Inspection on 17/05/06 for Shannon Court

This inspection was carried out on 17th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Shannon Court 16/11/09

Shannon Court 27/07/09

Shannon Court 27/09/07

Shannon Court 21/03/07

Shannon Court 13/09/05

Shannon Court 26/05/05

Shannon Court 30/11/04

Shannon Court 05/04/04

Similar services:

Springfield House

Springfield House

Sutton Lodge Nursing Home

The Shelley

1 Marten Road

St Helier`s Residential Hotel

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

CARE HOMES FOR OLDER PEOPLE Shannon Court Portsmouth Road Hindhead Surrey GU26 6DA Lead Inspector Susan McBriarty Key Unannounced Inspection 17th May 2006 09:00 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 Shannon Court DS0000017643.V295728.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. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shannon Court Address Portsmouth Road Hindhead Surrey GU26 6DA 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) 01428 604833 arichards@rmbi.org.uk Royal Masonic Benevolent Institution Mrs Marguerite Holloway Care Home 52 Category(ies) of Dementia (12), Dementia - over 65 years of age registration, with number (12), Mental disorder, excluding learning of places disability or dementia (5), Mental Disorder, excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (35) Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Out of the 52 accommodated, 35 may be in the category OP (older persons). Out of the 52 accommodated, up to 5 may fall within the category MD or MD(E) or a combination of both Of the 52 service users, up to 12 can be either DE or DE(E) or a combination of both. 13th September 2005 Date of last inspection Brief Description of the Service: Shannon Court is a care home for older people. The service is set in its own private grounds. It provides care for older Freemasons and dependent females of Freemasons. The accommodation for service users is provided on two floors, a shaft lift provides access to the first floor. The main building consists of four units known as houses. Alvernia House is ground floor accommodation supporting service users who are elderly, mentally frail. All bedrooms are single rooms with ensuite facilities. There are two passenger lifts accessing the ground floor in the main building. There is a large communal lounge in the main building with a licensed bar at one end and a shop at the other. Service users can purchase goods, for example toiletries, stamps and sweets. The bar and shop are accessible to service users. There is a games room, library and hairdressing salon in the main building all of which are accessible to the service user group. There is ample car parking available. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection for the inspection year 2006 –2007 under Inspecting for Better Lives. The inspection was a ‘key’ inspection and considered all the key standards, which are noted within the report. In addition the inspection report contains a judgement noting whether the home is poor, adequate, good or excellent at meeting the outcome areas. The inspection began at 8.20am and was carried out by two inspectors. During the inspection a number of documents were sampled including care plans, staff personnel files, policies and procedures and health and safety certificates. A number of staff and service users were spoken with. This inspection notes substantial improvements to the service provided following recent regulatory activity as a result of matters referred under the local authority safeguarding adults procedure. The matters in question have mainly been resolved or are close to resolution. What the service does well: What has improved since the last inspection? Significant improvement was found. Care plans were found to be accessible and understandable and members of staff had generally completed the records accurately and clearly. Staff personnel files were in good order and accessible including records of training undertaken by individual members of staff. The CSCI pharmacist carried out a separate inspection on the 19th May 2006 no requirements or recommendations were made during the inspection. This was also viewed by the CSCI as significant improvement. A number of complaints and concerns had been appropriately responded to by the RMBI and the CSCI and social services informed of the outcomes. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 7 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 Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users and their families or representatives are provided with adequate information to assist in making a decision about moving to the home. Improvements are needed to ensure all service users needs are assessed prior to admission into the home and to for service users and their representatives to know that the home can meet the needs of the prospective service user. EVIDENCE: The RMBI’s statement of purpose and service user guide were informative and set out well. A recommendation was made that where the statement of purpose identifies that couples may have two rooms that it be made clear that the rooms might not be next to each other in the first instance. The acting manager informed the CSCI that application forms and contracts are held separately from the care plans for the purposes of confidentiality. The contracts and application forms were not sampled during this inspection. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 9 During the previous inspection (see summary for details) it could not be confirmed that all prospective service users were adequately assessed prior to moving to the home. Pre-admission assessments ensure that the home can be clear about whether they are able to meet the service user’s needs. On the 17th May 2006 it was confirmed that a number of service users had not been assessed prior to moving to the home and that pre-admission information had been backdated for each of those service users. The home provides for service users with dementia and a ground floor accessible unit had been set up for the purpose. The pre-inspection report received from the home confirmed that members of staff had received training regarding dementia. The home does not provide for service users who need intermediate care and Standard 6 does not apply. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Considerable improvement was found during this inspection regarding care planning, the administration of medication and service users views of the service. The home ensures that service users health needs are appropriately met. Further work is required to ensure that service users are treated with respect and their right to privacy is upheld. EVIDENCE: During the previous inspection the CSCI found that care plans were difficult to read, as they were not in good order on the service user files. On the 17th May 2006 improvements were noted and the care plans were found to be accessible and generally clear. The care plans were being transferred to an alternative folder and evidence was provided to show that all the information available had been checked and that any deficits were known and had been documented. These shortfalls in information were in the process of being added to the care plans. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 11 Further work was required to ensure that members of staff recorded all the information under the headings used by the RMBI. For example one care plan noted that a specific service user was unwell and a doctor required. It took a while to confirm that an appointment had been made as the record had been placed under an incorrect heading. Significant improvement had been made with regard to the content of care plan documents, however one entry in particular was noted and discussed with the acting manager and deputy manager as being inappropriate. The managers must continue to remind members of staff to be mindful of the language used when writing on care plans. Requirements were made to ensure that information is recorded using appropriate language and using the correct documentation. During the previous inspection a number of service users had expressed concern that not all members of staff respected their privacy and dignity. The same concerns were not raised during the inspection of the 17th May 2006 although it is acknowledged that only a few service users were spoken with on this occasion. However the CSCI observed that a bedroom door had remained open whilst a member of staff was attending to a service user. The task the member of staff was assisting with could not be directly observed; bedroom doors must remain closed when members of staff are assisting with any personal care. A requirement was made to maintain the privacy and dignity of service users. Two of the care plans sampled evidenced behaviour that may place others at risk. Risk assessments to assist the home in reducing or making clear how members of staff must respond to those risks could not be found. It was required that risk assessments are in place where assessments evidence any behaviour that may be considered a risk to others or to the named service user. The care plans sampled evidenced that the health needs of service users including doctors, dentists, opticians and specialist services were met. The previous inspection had previously found significant deficits with regard to medication. For example there were a high number of signature omissions and over ordering and this corresponded with a high level of returns. Service users were expressing concern that medication was being given late and that not all members of staff understood their concern. Members of staff were completing administration of medication courses and were on occasion having their competency assessed by a person undertaking the same course. This was a concern given that the CSCI considered that competency was considered to be essential in order to safeguard service users. During February of 2006 the CSCI received a copy of the home’s medication audit evidencing that signature omissions had remained a significant issue. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 12 Due to the considerable concerns previously found regarding the receipt, recording, storage, handing and administration of medication as well as the lack of a consistent and coherent training course for members of staff the CSCI pharmacist inspector carried out a separate specialist inspection on the 19th May 2006 to check progress. The pharmacist inspector found considerable improvement across all aspects of the administration of medication and training as follows: 1. Medication is handled and administered by trained and competent staff who work to written procedures, which describe all of the tasks staff may be expected to undertake when handling medication. 2. Service users receive their medication as prescribed for them. 3. Service users are supported to safely look after and take their own medication, where this is appropriate. 4. All medication was stored securely for the protection of service users. 5. An audit of medication usage is kept to monitor usage. The pharmacist inspector made no requirements or recommendations during the inspection of the 19th May 2006. On the 17th May 2006 the CSCI found a number of small medication pots drying on top of radiators in some of the unit kitchens. It could not be confirmed as to the use of these pots. Discussion with staff indicated that there was a lack of clarity regarding the use of the medication pots. A requirement has been made that the administration of medication be reviewed to ensure safe working practices by all staff. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Continued improvement had been made regarding leisure and social activities although further work is required to ensure that service users can maximise their choice and control. The pre-inspection information confirmed that the cultural needs of the service users could be met however further information is required to ensure their religious needs are met appropriately. EVIDENCE: The service users male and female with the majority being female and white British and the staff team are mixed gender and ethnicity. It was not confirmed during the inspection or from the pre-inspection information whether the religious needs of the service users were being met. A requirement has been made to confirm appropriate access to service users religion of choice is available. The home had engaged an activity co-ordinator in late 2005 to assist the home in providing social and leisure activities. On the 17th May 2006 the acting manager informed the CSCI that the co-ordinator had begun working with service users who have dementia. A number of photographs were seen in the unit to confirm the type of activities the co-ordinator and acting manager said were being provided. In discussion with the co-ordinator it was confirmed that new equipment purchases had been made to support activities within the home Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 14 and that service users views are sought. A requirement was made that the coordinator receive training in dementia in order to further assist in understanding the specialist needs of the service user group. A ‘Friends of Shannon Court’ group had been working with the home for some time and application may be made for funding for specific items. In addition a member of the group visits the home on a regular basis and meets with individual service users where wished. The acting manager confirmed that the visiting person had received a satisfactory criminal record bureau check. Family, friends and representatives of the service users are able to visit the home at a time of their choosing and for a small payment can take meals there if they so wish. A meeting specifically for service users of the home could not be confirmed as having taken place. Minutes were seen of a relatives meeting that noted that service users could attend if they wished. The meeting was to discuss the issues facing the home following the concerns and matters referred under the local authority multi-agency procedures. Given the concerns raised by the service users during the previous inspection a meeting for those able to attend may have been useful. In addition the home has a number of service users who are able to voice their views and opinions and a meeting with minutes provided regarding agreed actions would further increase autonomy and choice. A requirement was made that the home seek the views of the service users with regard to holding regular meetings with outcomes documented and recorded through minutes of any meeting/s. The feedback during the previous inspection regarding the provision of food was generally good. The CSCI did not talk to the chef or kitchen staff during that inspection and no requirements were made regarding meals. However on the 17th May 2006 and in discussion with the chef it was found that the kitchen was short of staff and agency or bank members of staff were being used to cover any staffing shortfalls. Service users spoken with expressed the view that the food during the week was of an acceptable standard but that food over the weekend was poor. One service user expressed particular disappointment regarding the Sunday meal. The acting manager was aware of the problem and the matter had been raised with senior managers and the agency providing the staff although the issue remained unresolved. It was required that the matter be raised again given the feedback from service users. The menus were attached to the pre-inspection information and confirmed on the 17th May 2006 as providing a varied and diet. Fresh vegetables and fruit were available for use. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Considerable work had been undertaken to ensure that the homes complaint procedure was being followed. Further work is required to ensure that the multi-agency safeguarding of adults procedure is followed appropriately and that where there are concerns clear risk assessments are in place to safeguard others. EVIDENCE: During the previous inspection it was evident that the home had not been following the RMBI’s complaint and protection of vulnerable adults procedure or Surrey County Council’s multi-agency procedure for the protection of vulnerable adults. A significant number of complaints had not been responded to appropriately and/or no there was no evidence to support that the matters raised had received the attention necessary. A number of complaint records could not be located, where records were available they were inadequate or the CSCI expressed concerns regarding the outcomes. In a number of instances the matters raised by service users should have been referred for consideration under Surrey County Council’s safeguarding adults procedure. In agreement with the local social services, the CSCI and the RMBI a date in 2004 was agreed from which to investigate more thoroughly the concerns raised. The RMBI has investigated all the complaints made and had referred to Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 16 social services for consideration those matters that might be referrals under the multi-agency safeguarding procedure. Those service users involved and their families, where appropriate, had been approached and discussion had taken place regarding outcomes. During the inspection of the 17th May 2006 it was found that considerable progress regarding complaints had been made by the home. A complaints file had been set up and each complaint was held separately. All the information relating to a complaint was being held with the original complaint to enable clarity. Those complaints sampled by the CSCI were found to contain, the original complaint, details of the investigation into the complaint, the outcome and information as to whether the complainant was satisfied with the outcome. As stated in the summary of this report the RMBI had responded in an open and transparent manner to the matters raised and continue to work toward clear outcomes regarding the matters referred to under the safeguarding procedures. The process used to complete the work required by the RMBI was in partnership with Surrey County Council and was considered by the CSCI to have improved joint working relationships and significant improvement was found regarding the awareness and understanding of the protection (now safeguarding) of adults . The acting manager had designated May 2006 as being the month when the RMBI’s protection of vulnerable adults policy was highlighted as the ‘policy of the month’. Members of staff each received a copy of the policy and procedure and were asked to read and sign that they had