed several weeks or months following the date that staff had commenced employment at Shandon House and shortfalls with references and other documentation were noted. For example, one care assistant had no references on file and another had a reference that was dated 4th September 1991. Furthermore, records showed that staff had not been correctly inducted in accordance with the Skills for Care Common Induction Standards. A basic induction checklist was available on files for staff who had commenced employment since the last visit, however three were incomplete and the format did not meet the required specification of the national training organisation (Skills for Care). At the time of the visit the training matrix for the service could not be located therefore it was not possible to accurately determine the training needs of staff. Gaps in safe Working practice training were noted for all staff employed since the last visit and training records were not up-to-date. Care Homes for Older People Page 24 of 33 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administrative systems within Shandon House require ongoing development and monitoring to ensure the service is run in the best interest of the people who live there. Evidence: Since the last inspection, the former Registered Manager of Shandon House (Mrs Maxine Mason) had resigned from post. The Registered Provider had since employed three acting managers, the most recent appointment being Miss Sara Fowler who had managed the service since April 2009. The Registered Provider has confirmed that arrangements will be made for Miss Fowler to register with the Care Quality Commission subject to successful completion of her probation period. Miss Fowler reported that she had previously worked as a deputy manager of a care home for older people and records viewed confirmed the acting manager had completed a range of training that was relevant to her role, including the National Care Homes for Older People Page 25 of 33 Evidence: Vocational Qualification (NVQ) level 4 in Health and Social Care. At the time of the visit, the acting manager reported that she was working towards the NVQ level 4 Leadership in Management Award. Residents and staff spoken with confirmed the new acting manager was approachable and were of the opinion that it was too early to give feedback on her effectiveness as she had only recently commenced employment in the home. However, one resident reported that the new manager was very professional and that I would endorse the new manager. Prior to the inspection the previous acting manager completed an annual quality assurance assessment (AQAA). The document was not received within the required timescales and some information was missing or misleading. For example, the review dates for policies and procedures and the dates of maintenance certificates had not been recorded and some of the information received was found not to be being implemented in practice. The AQAA also detailed that there had been three deaths in the home and two in hospital in the past 12 months and the Commission had not received written notification of the deaths in accordance with Regulation 37 of the Care Home Regulations. Records were available which confirmed the Registered Provider continued to undertake monthly visits to the home in accordance with Regulation 26 of the Care Home Regulations 2001. The Registered Provider also continued to commission an external consultant to undertake an annual quality assurance assessment. This was last completed during April 2008 and the next is due to be completed during May 2009. Surveys have been distributed to residents in advance of this quality assurance assessment. The results of the previous assessment had been displayed in the reception area of the home for people to view and a suggestions box was also sited in the reception area, to enable residents and their representatives to contribute their views anonymously. Only one residents meeting had taken place since the last visit and this had been organised by the new acting manager during April 2009. The acting manager reported that she planned to organise meetings every three months. The acting manager reported that no changes had occurred in the management of residents personal monies since the last inspection. At the time of the visit the acting manager did not act as an appointee and the Registered Provider continued to be responsible for processing and distributing invoices for residents or their representatives for fees and any additional costs e.g. (chiropody, hair dressing, papers etc). The acting manager reported that she was responsible for looking after the Care Homes for Older People Page 26 of 33 Evidence: personal spending money of two residents. Records of transaction and cash balances were checked and found to be correct and receipts had been obtained to account for expenditure. The Annual Quality Assurance Assessment (AQAA) for the service confirmed a policy on Health and Safety was in place however the previous acting manager had not recorded the dates of the last review or certificates for maintenance of equipment within the dataset section. Consequently, service records were requested to view for the passenger lift, electrical wiring, hoisting equipment, gas installation, portable appliance testing, fire detection and alarm and the fire extinguishers. The acting manager was requested to arrange a service contract for the fire alarm and detection system (as the last certificate on file was dated 3/05/08 and for portable appliance testing (as the last certificate expired on 7/04/09). Likewise, the manager was requested to arrange for the call bell system to be inspected and serviced as the last recorded service was dated 27/03/08. Fire records were viewed during the visit. The records detailed that the fire alarm system had generally been tested on a weekly basis however some prolonged gaps in testing were noted e.g. from 14/03/09 to 3/04/09. No record of the emergency lights being tested or visual examinations of the fire extinguishers could be located and records of fire instruction training for day and night staff had not been maintained. A certificate was in place which confirmed the majority of the staff team had attended a fire safety lecture on 5th February 2009. The homes fire risk assessment remained in need of review as it was dated 16/10/06 as noted at the last inspection and the new acting manager reported that she was developing a building risk assessment as the previous assessment could not be located. It was not possible to determine which staff had completed training in Safe Working Practice topics as the training matrix could not be located on the day of the visit. Care Homes for Older People Page 27 of 33 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 3 14 The needs of prospective and 06/11/2008 current residents living at Shandon House must be assessed and kept under review. This will enable the service to identify needs and determine whether it is able to meet the needs of people considering living in Shandon House. 