CARE HOME ADULTS 18-65
Shassab, 144 Manchester Road, Chorlton, Manchester 144 Manchester Road Chorlton Manchester M16 0DZ Lead Inspector
Steve O`Connor Unannounced Inspection 13 February 2006 02:00p
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Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.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 Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.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. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Shassab, 144 Manchester Road, Chorlton, Manchester 144 Manchester Road Chorlton Manchester M16 0DZ 0161 860 4596 0161 860 4596 Address 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 Mohammad Iqbal Mr Mohammad Iqbal Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7), Old age, not falling within any of places other category (1) Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. 6. The home accommodates a maximum of 7 service users, aged 18 - 64 years, whose primary need for care arises from mental disorder (excluding learning disability and dementia). The care home provides a separate room where service users can meet visitors in private. All service users are offered the option of a single bedroom. (Service users share bedrooms only where two service users choose to share and have been offered two rooms to use). Minimum staffing levels will be maintained in accordance with the Residential Forum guidelines `Care Staffing in Care Homes for Younger Adults` and service users` assessed levels of need. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. One named service user whose primary need for care and accommodation is old age (OP) is accommodated. If the service user leaves the home the registration will revert to Mental Disorder (18 to 65 years of age, excluding learning disability and dementia). 23rd August 2005 Date of last inspection Brief Description of the Service: Shassab is a residential care home providing 24-hour personal care and accommodation for 8 adults with mental health problems and physical disabilities. The service specialises in culturally appropriate care of Asian people. The home is situated on the edge of Chorlton, South Manchester, close to local amenities and public transport routes. It is sited on a residential street and is of the same size and style as other houses surrounding it. It has a small car park to the front and a lawned garden at the rear. Bedroom accommodation is on the ground and first floors. There are 6 single and one double bedroom with hand washbasins. The home has access for people who require wheelchairs for mobility. The communal space is situated on the ground floor along with kitchen and laundry facilities. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.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 13 February 2006. During the inspection time was spent observing how staff support and interact with people, talking with some of the people who live at the home, with staff on duty and the registered manager. In addition people’s files, records and other relevant documentation were examined. As this inspection only looked at a limited number of standards the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the people living there. At the last inspection the home needed to work on several areas to make sure it met the required standards. Around half of these had been looked at by the home and the changes made. There were still some issues outstanding that were discussed with the home and the actions needed agreed. Since the last inspection, the CSCI has not received any concerns regarding the home. What the service does well: What has improved since the last inspection?
Of the standards assessed during this inspection and the requirements from the previous inspection report the home has not showed any significant improvement. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 6 What they could do better:
An area of work that the CSCI has raised with the home over several previous inspections is the need to be able to clearly show that the home has offered people the opportunity to experience a range of social, leisure, skill maintenance and development and community based activities. Part of this evidence is to develop a care plan reviewing system to show people’s goals and how the home has helped them achieve those goals. Also, how the recording of people’s day-to-day experience should evidence the support offered to meet people’s goals. The home still needs to make much more effort in providing the evidence to show that it is achieving the aims it sets out in their Statement of Purpose. The way that the home records people’s spending was still a problem. The system should be clear and easy to check that everything is accurate. This audit and monitoring should be clearly recorded in the home’s finance policy and procedure. Several problems were still evident with the home’s system for managing people’s finances. Receipts were not available for all spending and large sums of people’s money were being kept on the premises. The home must again review the way it manages people’s finances. The home supports people who are vulnerable to infections because of their health and the help they need with their continence. The home does have a policy on infection control that sets out good practice, but staff had not been provided with specific infection control training or clear ‘to-do’ guidance. The home were required in the last two inspection reports to make sure that all staff had the training and information they need to keep people safe from infection. This had not been completed. The systems for administering medication had several problems including the delivery/administering system, storage and recording. The CSCI Pharmacy Inspector was asked to visit the home to help them put the medication administration system right and the home must put into place all requirements and actions set by her. An action plan must be submitted to the CSCI setting out how the home is to meet the target of 50 of its staff completing the NVQ Level 2. The home must ensure that all staff have applied and received a CRB disclosure certificate and POVA check before they start employment. The home must undertake an audit of all the staff training needs and develop individual staff training plans that set out what training staff have undertaken, what training was required and when refresher training was needed. A Quality Assurance system must be developed to assess the quality of the service based on people’s views and of other relevant people. An action plan
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 7 must be developed as a result of this process and submitted to the CSCI within the set timescale. 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. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 8 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 Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 9 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): No judgement was made at this inspection. EVIDENCE: These standards were assessed during the previous inspection. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 10 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): No judgement was made at this inspection. EVIDENCE: The previous inspection report required the home to improve its care planning systems. The home had made progress in developing fuller care plans that included more than a person’s personal care and health needs. Further work was ongoing in addressing the care plan review system. As the work had not been fully implemented the requirement was reiterated and will assessed on the next inspection. The remaining standards were assessed at the previous inspection. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.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): 15, 16 and 17 People are supported to maintain family relationships, daily routines are based on people’s personal needs and the home provides them with a diet that people enjoy. EVIDENCE: The previous inspection report required the home to address the stated aims in its Statement of Purpose that its aims is to encourage people to be as independent as they can, to give people choices that affect their lives and to promote a fulfilling life providing, amongst other things, a range of leisure and recreational activities. This required an improvement in its recording and evidence to show that these opportunities were being provided. This has not yet been achieved and the requirement was reiterated. The home supports and encourages people to maintain family links and relationships. Families and friends are encouraged to visit people at home and will often take part in meals and religious events. Several people still visit their families on regular occasions.