understood the content. Basic training regarding the protection of vulnerable adults had been provided to members of staff earlier in 2006. However some further work was required as the policy seen by the CSCI on the 17th May 2006 directs staff to an out of hours service. A requirement is made that the policy and procedure is reviewed to ensure it is in line with Surrey County Council’s multi-agency protection of vulnerable adults procedure. During the inspection of the 17th May 2006 it was noted that a recent matter had not been referred to the local authority for consideration under the multiagency safeguarding adults procedure. An immediate requirement was made and the acting manager contacted the local social services during the course of the inspection and confirmed the outcome with the CSCI. A further requirement was made that the local social service office be contacted regarding any allegation that may require referral under the multi-agency procedures. The home or other member of the RMBI staff must not decide the matter without recourse to the local social service office. The RMBI had a policy regarding the use of restraint directing managers to provide a policy relating to the home that they manage directly. A requirement is made to confirm whether the home has a restraint policy in place and if so have the members of staff received appropriate training. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 17 The RMBI had previously confirmed with the CSCI that the whistle blowing policy seen at the home during the investigation inspection had not been replaced with the correct version and that the home now had the appropriate policy and procedure in place. The service users at the home are able to use their right to vote in local and national elections. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well laid out and provides adequate bathing and w.c facilities for service users. Some areas of the home require attention to décor and carpeting to ensure safety and improve presentation. The home was clean and hygiene was found to be adequate. EVIDENCE: During the investigation inspection a significant number of bedrooms were seen and all the communal areas. On the 17th May 2006 a full tour of the home did not take place, all of the communal areas were seen, some bedrooms and part of the grounds. The home is large with spacious and comfortable lounge areas. Window seating had also been provided at appropriate points in the home providing an opportunity for service users to sit quietly and be able to see what is happening in the home. Small dining areas were available in each of the units providing a more family approach to meal times. Some areas required further work to maintain a safe environment. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 19 Those bedrooms seen during both inspections had been personalised and were clean. The communal areas offer service users a wide range of facilities from the library to a number of lounges and quiet corners that could be used to meet with friends and family or to sit quietly if wished. An adequate number of bathrooms and toilets were available for use although towels were left in some of the bathrooms. Towels were left in the bathrooms and this may lead to communal usage and increase the risk of cross infection. A requirement was made to ensure that towels are not left in the bathrooms enabling communal use. A recommendation was regarding the storage of disposable gloves which were observed being left around the premises. The lifts were in good working order and chairs had been placed in specific locations to ensure that service users could access them whilst waiting for the lift to arrive. The seat in one of the lifts was checked and found to be on a very tight spring. This may be hazardous to use and any person pulling the seat down may trap their hand causing injury. It is required that lift seating is checked to ensure safe use. Some areas of the home were showing signs of wear and tear and it was required that a review of all the rooms take place and a plan of re-decoration with reasonable timescales be completed. One of the stair carpets was showing clear signs of wear on the top step; this may create a trip hazard. A requirement is made that the carpet be safely repaired or replaced. Other carpets within the home had tape across areas of wear, this may create a trip hazard and a requirement is made that those carpets affected are safely repaired or replaced. A number of emergency lights were noisy and the CSCI did not confirm if this indicated they were in need of repair or adjustment. A requirement was made that all areas of the home are reviewed with regard to repairs or replacements. The home is set in considerable grounds and the area around the home was well laid out. There was a separate garden for use by the service users resident in the dementia unit. Bright objects and objects that moved with the wind had been provided and the garden had been made safe and did not offer access to the wider parts of the grounds. The remaining garden although pleasant in appearance with grass and plants would not offer safe access to service users with a mobility problem unless they were accompanied by another person. It was required that the garden is risk assessed and consideration be given to the provision of hand rails or other options to enable more service users to use the grounds unaccompanied. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 20 Items for use by service users and staff were found around the home. For example batteries from hoists etc were being charged and some of these were on the floor or had been hung around handrails. It is required that this procedure be risk assessed in order to ensure that handrails can be used safely and any item on the floor does not present a trip hazard. The top floor is not available for use by service users however the area was found to be accessible and an unlocked cupboard containing hazardous items such as paint was found. It was required that access to the top floor be risk assessed to ensure that any risk identified receive appropriate attention and that consideration be given to preventing access by service users. All hazardous substances must be securely and safely stored. