CARE HOMES FOR OLDER PEOPLE
Shandon House 20 Crescent Road Birkdale Southport Merseyside PR8 4SR Lead Inspector
Daniel Hamilton. Key Unannounced Inspection 7th May 2008 09.25 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.V362771.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.V362771.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.V362771.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 10th May 2007 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 £396.55 per week. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes.
This unannounced site visit was carried out over one day and lasted approximately 8 hours. 13 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 viewed. The Registered Manager, 4 staff, and 7 residents were spoken with during the visit. Survey forms were also distributed to a number of staff, residents and / or their relatives prior to the inspection to obtain additional feedback about the home. All the key standards were assessed and progress / action taken in response to the previous recommendations from the last key inspection in May 2007 was reviewed. Full feedback was given to the manager during and on conclusion of this inspection. What the service does well:
Shandon House presented as a pleasant environment in which to live. Staff were observed to be attentive to the needs of residents and to treat the people living in the home with respect and dignity. Feedback received from residents was generally very positive and confirmed they were satisfied with the service provided. For example, comments from three residents included; “The staff do listen and act on what you say. They are very caring at all times”; “The staff are brilliant, kind and considerate and are always there when I need them” and “My care is really good.” Likewise, a relative reported; “Social Services were excellent. I arranged an appointment with Maxine Mason [Manager] and then she visited my parents at their home. I was initially very impressed and continue to be. It is very homely and the atmosphere very caring.” Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 6 Assessment, care planning and review systems had been established to ensure the needs of residents were identified and planned for and health care record confirmed that residents had regular access to health care professionals subject to individual needs. Residents spoken with confirmed that they could follow their preferred routines and lifestyle and that Shandon House was a relaxed place to live. Likewise, 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. Visitors were able to see residents at any reasonable time. Meals were well managed and discussion with residents and examination of records confirmed the people using the service were very satisfied with standard of catering and received a nutritious and balanced diet. Comments included; “The food is excellent and very nutritious”; “I always have a choice which is wonderful” and “I get plenty to eat and the food is very well prepared.” 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 knew who to speak to with any issues of concern. For example, a relative reported; “If there is a query they listen to you and discuss the problem readily in private if necessary. The staff are willing and helpful. They always find time for us.” Residents spoken with confirmed they felt safe living in the home and manager and her staff team demonstrated a good understanding of their duty of care to protect vulnerable adults from abuse. Systems had been developed to ensure the views of the people using the service were listened to and acted upon. What has improved since the last inspection?
Since the last inspection, the Registered Provider had made arrangements to provide the people living in Shandon House and / or their representatives with a contract / statement of terms and conditions. This ensured the people using the service were aware of their rights and obligations. The manager had updated the assessment documentation to ensure that equality and diversity issues i.e. ethnicity, gender and sexual orientation were taken into consideration during the assessment process, to ensure an holistic assessment of needs. Medication Policies and Procedures had been updated to ensure staff had more detailed guidance for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home and a suitable storage cabinet had been purchased to store controlled drugs.
Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 7 The Registered Provider had developed a programme for routine maintenance and refurbishment and had continued to invest money into the home in order to improve the environment for the people using the service. Furthermore, the Registered Provider had made arrangements to visit the home on a weekly basis and produced a monthly report on the conduct of Shandon House to ensure compliance with Regulation 26 of the Care Home Regulations 2001. Over 50 of the care staff team had attained a National Vocational Qualification in Care at level 2 or above and guidance on the Skills for Care induction standards had been obtained. Furthermore, all the staff team had completed training in Safe Working Practice topics to ensure the health and safety of staff and residents was promoted and protected. The contraventions in the Environmental Health Officers report dated 20/10/06 had been fully addressed and risk assessments had been completed to assess and control potential risks. What they could do better:
The Statement of Purpose / Service User Guide should be updated to include the new contact details of the Commission for Social Care Inspection. A controlled drugs register should be obtained to ensure suitable recording systems are in place for the recording of controlled medication in the event of a resident being prescribed a controlled drug. The Registered Manager should ensure staff record the administration of all prescribed creams on Medication Administration Records, to ensure a clear audit trail. A system should be established to ensure the competency of staff responsible for administering medication is kept under review. This will help to ensure best practice and minimise errors in the management of medication. Activities were provided for residents however the service should explore opportunities for community-based activities in consultation with residents. This will help to satisfy the recreational and social needs of the people using the service and ensure they have access to their local community / social events. The areas identified to the Manager during the inspection as requiring routine maintenance and / or refurbishment should be addressed as a matter of priority, to ensure the home is comfortable for residents and attractive and well maintained. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 8 The manager should ensure that all new staff complete a ‘Skills for Care’ induction, to confirm they are ‘Safe to Leave’ and competent to care for the people using the service. Staff should be supported to undertake specialised training in addition to Safe Working Practice and NVQ awards e.g. dementia and the conditions associated with caring for older people etc. This will help to develop staff awareness and promote best practice. The Registered Manager should complete a National Vocational Qualification in Care at Level 4, to ensure she has the necessary qualifications for her management role. The Fire Risk assessment should be updated following the installation of the new fire alarm system to ensure it meets the requirements of the local fire authority. 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.V362771.R01.S.doc Version 5.2 Page 9 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.V362771.R01.S.doc Version 5.2 Page 10 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 good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the necessary information and opportunities to choose a home that will meet their needs. EVIDENCE: A Statement of Purpose and Service User Guide had been manager in a standard format to provide information to prospective residents on Shandon House. The manager was the contact information for the Commission for Social Care details had changed since the last visit. developed by the current and / or advised to amend Inspection as the 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. A copy of the Statement of Purpose was also displayed in the reception area of Shandon House for people to reference. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 11 Discussion with the manager and the people using the service confirmed the Registered Provider had issued Contracts / Statement of Terms and Conditions to residents since the last visit. Signed copies were available on files viewed. The files of two residents who had moved into Shandon House since the last visit were examined during the inspection. Each file contained an information sheet and a ‘Pre-Admission Assessment’ that had been completed by the manager before each resident had moved in. A copy of a Social Work assessment had also been obtained for a resident who had been referred via Care Management arrangements. Assessment documentation completed by the manager was well constructed and enabled a detailed assessment of needs to be undertaken. The assessment forms had been updated since the last inspection to include additional information on equality and diversity issues i.e. ethnicity, gender and sexuality - as recommended at the last visit. Feedback received from residents and their representatives confirmed the manager had continued to undertake assessments of need prior to people being admitted to Shandon House and that they were encouraged to visit the home prior to deciding whether to move in. For example, a relative reported; “Social Services were excellent. I arranged an appointment with Maxine Mason [Manager] and then she visited my parents at their home. I was initially very impressed and continue to be. It is very homely and the atmosphere very caring.” Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 12 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 Annual Quality Assurance Assessment (AQAA) for Shandon House detailed that the home had a policy on ‘Individual Planning and Review.’ The manager confirmed that a Care Plan was developed following the outcome of an assessment of needs as noted at the last visit. Two files were examined during the inspection. Files viewed contained a Care Plan that had been signed by residents or their representatives. Care plans were well constructed and identified the needs and support requirements of each resident, together with the desired outcomes. Records showed that the manager had also undertaken a comprehensive review of each care plan on a monthly basis and that significant issues had been recorded. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 13 Risk assessments had been completed to identify and control potential / actual hazards and diary sheets, personal profiles, accident report forms, weight and health care records were also available for reference. Discussion with residents and examination of health care records confirmed the people using the service had accessed a range of health care services subject to individual need. Records of general practitioner, district nurse, dentist, optician and / or chiropodist appointments had been recorded on files and the outcomes of appointments had been documented. The manager reported that since the last visit arrangements had been made to update the medication policies and procedures within Shandon House and this was verified by reviewing the policies and procedures. 