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Inspection on 20/02/07 for Shannon Court

Also see our care home review for Shannon Court for more information

This inspection was carried out on 20th February 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is well managed leaving staff feeling supported and confident in their role, which is reflected in care delivery. A number of areas of good practice were noticed including the promotion of equality and diversity with the manager demonstrating an understanding of the needs of disabled people. There was evidence in record keeping that care practices are monitored in the home. Issues being brought to the managers attention by residents and relatives had been addressed, an example being menu planning. Staffing levels, training and supervision ensured outcomes were positive for residents. A resident newsletter is produced that states forthcoming activities and trips out. One resident said, " I really enjoyed our recent trip to Botany Bay." A qualified therapist provides massage and reflexology for residents. In addition to this an activity co-ordinator enables residents to participate in activities to the level of their capabilities. Records of activities are maintained with photographs of participating residents to aid memory function. The newsletter also contains poetry from residents and forthcoming birthdays residents and relative`s views on quality assessments are also included. A person centred approach to care planning has been implemented with resident stating how they want their care to be delivered. Comments made by residents included "I feel safe here," "All staff are very kind" and "Staff respect me".

What has improved since the last inspection?

The home has employed administrative staff, which allows care and management staff more time to spend with residents. Staff training had increased with 75% of staff now having achieved NVQ2 or equivalent. Improvements have been made to the environment. Some carpets in the down stairs lounge and dining room had been replaced from patterned to plain to benefit those residents with dementia who may experience visual problems. Several rooms have been upgraded to ensuite with only seven bedrooms in the home not having ensuite facilities at the time of this inspection. A new lift has recently been installed and sitting weighing scales have been purchased for those residents who cannot weight bear.

What the care home could do better:

Although the quality outcome for Shannon Court is good a number of inconsistencies were noted which must be addressed to ensure outcomes for residents remain positive. Assessments of residents need to be written in more depth and provide detailed explanations to care staff on the tasks they are to carry out. Filing systems need to be reviewed to ensure an adequate audit trail can be maintained. This was especially so in relation to care planning and staff recruitment procedures where inconsistencies had occurred in recording. Information to prospective residents and relatives is given in a brochure format with the complaints procedure being attattched. Both these documents required upgrading to provide appropriate information on which to base an informed choice. The home had made good progress in reviewing and developing their medication policies and procedures. However, this still requires expansion in relation to self-administration and risk assessments. Improvements to the environment had been made but more needs to be done to ensure an appropriate environment for residents who suffer from dementia.

CARE HOMES FOR OLDER PEOPLE Shannon Court 112 Radcliffe Road Bolton Lancashire BL2 1NY Lead Inspector Sandra Buckley Unannounced Inspection 20th February 2007 09:30 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 DS0000005699.V308228.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 DS0000005699.V308228.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shannon Court Address 112 Radcliffe Road Bolton Lancashire BL2 1NY 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) 01204 396641 01204 384412 Mrs Christine Flood Mrs Julie Morrison Care Home 59 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (42), Mental disorder, excluding learning of places disability or dementia (1), Old age, not falling within any other category (14) Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered number 59, there can be up to : 14 (OP) Older People, 42 (DE(E) Adults with Dementia over 65 years, 2 (DE) Adults with Dementia, 1 (MD) Adults with Mental Disorder The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 25th February 2006 Date of last inspection Brief Description of the Service: Shannon Court is a privately owned care home providing personal and nursing care for up to 59 older people, many of whom have dementia related care needs. The home is situated close to Bolton town centre, off the main Bolton to Bury road. It is within easy reach of bus routes and shops. Accommodation is on three floors with lift access. All bedrooms are single, many with en-suite facilities. The home does not have a garden, but there is a pleasant enclosed patio with garden furniture that is well used in fine weather. Fees range from £345.04 - £509.29 Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection, which included an unannounced visit to the home, took place by one inspector on the 20th February 2007. Time was spent talking to residents individually and in groups. Four staff, one relative and the manager were also spoken to. The inspector took a random tour of the building and looked at a selection of residents and staff records as well as other documentation including duty rotas, medication records and staff recruitment. Questionnaires were sent to resident’s relatives and GP’s. A total of fifteen were returned. All stated they were satisfied with the care in the home. Three said that on some occasions they felt there was insufficient staff on duty. Some of the comments made by residents were, “ I know who to speak to when I am not happy,” “The care here is great” and “I couldn’t be in a better home.” What the service does well: What has improved since the last inspection? Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 6 The home has employed administrative staff, which allows care and management staff more time to spend with residents. Staff training had increased with 75 of staff now having achieved NVQ2 or equivalent. Improvements have been made to the environment. Some carpets in the down stairs lounge and dining room had been replaced from patterned to plain to benefit those residents with dementia who may experience visual problems. Several rooms have been upgraded to ensuite with only seven bedrooms in the home not having ensuite facilities at the time of this inspection. A new lift has recently been installed and sitting weighing scales have been purchased for those residents who cannot weight bear. 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. The summary of this inspection report can be made available in other formats on request. Shannon Court DS0000005699.V308228.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 DS0000005699.V308228.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their families are given information on services the home offers prior to admission, providing an informed choice. The lack of detailed assessments in some instances may pose a risk to residents. EVIDENCE: Information is available to residents in a brochure format. The home needs to keep this under review to ensure it is updated and reflects information on what Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 9 the service offers. To compliment this a detailed statement of purpose is available in the reception. One relative said, “I was given information on the home but had chosen it on its good reputation in the community.” Each resident has an assessment of need completed prior to going in the home. Examination of four case files found that in two instances there was insufficient information obtained making a detailed care plan difficult to complete. Outcomes for residents were not affected on this occasion. However, inconsistencies remain and these issues need to be addressed. Shannon Court DS0000005699.V308228.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. In order to complement the holistic approach used by the home a full explanation of residents care needs in line with their assessments is needed to ensure outcomes for residents remain positive. Medication policies, procedures and the recording of medication need to be reviewed to ensure the protection off residents. Communication systems and staff training in maintaining privacy ensures the needs of residents are met. EVIDENCE: Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 11 The manager said the home has been reviewing assessment and care planning to provide a person centred, holistic approach to individuals. Examination of case files found care planning was approached by looking at the resident’s previous lifestyle and social history. These also stated how the resident wanted their personal care to be delivered. The inspector found these documents gave a clearer understanding of the residents as individuals. Unfortunately the lack of detailed assessments in two instances means that care planning may not have been adequate. Examination of two other case files found the assessed needs of residents had not been transferred fully into care planning. These lacked a description relating to the presenting problems. An example of this was a person with epilepsy’s care plan that should state what form this takes and what staff action should be taken on how to deal with the situation. The compilation of notes was not streamlined and required some organisation. The manager reported that the above issues had been noted and that the home was taking steps to address this matter. Staff at interview had a clear understanding of residents needs and maintaining privacy and dignity. Specified tasks are allocated daily at change of shifts together with an update on residents care needs. The manager produced written evidence of staff meetings, which encouraged care staff to access; care planning documents to gain a better understanding of residents needs. Care staff said that nursing staff always kept them aware of any changes in care delivery. One resident said “Staff look after us very well,” with another saying “All staff are very kind,” and “Staff are always available when I need them.” Fourteen questionnaires were retuned to the Commission for Social Care Inspection from professionals; residents and relatives all stated they were satisfied with the care and treatment at Shannon Court. There was evidence on case files that residents received support from health care professionals. These included physiotherapy, rehabilitation team, cognitive treatment and district nurses for those in the home funded for residential care. No residents had pressure sores at the time of this inspection. There was evidence that should a problem be identified residents have access to a tissue viability nurse and preventive equipment i.e. special mattresses. Sitting weighing scales had been purchased to ensure residents who cannot weight bear are monitored. Nutritional screening is undertaken on admission to the home. One nurse in the home had undertaken training in end of life care. The manager reported that their skills would be transferred to the benefit of other staff and residents. Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 12 Staff gave examples at interview on how to maintain resident’s privacy and dignity especially when receiving personal care. One resident said, “ Staff are always respectful to me” with another saying “The care is great here.” Accidents are recorded in full with the manager undertaking an analysis. The manager said that it had been identified a number of accidents were happening late evening and during the night. Action had been taken to purchase pressure mats and other equipment which had resulted in a reduction in accidents in the home. The home had made good progress towards meeting a recommendation made on the previous inspection relating to medication policies and procedures. However, these still require expansion to include a risk assessment and the procedure for self-medication and application of creams. Photographs of residents should also be in place to ensure identification. Medication was stored securely. Examination of the recording of medication found two omissions with no explanation why. The home should ensure that reasons for the omission of medication are recorded in full. Shannon Court DS0000005699.V308228.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A holistic approach to residents needs ensured that their emotional and physical needs were met. EVIDENCE: The home employs an activities co-ordinator and a member of staff who is trained in therapeutic, holistic treatments. These include hand or body massage, reflexology and Indian head massage. On the days when massage takes place the therapist wears a different coloured uniform. Staff said they were surprised and pleased that even residents with severe memory impairment recognised this change in colour and tried to communicate none verbally what their wishes were. Each resident has a therapy file and activity file which say what the resident has been involved in throughout out the day. Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 14 Many activities and trips out are photographed and then placed in the residents file to aid their memory. Residents spoke about their experiences one said “Massage is very nice what more could I want” and “ I really enjoyed our trip to Botany Bay.” The manager confirmed that a local church calls and offers communion for those residents wishing to take part. Residents who are able are encouraged to go home for weekends if within their capabilities. Residents talked about their daily life in the home saying, “I go to bed and get up when I want,” “ I feel safe here,” and “The food is quite good.” One resident talked about how good the Christmas activities were in the home. Observations throughout the day showed some residents helping with light domestic duties. Staff said this related to the residents past work experience demonstrating their knowledge of the good social histories of residents on file. At the time of this inspection a small sensory room was available for relaxation purposes. The manager said that the cellar of the home was presently being converted to provide a therapeutic room. A larger screen television had been purchased to enable better viewing for residents. The inspector sampled food served on the day of inspection, which was well presented and tasty. Interviews with the cook demonstrated their knowledge of resident’s preferences, likes and dislikes. A four weekly menu is used on rotation. The day of this inspection was Shrove Tuesday with pancakes being served for sweet. Residents spoke about how good the food was and they could have an alternative at lunch if the wished. An alternative to the teatime meal is reflected on the menu in the dining room. One resident said, “Night staff always bring our supper which is toast, cake, sandwiches or biscuits, although I have really missed my toast because the toaster is broke.” This was discussed with the manager who had already purchased a toaster and was awaiting an electrician to undertake a safety test. At interview the activities co-ordinator said she consulted with residents on a daily basis on their food preferences and choices of menu. During the afternoon fruit and finger foods are provided for snacks or for those residents who find sitting for long periods difficult. The dining room was bright and pleasant with two sittings for lunch enabling staff to provide assistance to residents who required this. Observations throughout the day found staff helped residents in a sensitive discreet manner. Staff were aware not to over stimulate the environment, which was relaxed and quite over the lunch time period. On this inspection no residents required special cultural diets. The manager gave examples of how this had been provided in the past with a gentleman of Afro Caribbean origin being provided with an individual menu and a gentleman form the Ukraine being encouraged to participate in cultural celebrations within their own community. Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 15 The home produces a newsletter, which states forthcoming activities any quality assurance undertaken and a list of resident’s birthdays. Residents may contribute to this adding their comments on developments in the home or favourite poetry. All residents were well groomed saying the hairdresser visits on a regular basis. Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents felt comfortable in raising any concerns. However, the complaints procedure needs to be reviewed to ensure residents entering the home are aware of the process. Staff training and induction ensure residents are protected from abuse. EVIDENCE: The manager reported that should a complaint be made it would be recorded. No complaints had been to the home or CSCI since the last inspection. All fourteen of the questionnaires returned to CSCI stated they knew who to complain to if they were not happy with the care provided by the home. Examination of the complaints policy found it did not reflect times scales for action. This document is given to perspective residents at the time of their admission and requires upgrading to ensure residents are aware of the process used. At interview residents said “I know who to speak to if I am not happy” and “ I would always complain to the person in charge” Protection of vulnerable adults training is included in staff inductions, NVQ training and is also through Bolton Social Services Department. Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 17 Staff at interview were able to give examples of how abuse may present and there role in reporting any such incident. One case of suspected abuse had been reported to CSCI and all other services involved. The CSCI was satisfied that the home had handled the investigation appropriately and followed procedures. Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,26. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have the benefit of a well-equipped, clean and safe environment, which is constantly reviewed and upgraded in line with their needs. EVIDENCE: The home employs a handy man 40 hours a week to keep a good standard of repair in the home. A new lift has been installed since the last inspection with the home continuing their programme of refurbishment. Several patterned carpets have been replaced in the lounge and dining areas to provide a more conducive atmosphere for those residents who suffer from dementia. However more needs to be done to the environment in relation to clear signage, utilising pictures and symbols as well as words. Different rooms Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 19 and areas should look different. Individual space should be personalised, especially to aid residents in recognising their personal bedrooms. Key areas should be easier to find, for example, toilets and bathrooms. Colour and design should be used to draw attention away from no go areas. Stimulation for residents should provide things to see and touch and be ready available. The manager expressed an awareness of things to be achieved and agreed that the process had started giving the example of person centred planning and replacement carpets. A number of ensuite rooms had been provided, with the home having all but seven rooms with ensuite facilities. Hospital beds making care delivery safer for staff and residents had replaced thirty beds. An additional seven air mattresses had also been provided. During the tour of the premises a number of bedrooms were randomly selected for inspection. These were found to be clean tidy and free from odour. All rooms had a homely appearance with some residents choosing to bring in personal possessions. Although there is no garden space a safe patio area provides pleasant seating for residents or those who wish to go for a walk outside. The environment is fitted with appropriate equipment to aid resident’s independence i.e. grab rails. Residents interviewed said “ I like to spend time in my room and listen to music it is very comfortable.” Another said, “I like my room and have my own things but I prefer to be with people.” Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff training, skills, numbers and gender mix ensure that residents needs are met. The lack of detailed recruitment procedures may pose a risk to residents. EVIDENCE: Standard 27 was deemed met by information provided by the manager, which stated that 74 of staff now holds NVQ2 or above. A trained therapist in massage and reflexology and activity co-ordinator provide additional stimulation and activities for residents. Resident’s needs are met through the numbers, skill and gender mix of the staff team. Of the 14 questionnaires returned to the CSCI only 3 stated that at times there appeared not to be many staff around. Three of the residents interviewed said, “Staff are always around when I need them,” and others said, “Staff are very kind.” Staff receive an initial induction into the home and maintaining the privacy and dignity of residents. This is followed by a more in-depth induction in line with Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 21 Skills For Care. A newly employed staff member confirmed they had been given additional literature to read and complete over a period of time. During staff interviews they confirmed they had received training in moving and handling, protection of vulnerable adults, food hygiene, first aid and dementia care. Examination of recruitment procedures in the home found inconsistencies in recording and obtaining appropriate checks on staff before commencement of employment. For example, in some instances dates were not recorded on application forms and references. One application had two references from the same referee and, in this instance, an additional character reference should have been obtained. Start dates of employment were not recorded making it difficult to assess if a criminal record bureau check had been completed prior to employment. One POVA first check did not have an application date. The inspector acknowledges that the home is not responsible for this aspect. However, it is the duty of the manager to ensure that checks are dated and in place before employment. The maintenance of staff files needs to be reviewed to ensure a clear audit trail. The manager reported that they had started to review the system and was able to show a sample copy that had been completed. Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effective communication and quality monitoring systems ensures that issues are addressed and dealt with resulting in positive outcomes for residents and their families. Recording and filing systems in the home need to be reviewed to ensure inconsistencies do not occur and resident’s positive outcomes are maintained. EVIDENCE: Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 23 The homes manager is a qualified RGN who holds the registered managers award. They maintain their professional development by attending short courses in line with residents needs i.e. dementia. The deputy manager is also nurse trained and has completed the registered managers award. They have recently completed a course to become a moving and handling trainer, benefiting new staff employed at the home. Discussions indicated that the manager understood the needs of disabled people and had awareness that they were sometimes subjected to unfair treatment, which needed to be challenged. The management style is open and relaxed with systems in place to ensure poor practice is addressed. An example of this is regular staff meetings, which were recorded showing staff had been reminded that residents care plans and daily notes must have more detail on care delivery. Staff at interview said they felt supported by the management team and could talk to them about any issues saying “The manger is always about the home and is very approachable.” Staff felt confident in their role, which was reflected in care delivery. Staff confirmed they received regular supervision and yearly appraisals. Relatives and residents meetings are held and recorded. There was evidence that issues brought forward had been addressed. Examples of these were menu changes and the wishes of relatives to be more informed of the affects and progression of dementia on residents in long term care. The manager reported that the home was trying to correlate information regarding the progress of dementia and the needs of the residents into a booklet for relatives in order to raise their awareness. At interview residents said, “The food is good here,” and “ Staff come round and ask us what we want for meals.” Records and monies held on behalf of residents were correct with receipts being retained for proof of purchase. The owners of the home carry out regular visits to assess the management and care delivery is being maintained to a good standard. A sample of records completed on these visits demonstrated that residents and relatives had been interviewed for their views on care delivery. The manager said these visits also gave them the opportunity to bring up any issues using the example of the home needing sitting weighing scales. At the time of the inspection these had been provided. Professionals undertake health and safety checks on equipment in the home. All staff having received training in health and safety, fire, moving and handling and fire prevention. Water temperatures are checked regular and recorded. Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 24 Throughout the inspection minor inconsistencies in recording and filing systems were noted especially in relation to care planning and staff recruitment that need to be addressed in order to maintain the positive outcomes for residents the home now provides. The manager reported the home has just completed an assessment for the Investors in People award. Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 3 Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 Good Practice Recommendations The registered person should keep under review the service user guide, which is presented in a brochure format ensuring it meets the National Minimum Standards. The registered person should ensure that assessments of residents are completed in full and in line with the National Minimum Standards. Assessments should be maintained in a uniform standard to ensure an audit trail. The registered person should ensure that the good practice of person centred planning is expanded to give staff a detailed explanation of how health issues relating to residents presents. This should also be linked to the assessed needs of residents. The registered person should ensure that the good progress made in the expansion of the homes policies and DS0000005699.V308228.R01.S.doc Version 5.2 Page 27 OP3 OP37 3 OP7 OP37 4 OP9 OP37 Shannon Court 5 6 OP16 OP22 procedures on medication continues to reflect the risk assessment and procedure for residents who self medicate. Ensuring that any administration or refusal of medication is recorded in full. The registered person should ensure that the complaints procedure is reviewed to reflect timescales for action. The registered person should continue with improvements to the environment especially in relation to those residents who suffer from dementia. More needs to be done to the environment in relation to clear signage, utilising pictures and symbols as well as words. Different rooms and areas should look different. Individual space should be personalised, especially to aid residents in recognising their personal bedrooms. Key areas should be easier to find, for example, toilets and bathrooms. Colour and design should be used to draw attention away from no go areas. Stimulation for residents should provide things to see and touch and be ready available. The registered person should ensure that dates of employment and references obtained are recorded. References should be from two separate individuals with one being the last employer allowing a clear audit trail to be maintained. 7 OP29 OP37 Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Shannon Court DS0000005699.V308228.R01.S.doc Version 5.2 Page 29 - 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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