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work is required to ensure that staffing levels are able to consistently meet the assessed needs of the service users, that qualifying training meets the expected levels and that the recruitment policy and procedure is followed by the management of the home. EVIDENCE: The staffing rotas provided by the home in the pre-inspection report evidence the staffing levels provided by the home through the week. Based on the information provided the weekend staffing levels are a little lower than that evident during the week. The investigation inspection highlighted issues regarding staffing matters and the RMBI had taken action to resolve those issues. The CSCI were unable to confirm that staffing levels were adequate to consistently meet the assessed needs of the service users. The requirement made from the inspection of the 17th May 2006 is with regard to the staffing levels recorded over the weekends; the requirement being that; the RMBI confirm that they consider the current staffing levels to be able to meet the assessed needs of the service users throughout the week. The pre-inspection report recorded that of the forty two (42) care staff eleven (11) were qualified to National Vocational Qualification (NVQ) Level 2 or above. A total of 24 of the care staff workforce. The same document noted that a further seven (7) care staff were expected to commence NVQ level 2, one to undertake NVQ Level 3 and two (2) to commence the NVQ Assessors Award. The NVQ qualifying training planned does not bring the home to the expected Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 22 50 of the workforce to be qualified to Level 2 or above by 2005. A requirement is made that the RMBI confirm how they intend to ensure that 50 of the workforce be qualified within a reasonable timescale. The home follows the RMBI recruitment procedure including application for satisfactory Criminal Record Bureau (CRB) checks. Those staff files sampled during the inspection of the 17th May evidenced that a PoVA first check had also been applied for in all but one instance. A requirement is made for the RMBI to confirm that all members of staff had received a satisfactory PoVA check prior to starting work at the home. During the previous inspection it was found that not all the guidelines provided by the Criminal Record Bureau had been followed in that the home had kept the original disclosures and some of the information required to be held centrally had not been recorded. The requirement to review the CRB guidelines had been met at the time of this inspection. During the previous inspection significant concerns had been raised regarding the state of the staff personnel files and the disciplinary procedures being followed by the home. Improvements had been made. The inspection of the 17th May 2006 found significant improvement. Staff personnel files had been re-organised and information was generally provided in an organised manner. Only one file sampled had not been fully dealt with. A concern has been raised with the RMBI under separate cover regarding one matter found during the course of the inspection. The RMBI had taken action following the multi-agency investigation to ensure that any outstanding matters relating to members of staff had been dealt with and the CSCI and social service informed of the outcomes. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement was found however further work is required to ensure that service users best interests remain paramount. A registered manager is not in place providing uncertainty to service users regarding the future management and ethos of the home. Quality assurance and financial procedures required further information to ensure that the service users financial safety were met and their views on the running of the home were listened to and acted upon. Staff supervision was not in place and affect the ability of members of staff to improve their awareness of the overall management and administration of the home. The review of the regulation 26 reports (see below) is an improvement and will assist in safeguarding service users. EVIDENCE: Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 24 The home had been through a number of management changes in the last nine (9) months and the acting manager who was present during the inspection of the 17th May 2006 was due to leave the same week as the inspection. The CSCI had not been made aware of how the RMBI intended to ensure that the home had clear sound management leadership from the 19th May 2006 onwards. The CSCI consider it essential that a manager is in place that can make certain that the work that has taken place to date and the further required work is completed to ensure the home can provide safely for the assessed needs of the service users. This matter has been raised separately from this inspection report with the RMBI. The pre-inspection report recorded that all service users maintain their own finances. A requirement was made that the RMBI confirm how those with dementia are assisted regarding their personal finances in order to safeguard their monies. During the previous inspection it was found that supervision and appraisal documents had not consistently addressed issues raised or clearly indicated if training stated as being required had been provided. On the 17th May 2006 the CSCI were informed that supervision sessions had started again. A requirement is made that the RMBI confirm that supervision and appraisal procedures have been reviewed to ensure that the documents clearly evidence members of staff progress and where concerns have been raised regarding performance. A further requirement was made for the RMBI to confirm that each member of staff will receive a minimum of six supervision sessions per year. A number of the policies and procedures viewed had not been reviewed since 2004. A requirement was made that the CSCI be informed of the reviewing process and when the RMBI expect to have completed their next review. The pre-inspection report documented when health and safety checks including the gas safety, fire drills, incidents and accidents, legionella testing etc had been completed. The information