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. Since the last visit the manager had arranged to purchase and install a cabinet to store controlled drugs however a controlled drugs register had not been purchased. Advice was given on where to purchase a suitable register. Declaration of individual wishes with regard to the administration of medication had been completed and signed by residents and / or their representatives. At the time of the visit none of the people using the service administered their own 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. Previous records confirmed that staff designated with responsibility for administering medication had completed external medication training. No system had been established to monitor the competence of staff responsible for the administration of medication. Medication administration records (MAR) viewed had been correctly completed to account for the administration of medication with the exception of prescribed creams. The manager reported that the creams had always been administered to residents but that staff did not realise that they needed to sign the MAR to confirm the administration of creams. Residents spoken with confirmed that their creams had been administered on a daily basis and the manager was reminded that all prescribed creams must be recorded on MAR to provide a clear audit trail. 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 good understanding of the principles of good care practice and were observed to treat people with respect and dignity during the visit. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 14 Residents spoken with complimented the service provided. Comments included; “The staff do listen and act on what you say. They are very caring at all times”; “The staff are brilliant, kind and considerate and are always there when I need them” and “My care is really good.” Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 15 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 within the home is generally flexible and varied to meet the preferred routines, expectations and preferences of the people living in the home. EVIDENCE: A weekly programme of activities had been developed which was displayed in the reception area of Shandon House. The manager reported that the programme was a guide only and that residents were asked on a daily basis for their activity preferences. The programme indicated that activities commenced at 2.00 pm on a daily basis and took place in the lounge area. Activities on offer included; Music and Dance on Monday, Bingo on Tuesday, Sewing, Knitting and / or Crosswords on Wednesday, Guessing Game on Thursday, Arm Chair exercises on Friday, Word Game on Saturday and a Quiz on Sunday. Information on the recreational interests, social and recreational needs of the people using the service were recorded within care plan documentation and direct observation and examination of activity records confirmed a basic range of activities was provided on a regular basis. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 16 Some residents spoken with expressed an interest in external trips as most of the activities were provided within the home. For example, one resident reported; “I think more activities could be done for us outside of the home.” This point was acknowledged by the manager and was detailed in the Annual Quality Assurance Assessment for the service as an area for improvement in the next 12 months. Representatives from local churches continued to visit residents at Shandon House periodically, subject to individual needs. This was confirmed by a relative who reported; “The home encourages visits from outside people. My mother regularly has visits from people in Formby including the local church.” Residents spoken with confirmed that they could follow their preferred routines and lifestyle and that Shandon House was a relaxed place to live. Likewise, 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. Visitors were able to see residents at any reasonable time. A four-week rolling menu had been developed in consultation with the people using the service. The menu provided evidence that residents received a wholesome and nutritious diet and additional drinks were served throughout the day. 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. Dining tables were equipped with tablecloths, napkins, flowers and condiments. The cook was spoken with during the visit and demonstrated a good understanding of the dietary needs and preferences of residents. The manager reported that puree meals were being provided at the time of the visit and confirmed that other health, religious and / or cultural dietary needs would be accommodated as required. The inspector was invited to join residents for lunch on the day of the inspection and was impressed with the standard of catering. Feedback received from residents regarding the meals was positive. Comments included; “The food is excellent and very nutritious”; “I always have a choice which is wonderful” and “I get plenty to eat and the food is very well prepared.” Furthermore, one relative reported; “You can never please everyone – They do try to prepare food which appeals to individuals. The cook brought some smoked fish for my mother.” Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 17 Staff were observed to be available to offer support to residents during mealtimes as required. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 18 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 complaints would be responded to within 28 days. The procedure was in need of review as the contact details of the Commission for Social Care Inspection were incorrect. No complaints had been referred to the Commission for Social Care Inspection since the last inspection and the Annual Quality Assurance Assessment (AQAA) for the service detailed that there had been no complaints in the last 12 months. This was verified by checking the complaints record log for Shandon House and by speaking to residents and staff. Feedback received from residents and / or their representatives 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 listened and acted upon what they said. None of the residents spoken to during the visit had any complaints about the service provided at Shandon House. One relative stated; “If there is a query they listen to you and discuss the problem readily in private if necessary. The staff are willing and helpful. They always find time for us.”
Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 19 The AQAA for Shandon House detailed that there had been no adult protection referrals or investigations since the last visit and residents spoken with confirmed that they felt safe at Shandon House. Policies and procedures had been developed to provide guidance to staff on how to respond to suspicion or evidence of abuse. The policies included a copy of the ‘City of Liverpool and Borough of Sefton – Safeguarding Adults procedure’ and internal policies on ‘Abuse’ and ‘Whistleblowing.’ The manager was advised to also provide residents with information on who they could speak to / contact should they feel vulnerable or at risk of abuse. Record showed that all the staff team had completed training in the Protection of Vulnerable Adults from Abuse and staff spoken with demonstrated a good understanding of the different types of abuse, reporting procedures and their duty of care to safeguard the welfare of the people using the service. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 20 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. Shandon House continues to receive investment however some areas of the home remain in need of maintenance and refurbishment, to provide residents with a safe, wellmaintained and comfortable environment in which to live. EVIDENCE: Since the last visit, the maintenance person had terminated his employment at Shandon House and a contractor hired to maintain the grounds and the home. A maintenance log was in place to record work in need of attention and risk assessments had been completed periodically to monitor the condition of the environment. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 21 Since the last inspection the Registered Provider had developed a maintenance and refurbishment programme and continued to invest money into the home. For example, a new fire alarm system had been installed and new carpets fitted to the hall, stairs, and landing areas and two bedrooms. Furthermore, the external brickwork, front garden wall, lounge, dining area and two bedrooms had been painted or redecorated. New curtains had also been fitted to the lounge. Some areas of the home were in need of redecoration following the installation of the new fire alarm system and five bedrooms viewed were in need of complete refurbishment. Likewise, one bathroom viewed was in need of refurbishment and redecoration and another bathroom needed some minor maintenance including the fitting of a toilet roll holder to make the environment more homely and comfortable for residents. It was noted that the dining room furniture and lounge chairs were scuffed / damaged as noted at the last visit. The manager reported that the Registered Provider had ordered new furniture for these areas, which was waiting to be delivered. Records showed that an Environmental Health inspection had been carried out during November 2007 and that there were no contraventions. The Fire Authority had also undertaken an inspection during January 2008 and issued some requirements. A further visit was scheduled during May 2008 to ensure compliance. The home continued to employ a part-time domestic. Areas viewed during the visit were generally tidy and feedback received from residents and their representatives via survey forms and discussion confirmed the home was kept fresh and clean. Infection Control polices and procedures and Control of Substances Hazardous to Health data sheets were available for staff to reference. Training records showed that all the staff team had completed ‘Health and Safety and Infection Control’ training. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 22 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 sufficient numbers of staff who are correctly recruited. Some staff have not completed the necessary induction training and would benefit from specialised training, to improve awareness of the conditions associated with caring for older people and promote best practice. EVIDENCE: Thirteen people were living in the home on the day of the visit. The manager reported that staffing levels remained the same as at the last inspection and 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. Feedback received from the people using the service and their representatives was positive regarding the staff team. Comments included; “All [staff] are very good and understanding”; “The staff are superb and have been consistent over the last 2 years” and “Maxine Mason [Manager] and her staff are always very good.” Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 23 At the time of the visit 12 care staff were employed to work at Shandon House. Training records showed that seven staff (58.33 ) had completed a National Vocational Qualification (NVQ) at level 2 or above in Care. The manager reported that another member of staff (8.33 ) had also completed the award and was waiting to receive a certificate. Once the outstanding staff member has completed the award, 8 staff (66.66 ) will have completed a National Vocational Qualification in Care at level 2 or above. Previous inspection records confirm that the home had a recruitment policy. The manager reported that three staff (a new cook and two 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 and that staff had been correctly recruited to safeguard the welfare of residents. Since the last visit the manager had made arrangements to obtain an induction pack that complied with the Skills for Care Induction Standards. Only one of the two care staff recruited had evidence of a ‘Skills for Care’ induction on file and some parts of the documentation were incomplete and had not been signed off. The home’s training matrix showed that all of the staff team had completed training in Safe Working Practice topics i.e. Moving and Handling, First Aid, Food Hygiene, Fire Prevention and Health and Safety and Infection Control. Staff had also completed additional training including; medication and abuse awareness. The manager was advised to explore other training opportunities for staff that was relevant to their role. For example, dementia awareness, conditions associated with old age etc. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 24 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 good. This judgement has been made using available evidence including a visit to this service. The service and administration systems are generally managed effectively. This safeguards the welfare and promotes the best interests of the people using the service. EVIDENCE: The Manager of Shandon House (Mrs Maxine Mason) is registered with the Commission for Social Care Inspection and has managed the service for over three 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 as previously noted.
Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 25 The manager had not undertaken the National Vocational Qualification level 4 in Care as recommended at the last visit. Action should be taken to address this matter to ensure the manager has the necessary qualifications for her role. The people using the service confirmed the home was well managed and staff spoke highly of the support they received from the Registered Manager. The manager applied a ‘hands on’ approach to her management role and demonstrated a clear understanding of the key principles and focus of the service and areas for further development. The Registered Provider continued to commission an external consultant to undertake an annual quality assurance assessment. This was last completed during April 2008. Records showed that the manager had also distributed a brief questionnaire to residents and / or their representatives during February 2008 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. Examination of records revealed that the Registered Provider had undertaken Regulation 26 visits and produced reports as previously recommended. Only one residents’ meeting had taken place since the last visit during February 2008 and the manager was advised to increase the frequency of these meetings in consultation with the people using the service. The 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 manager did not act as an appointee or handle any of the residents’ finances. 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 Annual Quality Assurance Assessment (AQAA) for the service confirmed a policy on ‘Health and Safety’ was in place as previously noted. The document also provided confirmation that services and equipment within the home were regularly serviced. A public liability insurance certificate was displayed in the reception area of the home. Fire records were viewed during the visit. The records detailed that the fire alarm system had been tested on a weekly basis and confirmed 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 April 2008. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 26 The home’s fire risk assessment was in need of review as it was dated 16/10/06 and a new fire alarm system had been recently fitted. Commissioning and Electrical installation certificates were available to confirm the system had been correctly installed in accordance with the relevant regulations. Risk assessments had been undertaken to address Safe Working Practice topics and records confirmed the service continued to use the ‘Safer Food Better Business Manual’. Staff had completed training in all Safe Working Practice topics as identified in Standard 30. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 27 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 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 3 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 3 Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 28 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. 2. Refer to Standard OP1 OP9 Good Practice Recommendations The Statement of Purpose / Service User Guide should be updated to include the new contact details of the Commission for Social Care Inspection. A controlled drugs register should be obtained to ensure suitable recording systems are in place for the recording of controlled medication in the event of a resident being prescribed a controlled drug. The Registered Manager should ensure staff record the administration of all prescribed creams on Medication Administration Records, to ensure a clear audit trail. A system should be established to ensure the competency of staff responsible for administering medication is kept under review. This will help to ensure best practice and minimise errors in the management of medication. The home should explore opportunities for communitybased activities in consultation with residents, to ensure people have access to their local community/social events.
DS0000069402.V362771.R01.S.doc Version 5.2 Page 29 3. 4. OP9 OP9 5. OP12 Shandon House 6. OP19 7. OP30 8. OP30 9. 10 OP31 OP38 The areas identified to the Manager during the inspection as requiring routine maintenance and / or refurbishment should be addressed as a matter of priority, to ensure the home is comfortable for residents and attractive and well maintained. The manager should ensure that all new staff complete a ‘Skills for Care’ induction, to confirm they are ‘Safe to Leave’ and competent to care for the people using the service. Staff should be supported to undertake specialised training in addition to Safe Working Practice and NVQ awards e.g. dementia and the conditions associated with caring for older people etc. This will help to develop staff awareness and promote best practice. The Registered Manager should complete a National Vocational Qualification in Care at Level 4, to ensure she has the necessary qualifications for her management role. The Fire Risk assessment should be updated following the installation of the new fire alarm system to ensure it meets the requirements of the local fire authority. Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shandon House DS0000069402.V362771.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!
