Inspection on 04/01/06 for Shapland Close

This inspection was carried out on 4th January 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shapland Close 06/10/09

Shapland Close 11/02/09

Shapland Close 15/01/08

Shapland Close 07/09/06

Shapland Close 06/09/05

Shapland Close 07/09/04

Shapland Close 29/04/04

Shapland Close 17/02/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOME ADULTS 18-65 Shapland Close Wilton Road Salisbury Wiltshire SP2 7EJ Lead Inspector Alison Duffy Unannounced Inspection 4th January 2006 09:10 Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 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 Shapland Close DS0000028422.V275593.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 Adults 18-65. 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. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shapland Close Address Wilton Road Salisbury Wiltshire SP2 7EJ 01722 419777 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) SCOPE Mrs Elizabeth Jean Tooze Care Home 8 Category(ies) of Physical disability (8) registration, with number of places Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Shapland Close is a residential care home registered to care for eight adults with a physical disability. The home is situated on the outskirts of Salisbury, within close proximity to local amenities. The home is managed by SCOPE and the Registered Manager is Mrs Elizabeth Tooze. Shapland Close consists of two purpose-built bungalows with disabled access throughout. Each bungalow has four single bedrooms, a spacious lounge with dining area, an adjoining kitchen and specialised bathing facilities. A range of individualised, specialised equipment is also in place. All areas of the home are well maintained and decorated and furnished to a high standard. An additional bungalow contains the office and staff sleeping in room. Staffing levels are maintained at a minimum of five during the day. This enables two to be in each bungalow with an additional member of staff responding to individual need between the two. At night there is one waking night staff member in each bungalow. Another member of staff provides sleeping in provision and an on call management system is also in place. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 4th January 2006 from 9.10am 1.15pm. On arrival at the home three service users were receiving staff assistance to get ready for their day service. The homes own transport was used to facilitate the journey and a driver and escort were also provided. Two other service users remained in the home and followed a day care programme with one-to-one staff support. It was not possible to gain specific feedback from service users regarding care provision. The interpretation of wellbeing was therefore based on various observations and interactions. All service users appeared comfortable, content and settled within their environment. Staff interacted with service users in a positive manner and a relaxed atmosphere was apparent. The inspector toured the accommodation with Mrs Tooze and discussion took place regarding current care provision, staffing, training and quality assurance. Risk assessments, care planning information, recruitment documentation, menus and the fire log book were also viewed. What the service does well: What has improved since the last inspection? What they could do better: Although care-planning information has been up dated, any changes in condition or need must be stipulated therefore ensuring a continuing process of review. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 6 Fire safety, although satisfactory would benefit from greater clarity within documentation. 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. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home has a detailed organisational admission policy that assures appropriate, well-managed placements. EVIDENCE: As all service users have lived at the home for a number of years it was not possible to view recent assessment documentation. Discussion however, took place with Mrs Tooze regarding admission and it was evident that the home has a detailed, established policy that would be followed as required. Prospective service users would almost certainly have a care manager and a comprehensive assessment would be sought. Mrs Tooze reported, due to the complexity of need that the home expects to manage, the receipt of detailed information would be essential. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Care planning is of a good standard and demonstrates clear awareness of need. An established system of review however would enable all information to be up to date and an accurate reflection of wellbeing. Risk-taking is strictly managed with service users’ complex needs dominating activity to ensure safety and welfare. EVIDENCE: At the last inspection, it was noted that care plans although detailed, comprehensive and informative were not dated. Dates were stipulated on some risk assessments and specific programmes, such as physiotherapy, yet a recent review had not taken place. It was therefore not possible to determine whether the information was an accurate reflection of current need. A requirement was therefore made to address this matter. In response to this, care plans had been formally reviewed. Some have also been updated with evidence of hand written additions. One service user however has recently been very unwell, yet changes to the care plan had not been made. Mrs Tooze reported that such changes would have been highlighted within daily handover plans, although agreed she would address the matter with the staff team. Risk assessments have also been updated although Mrs Tooze was advised to Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 10 ensure staff replace out of date documentation within care plans rather than purely storing new information in a separate file. All plans now contain an up to date photograph and detailed information regarding preferred daily routines, assistance required with daily living tasks, communication plans, health matters and social interests. Guidelines are in place regarding the use of equipment and in some instances, photographs are used for clearer explanation. Discussion took place with Mrs Tooze regarding risk-taking and it was apparent that this was a difficult area with service users at this present time. Due to the complexity of need and deterioration of many service users’ health, activities presenting a level of risk such as horse riding, have been withdrawn. Mrs Tooze reported that, in this instance, the risks had been assessed as too high. Risk-taking is therefore generally concerned with everyday life and the management of a condition. For example service users with epilepsy are encouraged to swim although they may have a seizure in the water. This is deemed an acceptable risk as control measures can be applied. Due to service users’ vulnerability, Mrs Tooze reported that all staff would apply caution to all activity therefore fully supporting the health and safety of individuals. SCOPE has a generic missing person procedure although its relevance is limited at this time. Mrs Tooze reported that existing service users would not be able to leave the building unescorted and always receive full support when out. The need for the procedure to be instigated would therefore not arise. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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 17 Service users are assisted to undertake meaningful activity and be an integral part of the community. The home has a varied menu that is based on service users’ requirements, preferences and healthy eating. EVIDENCE: Through discussion and viewing documentation it was apparent that day service and college placements continue to be successful. As well as purposeful activity, service users continue to have access to a wide range of specialist input such as physiotherapy, music therapy, speech and language therapy and occupational therapy. One service user receives day care at the home and has a detailed programme of activity to follow. One-to-one staff support is given and documentation demonstrates whether specific activities were undertaken. Such documentation also demonstrates new opportunities that are being investigated. Being an integral part of the community is somewhat challenging due to the location of the home. Shapland Close does not have any immediate neighbours Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 12 yet is within close proximity to local amenities. The home has its own transport linked to individual need. This is used to facilitate journeys as required on a daily basis. Service users regularly attend local groups and activities and some enjoy church. Walks around the local area are made and trips into town are undertaken as required. All service users are registered on the electoral role. Shapland Close has a rolling menu, which is adapted according to the seasons and activities being undertaken. Structure is therefore in place although flexibility is built in. Service users generally have their main meal in the evening although also have cooked meals at their day service. A record of such is maintained which demonstrates variety. Eating and drinking is stipulated within care planning information and specific equipment and/or requirements are clear. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19 Detailed documentation demonstrates a high level of personal support and well-managed health care. EVIDENCE: Service users continue to receive full assistance from staff in all aspects of daily living. This is clearly detailed within care planning information. A range of individualised equipment is in place and procedures for such are clearly stated. Some service users are unable to express how they wish their care to be delivered. In such instances staff rely on gestures, facial expressions, general contentment and individual communication systems. Advice is gained on a regular basis from specialised services and staff also work closely with family members. The home operates a key worker system and facilitates one-to–one work with service users. As stated earlier in this report, service users have access to general and specialised health care on a regular basis. Positive relationships were reported with the local GP although one service user continues to have a GP in the vicinity of his parental home. Temporary registration in Salisbury is therefore undertaken. Referrals for specific requirements such as wheelchair services are made as required and out patient appointments are attended with staff or family assistance. Services such as physiotherapy and speech and language therapy are an integral part of service users’ health care provision. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 14 Programmes of such and guidelines for staff are clearly stated within individual plans of care. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home has a clear, well-managed complaint procedure that encourages views to be raised in order to develop practice and ensure the well being of service users. EVIDENCE: As noted at the last inspection, the home has a detailed and comprehensive complaints procedure devised by SCOPE. The procedure is readily accessible and encourages views to be raised and resolved as quickly as possible. Mrs Tooze aims to be approachable and meet with parents informally when they visit the home. This encourages matters to be addressed through general conversation although six monthly parents meetings are also held. At this time, due to complexity of need, service users’ involvement with the formal complaint procedure is limited. All service users are therefore reliant on others to recognise any forms of discontentment. The home has clear reporting procedures on receipt of a formal complaint. Since the last inspection Mrs Tooze has competently addressed issues. Documentation of such is clear and emphasises the wish to resolve and address practice as required. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28 and 30 Shapland Close provides a good standard of accommodation, which meets service users’ specialised needs in a comfortable and homely manner. EVIDENCE: Shapland Close consists of two purpose built bungalows, which are located in a quiet position away from the main road, on the outskirts of Salisbury. All amenities are within close proximity. All service users have a single room, which is decorated and furnished to a high standard. All rooms have specialised equipment including an overhead hoist, an individualised bed and armchair and commode as required. Despite such equipment, the rooms are homely and personalised to a high degree. Each bungalow has it own facilities although the laundry is shared. Within each bungalow there is a spacious lounge and dining area that is homely and comfortably furnished. Both kitchens are well equipped and on the day of the inspection both areas were ordered, clean and tidy. One kitchen has recently been refurbished which further enhances the quality of the environment. Laundry facilities are located within an outside building, which is not ideal as staff are required to go outside for such. The situation is well managed Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 17 however and current facilities were reported to meet existing need. All equipment is domestic in style, which was a considered choice by being more cost effective despite its high usage. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 Staffing levels are maintained as agreed by the previous Registration Authority although agency staff are often required to enable this. EVIDENCE: Staffing levels continue to be maintained at five or six staff on duty during the waking day with a minimum of two in each bungalow. At night each bungalow has one waking night staff and an additional member provides sleeping in provision. There is also an on call management system. The home has recently experienced some staffing shortages due to vacancies, maternity leave and long-term sickness. Mrs Tooze reported that matters are improving although some agency use is still required. In such instances the same agency staff are requested in order to ensure consistency. One service user has recently had a lengthy stay in hospital. Despite staff shortages, the staff team also provided staff cover within the hospital in order to ensure familiarity and the meeting of need. Since the last inspection one member of staff has commenced employment at the home. The recruitment documentation of this appointment was viewed and it was noted that all checks had been undertaken. Due to the employment history however of the individual, references were limited. This was discussed with Mrs Tooze who reported that within usual circumstances a reference from the candidate’s present employer would be sought. A POVAFirst check had been received before the commencement of employment and an application for Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 19 a CRB disclosure had been submitted. All candidates are sent a range of information as standard practice. Such information includes a job description and terms and conditions of employment. At the last inspection a requirement was made to review all training profiles, as it was not clear whether all staff had undertaken first aid or epilepsy training. Mrs Tooze reported that a review had been made and shortfalls with first aid training had been identified. Mrs Tooze stated that a number of courses have been programmed yet many had been cancelled. It was evident that such cancellations were providing difficult to manage in order to ensure training requirements are met. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 39 The home continues to be well managed with a service user focus. Mrs Tooze has developed established systems in order to gain feedback about the home and ways in which service provision can be developed. Fire safety systems have been addressed and are now satisfactory managed. EVIDENCE: On the day of the inspection Mrs Tooze was undertaking an early shift as part of the working roster. Mrs Tooze reported that although her management hours are not an integral part of the care staff roster, she often covers shifts if agency staff are difficult to access. Through discussion it was evident that Mrs Tooze has a genuine concern for services users and has a clear awareness of need. Mrs Tooze has NVQ 4 in Management and has recently successfully completed the Registered Manager’s Award. Mrs Tooze has clear expectations of service provision and has established systems, such as staff meetings in order to promote this to the staff team. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 21 Shapland Close has an established quality action group. The group, which consists of a parent, a representative from CTPLD and Mrs Tooze meet on a six monthly basis and discuss various objectives. A parents meeting is held before the group in order to enable involvement and further views. Minutes of the group are taken and distributed to all interested parties. Mrs Tooze reported that that the group is extremely valuable and aids as a forum to develop service provision. The quality action group is currently the home’s only format of quality assurance although future changes with CSCI will almost certainly promote additional measures in the future. Health and safety systems were not fully addressed on this occasion. However the fire log book was viewed as a number of checks had been missed before the change over of the home’s fire precaution officer. At the last inspection documentation demonstrating the external servicing of the fire extinguishers was also unable to be located. This was sent to CSCI following the inspection. Within this inspection, satisfactory fire safety was noted. The log was found to contain an up to date record of required checks. These included the fire alarm systems and emergency lighting as well as a visual check of the means of escape and the fire extinguishers. A fire drill had taken place in each identified period although Mrs Tooze was advised to include the time and a brief account of the drill. Fire instruction had taken place yet not all staff had signed to demonstrate their receipt of such. Documentation demonstrated regular external servicing of the fire alarm system and extinguishers. Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 3 X X X X Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 23 No Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15 Requirement The Registered Person must ensure that care-planning information is regularly updated in order to reflect a change in condition or need. Timescale for action 04/01/06 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. Refer to Standard YA6 Good Practice Recommendations The Registered Person should ensure that all out of date documentation is removed from care plans and is replaced with up to date information that has been undertaken yet separately stored. The Registered Person should ensure that all staff sign and date the fire log book in order to demonstrate their receipt of fire instruction. This was identified at the last inspection. The Registered Person should ensure that the time and a small account of each file drill are maintained. 2. YA42 3. YA42 Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Shapland Close DS0000028422.V275593.R01.S.doc Version 5.1 Page 25 - 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!