provided in the pre-inspection report was confirmed through evidence provided during the inspection of the 17th May 2006. As noted previously in this report it was a concern to find that no action had been taken with regard to a safeguarding adults matter. It is essential that the RMBI ensure that all members of staff are fully aware of the action required following any allegation which may require a referral under the local authority multi-agency procedures. The investigation inspection carried out by the CSCI in December 2005 and January 2006 required that the RMBI review action taken by the organisation following receipt of Regulation 26 reports. By the time of this inspection the Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 25 RMBI had completed an internal review to ensure that any further issues raised through Regulation 26 reports are dealt with promptly. A Regulation 26 report is completed by those organisations that own or are responsible for more than one care home and/or care home with nursing. The reports enable organisations to carry out an internal review of the services provided including the quality of that service. During 2005 a number of Regulation 26 reports completed by the RMBI identified problems within the home however the actions taken to resolve the matters raised were unclear. A further requirement was made that the RMBI forward a copy of the outcome of the investigation into this matter to the CSCI. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 3 3 Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1) (a-d)(2) Requirement The registered person must confirm to the CSCI that appropriately qualified members of staff will assesses all service users admitted to the home in the future, prior to admission. The registered person must ensure that a risk assessment is completed where risk to the service users or others have been identified. The registered person must ensure that the bedroom doors of service users remain closed to promote privacy whilst members of staff provide assistance with personal care. The registered person must ensure that the use of inappropriate language by members of staff in documents and records kept by the home ceases. The registered person must ensure that appropriate training is provided to members of staff providing activities. The registered person must confirm to the CSCI in writing DS0000017643.V295728.R01.S.doc Timescale for action 02/06/06 2 OP7 13(4)(c) 02/06/06 3 OP10 12(4)(a) 31/05/06 4 OP10 12(4)(a) 31/05/06 5 OP12 12(4) 14/06/06 6 OP12 16(3) 24/06/06 Shannon Court Version 5.2 Page 28 7 OP14 12(2) 8 9 OP15 OP18 16(2)(i) 13(6) 10 OP18 13(6)(7) 11 12 OP19 OP19 13(4)(c), 23(2)(b) 23(2)(b) 13 OP19 13(4)(a) (c) 14 15 16 OP19 OP19 OP27 13(4)(a) 13(4)(a) 18(1)(a) how the religious needs of the service users are met. The registered person must review the option of enabling service users meetings to take place on a regular basis. The registered person must review the weekend provision for meals to ensure their quality. The registered person must review and update the organisations policy and procedure for the safeguarding of adults and ensure it is in line with the local multi-agency protection of vulnerable adult procedures. Timescale of 28th February 2006 not met. The registered person must inform the CSCI if there is a local restraint policy and if so has appropriate training be provided to members of staff. The registered person must safely repair or replace those carpets showing signs of wear. The registered person must review those areas of the home requiring repair and make good where required. The registered person must review and risk assesses the leaving of and charging of batteries in the communal areas of the home. The registered person must risk assess the accessibility of the top floor by service users. The registered person must risk assess the garden to ensure safe access for service users. The registered person must review the staffing levels and submit written proposals to the CSCI regarding how they intend to ensure adequate numbers of staff are on duty across the DS0000017643.V295728.R01.S.doc 02/06/06 02/06/06 14/06/06 14/06/06 30/06/06 30/06/06 14/06/06 14/06/06 14/06/06 14/06/06 Shannon Court Version 5.2 Page 29 17 OP28 18(1)© 18 OP29 19(9) 19 OP31 8 20 OP31 9 21 OP33 24 22 OP33 24 23 OP35 17(2) Schedule 4(9) 18(2)a 24 OP36 twenty four hour period. The registered person must inform the CSCI of how they intend to meet the 50 of staff trained to NVQ Level 2 by 2005. The registered person must confirm to the CSCI that all members of staff are in receipt of a satisfactory PoVA check prior to commencing work. The registered person must ensure that an application for registration of a manager is made. The registered person must confirm to the CSCI the arrangements for the ongoing management of the service. The registered person must provide a copy of the last quality assurance audit carried out regarding this care home. The registered must forward a copy of the outcome on the investigation and review of monthly reports and visits required under Regulation 26 of The Care Homes regulations 2001. The registered person must confirm how the finances of those service users with dementia are managed and safeguarded. The Registered Person must ensure that care staff receives formal supervision at least 6 times a year. Previous timescale of 28/02/06 not met. The registered person must ensure that all substances hazardous to health are safely and securely stored. 14/06/06 14/06/06 24/06/06 14/06/06 14/06/06 14/06/06 14/06/06 14/06/06 25 OP38 13(4) 14/06/06 Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 30 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 OP3 OP19 Good Practice Recommendations It is recommended that the statement of purpose clarifies the accommodation that may be available to couples on admission. It is recommended that the leaving of disposable gloves around the premises be reviewed. Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 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 Shannon Court DS0000017643.V295728.R01.S.doc Version 5.2 Page 32 - 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. 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