2 7 13 Risk assessments must be undertaken and kept under review to safeguard the welfare of all the people living in Shandon House. This will help to ensure that unnecessary risks to the health and safety of residents are identified and so far as possible eliminated. 06/11/2008 3 7 15 A plan of care must be completed and kept under review for all the residents living in Shandon House. This will provide assurance to the people living in the home that their care needs will be met and provide guidance to staff on how to deliver person-centred care. 06/11/2008 4 29 19 Staff must not commence 06/11/2008 Page 28 of 33 Care Homes for Older People employment in Shandon House until two satisfactory references and a Protection of Vulnerable Adult or a Criminal Record Bureau Certificate have been received. This will help to protect the welfare of vulnerable adults. 5 30 19 Documentary evidence of induction and ongoing training must be maintained and available for inspection. This will provide evidence that staff are trained and competent to undertake their role and responsibilities effectively. 06/11/2008 Care Homes for Older People Page 29 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 37 37 The registered provider must ensure that the Care Quality Commission is notified without delay of the occurrence of death, illness and other events. This will ensure compliance with Regulation 37 of the Care Home Regulations 2001. 02/07/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The Statement of Purpose and Service User Guide should be updated to include the correct details of the acting managers qualifications, details of the Care Quality Commission and more information on the assessment criteria and fire policy and procedures. This will ensure the people using the service access to key information on the service. Weight records should be routinely monitored and recorded as part of the care planning process, to ensure the welfare of residents is safeguarded. 2 7 Care Homes for Older People Page 30 of 33 3 7 Risk assessments should be updated to include detailed information on the control mechanisms. This will enable staff to understand how to control and respond to potential risks Care plans should be updated to include information on how the routine health care needs of residents are to be met and the frequency of appointments. This will help to maintain a proactive approach to health care and ensure residents have access to all their entitlements to NHS services. A declaration of wishes should be should be available on each residents file, to provide evidence of individual wishes with regard to the administration of medication. Variable dosages of medication and the date that medication is received into Shandon House should be recorded on Medication Administration Records, to provide a clear audit trail. Handwritten Medication Administration Records should be countersigned by a suitably trained member of staff, to verify that the prescribed instructions are correct. The programme of activities should be reviewed in consultation with residents and be updated to include opportunities for community based activities. Management systems should be developed to ensure activities are coordinated on a daily basis and records of the date, activity, participants and facilitator should be maintained. This will help to provide evidence that the people using the service engage in meaningful personcentred activities. Records of the meals served to each resident at breakfast should be maintained, to enable the dietary intake of each resident to be monitored. Management systems should be developed to ensure the menu plan for the home is reviewed with residents on a regular basis. This will ensure the menu is varied and reflects the dietary needs and preferences of all the residents. Records of complaints, concerns and allegations should be improved to ensure the date, name and contact details of complainant, details of complaint, action taken and outcomes are clearly recorded. This will help to provide a clear audit trail and evidence that the views of the people using the service and their representatives are listened to and acted upon. A copy of the City of Liverpool and Borough of Sefton Page 31 of 33 4 8 5 9 6 9 7 9 8 12 9 12 10 15 11 15 12 16 13 18 Care Homes for Older People Safeguarding Adults procedure should be obtained and available for the manager and staff to reference, to ensure an appropriate response to suspicion or evidence of abuse. 14 18 The manager and all staff should complete training in the Protection of Vulnerable Adults periodically and evidence of the training should be maintained for reference. This will help to provide evidence that staff have completed and understand their duty of care to protect vulnerable adults from abuse. A maintenance and refurbishment plan should be developed and available for reference, to provide evidence of proactive planning for the renewal of the fabric and decoration of the environment. The areas identified to the acting manager as requiring maintenance and refurbishment should be rectified as a matter of priority, to ensure the environment is comfortable, attractive and homely for residents. Control of Substances Hazardous to Health (COSHH) data sheets should be obtained and available for staff to reference, to safeguard health and safety. The Registered Provider should ensure the acting manager submits an application to register with the Care Quality Commission as the manager of Shandon House, to ensure compliance with the relevant regulations. Management systems should be developed to ensure all equipment within the home is routinely serviced, to ensure the health and safety of residents, staff and visitors. The emergency lighting should be tested and the extinguishers visually inspected on a monthly basis, to ensure best practice. Night staff should receive fire instruction refresher training every three months and day staff every six months as recommended by the fire service. This will ensure staff fully understand the fire procedures in the event of an emergency. The fire risk assessment should be kept under review and updated following the installation of the new fire alarm system, to ensure it meets the requirements of the fire authority 15 19 16 19 17 26 18 31 19 38 20 38 21 38 22 38 Care Homes for Older People Page 32 of 33 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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