Inspection on 25/02/06 for Shannon Court

This inspection was carried out on 25th February 2006.

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.

Other inspections for this house

Shannon Court 20/02/07

Shannon Court 23/06/05

Shannon Court 25/01/05

Shannon Court 21/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Chirnside House

Rosehill Residential Home

Ruskin Lodge

Ruskin Lodge

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

CARE HOMES FOR OLDER PEOPLE Shannon Court 112 Radcliffe Road Bolton Lancashire BL2 1NY Lead Inspector Rukhsana Yates Unannounced Inspection 25th February 2006 10:30 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.V284262.R01.S.doc Version 5.1 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.V284262.R01.S.doc Version 5.1 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 (1), Dementia - over 65 years of age registration, with number (43), Old age, not falling within any other of places category (15) Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered number 59, there can be up to : 15 (OP) Older People, 43 (DE(E) Adults with Dementia over 65 years, 1 (DE) Adults with Dementia . The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 23rd June 2005 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. Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced weekend visit and carried out over the course of a day. Most of the day involved talking with residents, staff members, the deputy manager and visitors, and watching the way in which staff talked with residents and helped them with personal care. The remaining time was spent looking around the home and some bedrooms, and reading care plans, and other paperwork relating to the care and safety of residents. The key standards not covered at this inspection were assessed at the last inspection in June 2005. What the service does well: What has improved since the last inspection? What they could do better: The home needs to have a written plan that shows residents and their relatives how their views affect the way improvements are planned and made. Fire safety checks need to be improved. Advice was given about making changes to the induction process for new staff. Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 6 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 DS0000005699.V284262.R01.S.doc Version 5.1 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.V284262.R01.S.doc Version 5.1 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): 3 Each person considering moving to Shannon Court has their needs assessed before admission. The admission process ensures that new residents, or their relatives, know what to expect of the service from the outset. EVIDENCE: Records and discussions confirmed that the manager or deputy manager visits prospective residents, in their own home or in hospital, to assess whether the home can meet their needs. Care files contained community care assessment documentation from the referring social worker for those funded by the social services department. Care plans were developed from the initial assessment. For residents with dementia related needs, mental health assessments had been carried out by health professionals and consultants involved. The file of a resident admitted recently contained detailed risk assessments and a wideranging neuro-psychiatric assessment. Daily reports showed that observations are being recorded during the settling in period, from which the care plan will be devised over the coming weeks. Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 9 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 and 10 The home has worked well to improve care plans, resulting in good information about the personal, health and social care needs of residents. Staff have a good understanding of the principles of privacy and dignity and apply them in practice for the benefit of residents. EVIDENCE: Managers and staff have worked hard to improve care plans in line with recommendations made at the last inspection. A person-centred approach has been introduced, resulting in a shift from general nursing interventions to better information about each person and ways in which staff should provide good care, particularly in relation to people with dementia. Areas covered by the new format include expression, safety, medication, washing and dressing, routines, communication and emotional support. The process of updating and improving information has involved staff at all levels, including the activities organisers, and relatives of residents. In discussions, it was apparent that staff felt positive about the changes to care plans and said that the insights they gained in the process have changed their thinking and approach to care delivery. Staff members also demonstrated a very good knowledge of Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 10 residents’ needs and a sensitive approach to difficult behaviours. Records showed that each area of the care plan and risk assessments has been evaluated each month. Health care needs are well met, with referrals made to health professionals, such as dieticians, GPs or consultants as necessary. Nutritional assessments were in place and intake charts maintained for people at risk of poor intake. Observations made during the course of the inspection confirmed that residents are treated with respect and their rights to privacy and dignity upheld. These principles and how they should be applied in practice are covered during induction training and monitored by managers using direct observation. Staff are being coached, through appraisals, on how to respond to presenting behaviours and developing effective therapeutic interventions. Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 11 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 and 14 The home is making very good progress in gathering information about individual interests and developing resources to improve personal and therapeutic outcomes for residents. Open visiting arrangements help residents to maintain contact with friends and family as they wish. Residents are encouraged to exercise choice in their daily routines. EVIDENCE: The home continues to look at ways to improve activity provision for residents. There are two full time activity organisers in addition to therapy staff. They have been spending time with residents to gather information about their personal histories and interests. The activity organisers have attended a 3 day course, ‘Dementia Care and Activities’, which they found useful and are keen to try new ideas with residents and purchase further resources and games. The home has a relaxation / sensory room, and a therapy room that is suitably equipped and decorated for residents to enjoy body and Indian head massage, with staff qualified in using these techniques. The therapist is now trained in reiki, reflexology and hot stone therapy. The activity organisers are to train in aromatherapy and beauty therapies. In addition, a new therapy and activities room is being built, and there are plans to extend some of these activities to evenings and weekends when visitors are able to see the developments and Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 12 benefits to residents. The effects of these inputs should be recorded for each resident and will be explored at the next inspection. In terms of daily routines, it was apparent that rising and mealtimes are flexible, and staff promote individual choice wherever possible. At the last inspection, it was suggested that the home uses photographs or other formats to enable residents to exercise choice at mealtimes. The deputy manager stated that this is still to be progressed. The home has open visiting arrangements, and relatives consulted described a welcoming atmosphere and well informed staff who keep them abreast of any issues affecting their relative. Trips out and use of community facilities has been limited over the winter months, and this aspect will therefore be assessed in more detail during the next inspection. Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 13 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 and 18 Residents and their relatives are encouraged to air their views, and the home responds to complaints thoroughly to ensure satisfactory outcomes. Written guidelines and staff training help to ensure the protection of residents. EVIDENCE: The home has a clear complaints procedure that is included in the service users’ guide. In discussions with visitors, it was apparent that they had confidence in the management in terms of dealing with any issues or concerns they may raise. The evidence from complaints processed shows that they are thoroughly investigated, that records kept by the home accurately inform the findings, and that the manager seeks to maintain a high standard by responding promptly to areas for improvement highlighted by residents, relatives or the CSCI. Where residents were unable to exercise their rights directly due to mental health needs, advocacy arrangements were accessed, ranging from consultation with relatives and social workers, to the use of independent advocacy services. The home has the local authority guidelines about the protection of vulnerable adults. Staff have a good understanding of the home’s adult protection and whistle-blowing procedures and confirmed that they have attended training covering these topics. The process for recruiting staff includes the required background checks to ensure residents’ welfare is protected. Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 14 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 and 26 Shannon Court provides a clean, comfortable, well-maintained environment for residents. The home recognises that people who have dementia benefit from plain colour schemes to promote their mental health and has taken account of this when redecorating and refurbishing the living environment. EVIDENCE: An ongoing programme of redecoration and refurbishment continues to be implemented. At the last inspection it was highlighted that some areas had heavily patterned wallpaper and carpets, and that these could increase the feelings of confusion and disorientation experienced by residents with dementia. Plain colour schemes and carpets are now in evidence as part of the ongoing programme of redecoration and refurbishment. All bedrooms are single. The home has a good choice of communal areas including lounges, conservatories, dining rooms and a “quiet room”. Although there is no garden, the enclosed patio has seating and plants to create a pleasant area enjoyed by residents and their visitors in fine weather. There was evidence if disability equipment provided to meet individual assessed Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 15 needs. Facilities include an assistance call system, portable hoists, pressure relieving equipment and assisted baths and showers. Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 16 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): 28, 29 and 30 The staff group has the knowledge, skills, training and management support it needs to effectively meet the care needs of residents, and low turnover provides good continuity of care. The recruitment process ensures that the staff employed are suitable, and the welfare of residents protected. The induction process for new staff could be improved. EVIDENCE: Residents and visitors consulted during the inspection spoke highly of the managers and staff and expressed confidence in their ability to provide a good quality of care. Staff files show that the manager carries out all the necessary checks before employing a new staff member. The deputy was advised to ensure that references are signed by the referee. Once employed, staff undertake an induction period and receive further training and the support they need to carry out their role. Records showed that new staff need to gradually work through a phased induction and the managers were advised to obtain the new Skills for Care induction standards and use them for new staff. In addition to NVQ training, staff at the home are motivated to develop themselves and their practice, and have attended training related to dementia care. Training records are well maintained. The home has a high proportion of staff, at all levels, with NVQ qualifications. These currently stand at 21 (out of 35) care staff, 3 domestics, 1 kitchen staff, 2 activities organisers and 2 therapists. The manager and deputy are qualified NVQ assessors and regularly observe care practices as part of their role. Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 17 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 and 38 Effective management arrangements ensure that the home runs smoothly, that residents’ needs are met and staff feel well supported. The manager seeks and records the views of residents and visitors, and a summary should now be produced that will show residents and others how their views are being used to improve the service. The health and safety of residents and staff are promoted through a variety of safety checks and staff training. Fire safety checks require improvement. EVIDENCE: The home is well organised in terms of administration, care delivery and staff support and training. Comments from residents, visitors and staff confirm that the manager and deputy work well together and are able to communicate a clear sense of direction and leadership. There is an open approach to running the home and suggestions and ideas for improvement are responded to with enthusiasm and commitment. The manager has completed the Registered Manager’s Award. Staff feel well supported in their work and in developing Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 18 themselves professionally. Communication is good with staff meetings taking place at all levels. Individual supervision and appraisal meetings take place with each member of staff. Records of these show that a good range of topics are discussed and the meetings are used to improve care practices through coaching. The home has made good progress in developing a quality assurance system. Questionnaires for residents and visitors are being used to obtain their views about the home. The information now needs to be summarised and distributed. It was suggested this may be done via a newsletter. Safe and secure systems were seen to be in place for administering residents’ finances, with accurate records kept of transactions. Satisfactory health and safety measures are in place at the home in respect of gas and electrical equipment checks. Fire safety checks need to be robust. The weekly check on the means of escape were not up to date, and a keypad on the first floor was not working, resulting in a locked fire escape door. All checks listed in the fire precautions log need to be carried out at the stated intervals. Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 19 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 20 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. 1. Standard OP33 Regulation 24 Requirement The results of quality surveys need to be collated and summarised in an annual development plan for the home. All checks listed in the fire precautions log need to be carried out at the stated intervals. Timescale for action 03/04/06 2. OP38 23 26/02/06 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. 3. Refer to Standard OP29 OP15 OP30 Good Practice Recommendations References obtained during the recruitment process should be signed by the referee. The home is advised to use photographs or other formats to enable residents to exercise choice at mealtimes. The managers were advised to obtain the Skills for Care induction standards and to use them for new staff. Shannon Court DS0000005699.V284262.R01.S.doc Version 5.1 Page 21 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: 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 DS0000005699.V284262.R01.S.doc Version 5.1 Page 22 - 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!