CARE HOMES FOR OLDER PEOPLE
Shardlow Manor 111 London Road Shardlow Derby Derbyshire DE72 2GP Lead Inspector
Claire Williams Unannounced Inspection 15th November 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 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. Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Shardlow Manor Address 111 London Road Shardlow Derby Derbyshire DE72 2GP (01332) 792466 (01332) 792466 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) Mr Kevin James Popowycz Mrs Tracey Jane Popowycz Ms Emma Salt Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: Shardlow Manor is a Care Home registered to provide personal care and accommodation for up to 28 people in the category of older persons. Shardlow Manor Care home is situated in the village of Shardlow, which is located on the main A6 route from Derby to Loughborough. The home has a front garden patio area, and a car park. Shardlow Manor has 22 single rooms, 17 have ensuite facilities and 3 double rooms. A variety of lounge and dinning room space is provided. The accommodation is on two floors, and there is a chair lift for access to the first floor. Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and commenced at 9am. The visit lasted 4 hours. The inspector checked the previous requirements and recommendations made in the previous inspection report, and checked the key areas that were required to be assessed in a 12-month period. She examined care files and associated documents, medication, and training was discussed. The inspector joined the residents for their lunchtime meal and a full tour of the building was undertaken. Time was spent observing residents and staff interaction, and the inspector spoke with 10 residents and 3 staff members. The Registered Manager and the Assistant Manager assisted the inspector with the inspection. For the purpose of this report the people who live in this home will be refereed to as ‘Residents’. What the service does well: What has improved since the last inspection?
Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 6 The staff team have implemented a new document in the resident’s files, which is used to record the involvement from the resident or their representative in the development and review of their care plan. The home has recruited an activities co-ordinator that now visits the home on a Tuesday and Thursday and facilitates activities and outings. A policy and a consultation exercise have been undertaken in relation to residents having a choice concerning the gender of the staff member delivering their personal care support. The Registered Manager is consulting all staff that was in employment before the National Minimum Standards became law, in order to obtain updated information about their employment history. 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. Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 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 Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 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): These standards were not assessed on this occasion as they were assessed on the previous inspection visit. EVIDENCE: Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 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, and 8 The staff team have a good understanding of the residents support needs. This is evident from the positive relationships, which have been formed between the staff and the residents. EVIDENCE: The inspector examined three care plans to ensure that the requirements made in the previous inspection report had been addressed. All three care plans were completed in full, covered aspects of the resident’s health, personal and social care needs, and were up to date. All of the care plans had been reviewed regularly and the staff team now consult the residents and they sign to verify their involvement in this review, and in the development of their care plan. The inspector spoke with several residents during the inspection and many positive comments were received about living in this home and the quality of care they receive. Residents comments included; the staff are “excellent and caring”, “the home is the best one ” “the quality of the care is good”, “the staff always treat us with dignity and respect, “everything is perfect here”. Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 10 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 Social activities are well managed, creative, and provide daily variation and interest for people living in the home. EVIDENCE: In response to the previous inspection report the Registered Providers have recruited an activities co-ordinator who now facilitates regular social activities for the residents on a Tuesday and Thursday. Some of the artwork from these sessions was displayed around the home. Residents have responded positively about this provision and comments made to the inspector confirmed their enjoyment in participating in these sessions. The residents also commented on how they were looking forward to the planned trip for a meal and Christmas shopping the following week. Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, and 18 The home has an effective complaints and adult protection procedures, in order to safeguard residents. Resident’s legal rights are protected. EVIDENCE: The home has a complaints procedure and recording system in place. The residents spoken with were aware of the procedure and informed the inspector that they would not hesitate to raise any concerns they had with the staff or the manager. The home has not received any complaints this year. The Commission for Social Care Inspection received a letter of compliment about the home, commenting on how the staff team are “kind and considerate” and “nothing is to much trouble”. Resident’s legal rights are protected within the home, and they are encouraged to exercise their political views through the provision of postal votes. The home has a Vulnerable Adults policy in place that links in with the Derbyshire Vulnerable adult’s procedures. All of the staff team have undertaken some form of abuse training either internally or through their NVQ training. The Registered Manager intends to plan some internal training for the seven staff members who have not completed abuse training. There have been no incidents at the home this year. Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 12 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, 20, 21, 22, 23, 24, 25, and 26 The home is furnished and maintained to a good standard and offers homely and spacious facilities for residents to enjoy. EVIDENCE: The inspector undertook a full tour of the environment. All areas of the home are decorated to a good standard and were free from any odours. The Registered Provider has a redecoration and renewal programme in place. The residents spoke positively about the standard of cleanliness in the home. Residents commented positively on how “lovely the home is decorated, and “how nice their bedroom is”. The inspector was invited to view some of the bedrooms by the residents. All bedrooms were personalised with resident’s own belongings, and had the appropriate fixtures and fittings available. All communal and bathroom areas were well maintained. Equipment is available in some of the bathrooms in order to assist with personal care. There are adequate facilities available in the home in accordance with the residents needs.
Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29 The home is staffed according to the needs of the residents. The recruitment procedures safeguard residents from potential risk EVIDENCE: The rota for the previous week and the dependency levels for the residents currently living at the home was obtained. A calculation of the service user dependency levels was used to calculate the required staffing levels. (The Department of Health Residential Staffing Forum guidelines for Older Persons were used to collate the data). The hours provided was in accordance with the current dependency levels. Catering and Domestic hours were satisfactory. In response to the previous inspection report the registered manager has now obtained the outstanding CRB for one of the staff team. All staff are now recruited in accordance with the requirements of the regulations and good practice. Residents spoke very positively about the staff team and the standard of care they provide. The residents felt that the staff team are well trained as they deliver good quality care. The residents confirmed that there are always adequate staff members on duty and that they meet their support needs. Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 14 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 The manager is supported well by the senior staff in providing leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The Registered Manager is experienced, competent and provides clear leadership and has good management skills. The inspector received positive feedback from both residents and staff on how supportive and approachable the Registered Manager is. She ensures that the home is managed in accordance with the best interests of the residents. The Registered Manager intends to send out a quality assurance questionnaires in the beginning of the New Year in order to obtain feedback about the home. The home has effective quality assurance systems in place monitoring the standards in the home. Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 15 The inspector checked the financial records and the money held in safekeeping for five residents. All of the resident’s money was stored separately in individual purses. All money held cross-referenced to the balance recorded on the transaction sheets. Receipts are obtained for purchases made on behalf of the residents, and two staff members countersign the majority of the transactions made. The inspector checked some of the health and safety systems in place at the home. All of the staff team had received updated Fire training. The gas and electrical installations certificates were up to date. The Fire Officer visited earlier in the year and a plan has been implemented to commence the completion of the work required. The checks on the water temperatures and checks required to prevent legionella were up to date. The lift has been serviced on a six monthly basis. The electrical appliances have not yet been be PAT tested. The Environmental Health Officer inspected the home in July 2005 and made requirements and recommendations. The Registered Providers are in the process of addressing all of the required areas. Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 17 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. 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 3 Refer to Standard OP7 OP8 OP24 Good Practice Recommendations The Registered Manager should try and expand the proforma used to record service users care plan and support needs. The Registered Persons should consider purchasing chair scales to enable all service users to be weighed regularly. The Registered Manager should formally record service users preferences in regard to the furniture available as required by National Minimum Standard 24.2, in residents care files. (Recommendation carried forward from previous inspection report.) The Registered Persons should consider covering the radiators with guards. (as recommended by the Environmental Health Officer) The Registered Manager should ensure that all electrical appliances are PAT tested. 4 5 OP38 OP38 Shardlow Manor DS0000020093.V266085.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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