Inspecting for better lives Random 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: The rating was made on: two star good 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. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Daniel Hamilton Date: 0 6 1 0 2 0 0 8 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): Type of registration: Number of places registered: SBS Care Homes Limited care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category 0 Over 65 20 Conditions of registration: 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. All the 20 bedrooms are for single occupancy and thirteen have en-suite toilets. The home has a pleasant garden and Care Homes for Older People Page 2 of 12 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 #396.55 per week. Care Homes for Older People Page 3 of 12 What we found:
The reason for this Random Inspection was to conduct an investigation into an anonymous complaint. The complainant reported a number of concerns regarding: assessment and care planning processes; food stocks, menu planning and meal choices; staffing levels; recruitment and selection practice and the conduct of staff and the acting manager. Outcome area - Choice of Home. The complainant reported that a residents needs had changed upon being discharged from hospital and that a re-assessment of the persons needs had not been undertaken and staff did not have access to the necessary equipment to manage the residents needs. The complainant also highlighted concerns regarding assessment practice for two other residents. Examination of records revealed that a residents needs had not been re-assessed following discharge from hospital and staff spoken with reported that the residents needs had significantly changed. Staff reported that the resident had been supplied with a hospital bed and that they had access to a hoist, sling and slide sheet to enable them to transfer, move and handle the resident safely. Records were also viewed for two residents who had been admitted to the home since the last inspection. An assessment of needs had been completed for only one of the residents by a social worker. It was not possible to determine whether the assessment had been completed prior to the resident being admitted to the home as the dates of the admission had not been recorded in the admission register for Shandon House or in the residents personal file. There was no assessment on file for the other person who has since been discharged from the home. Outcome area - Health and Personal Care. The complainant reported that a care plan and risk assessment had not been updated or kept under review for a resident whose needs had changed upon being discharged from hospital. The complainant also reported that there were no care plans or risk assessments in place for two new residents. Examination of records revealed that a care plan had not been updated or kept under monthly review for a resident who had been discharged from hospital. Records were viewed for two residents who had been admitted to the home since the last inspection. A basic care plan had been completed for only one of the residents by a social worker however this did not describe in detail the action required by staff to meet the needs of the resident. There was also no care plan on file for the other person who has since been discharged from the home. Both of the files viewed did not contain any supporting evidence to confirm potential and actual risks had been assessed or reviewed as part of the care planning process. Outcome area - Daily life and Social Activity. The complainant reported concerns regarding the absence of a cook at Shandon House, the level of food stocks, menu planning and meal choices. Care Homes for Older People Page 4 of 12 Upon arrival at the home, it was noted that a chef was on duty. The chef reported that he had recently been appointed. Stock levels viewed were considered adequate at the time of the visit although it was noted that the amount of fresh vegetables in Shandon House was low. The chef acknowledged this point and was able to provide evidence of an order form for more vegetables, which were due to be delivered the next day. It was noted that a four-week rolling menu was in operation as noted at the last inpection. The chef reported that he was planning to review the menu in consultation with the people using the service. Records of the meals served to individual residents had only been recorded for tea-time meals and these provided evidence of different choices. A limited range of alternative choices had been recorded on the menu board and on the menu plans. No concerns were received from the people using the service regarding the standard of catering or meal choices during the visit. Outcome area - Staffing. The complainant reported concerns regarding recruitment and selection procedures, staffing levels in the home and the absence of a domestic. The acting manager reported that three staff had been employed at the home since the last inspection. The personnel files of the three employees were viewed during the visit and a number of concerns were noted. For example, all the three staff had commenced employment at the home without appropriate references and Protection of Vulnerable Adults (POVA) or Criminal Record Bureau (CRB) checks having been undertaken. The first file viewed contained no references and a CRB that related to employment in another service. The second file viewed contained only one reference (dated after the employee had commenced employment) and a CRB that related to employment in another service and which was dated after the employee had commenced employment. The third file also contained no references and a photocopy of a CRB that was dated approximately 30 months prior to the employees start date and which related to employment in another service. None of the files contained evidence of induction training or a record of ongoing training completed during the employment period at Shandon House. Other issues of concern were also noted which were discussed with the acting manager. Examination of rotas and discussion with staff confirmed there were normally three staff on duty during the day-time and two waking night staff during the night. On the day of the visit there were only two staff on duty as an employee was absent due to personal reasons. Senior staff reported that they had attempted to cover the shift but had been unsuccessful. It was noted that there were other occasions when the staffing levels had reduced to two staff on duty. The complainant reported that the staffing in the home had sometimes reduced to one member of staff. No evidence could be found to substantiate this allegation. Staff spoken with were of the opinion that a minimum of three staff were required at all times during the day to safely meet the needs of residents, as they were also undertaking cleaning and laundry duties due to the absence of a domestic and were providing care to two highly dependent people on the second floor of the premises. A system was not in place at the time of the visit to monitor the dependency needs of the people using the service and the resultant staffing levels and this should be established to ensure best practice and to safeguard the welfare of the people using Care Homes for Older People Page 5 of 12 the service. No concerns were received from the people using the service regarding the quality of care provided on the day of the visit and the acting manager reported that the vacancy for a domestic had been advertised in a local job centre, together with a part-time handyperson. Areas viewed during the visit appeared clean and hygienic. Outcome area - Management & Administration. The complainant reported concerns regarding the working pattern of the acting manager, the arrangements for rota planning and ordering and administering medication and the conduct of an employee working in the home. At the time of the visit the service did not have a manager in post who was registered with the Commission for Social Care Inspection. The acting manager reported that she had obtained the application forms to register as the manager and had enrolled to undertake a management qualification. It was not possible to explore the range of training completed by the acting manager as there was no record or documentary evidence of training completed available for inspection. It was not possible to verify the working hours and pattern of the acting manager as the hours worked by the acting manager had not been recorded on the rota. On the day of the visit the acting manager did not arrive at work until approximately 10.45 am due to personal reasons. The acting manager reported that she normally worked from 9.00 am to 5.00 pm each day and additional hours, subect to the needs of the people using the service. Staff spoken with advised that the acting manager was normally in work anytime from 8.00 a.m. Discussion with the acting manager and staff confirmed the acting manager had taken over responsibility for rota planning at the request of the owner of Shandon House. The acting manager also reported that she was involved in ordering medication with senior staff and provided evidence that all staff responsible for administering medication had completed medication training. The acting manager was also advised to ensure that the competency of all staff responsible for administering medication was assessed periodically, to ensure best practice. The acting manager reported that she had not received any complaints or concerns regarding the conduct of any employee in the home and this was checked by examining the homes complaints record. Records were available to confirm that appropriate action would taken in respect of the conduct of staff working in home, should the need arise. No issues of concern were raised by staff on duty regarding the conduct of their colleagues and staff spoken with demonstrated a sound understanding of their duty of care to protect vulnerable people from abuse. What the care home does well: What they could do better:
Arrangements must be made to ensure the needs of prospective and current residents are assessed and kept under review. This will enable the service to undertake an holistic assessment of each residents needs and to determine whether the service is Care Homes for Older People
Page 6 of 12 able to meet the needs of people considering moving into Shandon House. A care planning system must also be established and kept under review, to ensure the needs of the people using the service are appropriately planned for. This will provide assurance to the people living in the home that their needs will be met and provide guidance to staff on how to deliver person-centred care. Risk assessments must also be undertaken and kept under review to safeguard the health and welfare of 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. Recruitment and selection procedures must be improved. Staff must not commence employment in the home until two satisfactory references and a Protection of Vulnerable Adult (POVA) or Criminal Record Bureau (CRB) certificate have been received. This will help to safeguard the welfare of the people using the service. Documentary evidence of induction and ongoing training must be maintained and available for inspection to confirm all staff are trained and competent to undertake their roles and responsibilities effectively. A record of the daily meals provided to each resident should be maintained, to provide evidence that the diet is satisfactory and the choices of the people using the service are accomodated. A system should be established to monitor the dependency levels of the people using the service and the resultant staffing levels in the home. This will ensure best practice and confirm appropriate staffing levels are in place at all times. The acting manager should undertake periodic assessments of competency for all staff responsible for administering medication, to monitor the ongoing practice and training needs of staff responsible for administering medication. The acting manager should record her daily hours of work on the rota, to provide information on the management hours worked at Shandon House. The acting manager should also submit an application to register as the manager of Shandon House to the Commission for Social Care Inspection, to ensure compliance with the relevant regulations. 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 2. Care Homes for Older People Page 7 of 12 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These requirements were set at the last inspection. They may not have been looked at during this inspection, as a random inspection is short and focussed. The registered person must take the necessary action to comply with these requirements within the timescales set.
No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 8 of 12 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 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 06/11/2008 Care Homes for Older People Page 9 of 12 met and provide guidance to staff on how to deliver person-centred care. 4 29 19 Staff must not commence 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. 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 06/11/2008 06/11/2008 1 15 A record of the daily meals provided to each resident should be maintained, to provide evidence that the diet is satisfactory and the choices of the people using the service are accommodated. The acting manager should record her daily hours of work on the rota, to provide information on the management hours worked at Shandon House. A system should be established to monitor the dependency levels of the people using the service and the resultant staffing levels in the home. This will ensure best practice and confirm appropriate staffing levels are in place at all times. The acting manager should undertake periodic assessments of competency for all staff responsible for administering medication, to monitor the ongoing practice and training needs of staff responsible for administering medication.
Page 10 of 12 2 27 3 27 4 30 Care Homes for Older People 5 31 The acting manager should submit an application to register as the manager of Shandon House to the Commission for Social Care Inspection, to ensure compliance with the relevant regulations. Care Homes for Older People Page 11 of 12 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got 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 Helpline: 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 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 © (2008) 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. Care Homes for Older People Page 12 of 12 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