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 12 People’s routines appear to revolve around activities such as meal times, group activities and individual choices. Some people can be independent in the community and set their own routines whilst others have a more structured day. Those people who wish to have their own room key and can spend time in others company or on their own, mail is given direct to the person unless support is required and people participate in domestic tasks according to their ability. Restrictions of movement around and out of the house are based on the safety of the individual. People’s food likes and dislikes are recorded in their care plan. Those with specific dietary needs are catered for and the choice of meals is discussed with people on a daily basis. The menu offered is based on people’s religious and cultural needs. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.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): 20 The home does not have the medication administration system in place to fully protect people. EVIDENCE: The previous inspection report required the home not to store a specific medication in the main fridge. This has not been actioned. The home uses a blister pack medication administration system from a local pharmacist. It was found that the film on one container was not fitted correctly and all the medication tipped out whilst being inspected. There were two separate types of blister pack used which could cause confusion and a mistake had been made in administering the wrong days medication. The delivery of medication was not recorded correctly. The Pharmacy Inspector was contacted and requested to visit the home to provide guidance. The home must seek the guidance of the CSCI Pharmacy Inspector and put into place all requirements and actions set by her. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 14 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 had the systems in place to allow people to express their complaints. EVIDENCE: The home has a complaint procedure setting out how people can raise their concerns and what other organisations, including the CSCI, can be contacted to raise complaints and concerns. The procedure was available in written form and had been discussed during the informal ‘chat sessions’. The home had received no formal complaints since the last inspection. The previous inspection report required the home to develop a clear monitoring and auditing system for the management of people’s personal finances that the home controls. The policy had been reviewed and included the procedure for recording transactions it did not include the monitoring and auditing system as was required. The requirement was reiterated. In addition, the home were required to make several changes to the way it recorded how it managed people’s money. This included accurate recording of actual amounts spent, obtaining receipts for all spending and not keeping large amounts of people’s cash on the premises. None of these actions had been met to the required standard. The requirements were reiterated. A person’s money that was being kept in one of the home’s own accounts had now been transferred to the local authority to act as appointee and account holder for the person. The remaining standard was assessed during the previous inspection.
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 15 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): No judgement was made at this inspection. EVIDENCE: The previous inspection report required the home to provide the staff team with updated infection control training due to the vulnerability of some of the people they support. This had not been actioned and the requirement was reiterated. The remaining standards were assessed during the previous inspection. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 16 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): 32, 34 and 35 The home does not have the systems in place to show that people are supported by a trained and qualified staff who are safe to work with vulnerable people. EVIDENCE: The NVQ provider used by the home stopped providing the course and so this has prevented several of the staff from completing their NVQ. It was seen that an alternative provider had been found but they had not yet started to assess the staff. An action plan must be submitted to the CSCI setting out how the home is to meet the target of 50 of its staff completing the NVQ Level 2. The home has not needed to recruit any new staff since the last inspection. As the home is a family business several of the staff are a part of the owners family. Not all staff had current Criminal Record Bureau (CRB) disclosure certificates although the application forms were seen. The home must ensure that all staff have applied and received a CRB disclosure certificate and POVA check before they start employment. Staff files did not make it clear whether each staff member had an individual training plan/log. The home must undertake an audit of all the staff training and develop individual staff training plans that set out what training staff have undertaken, what training was required and when refresher training was needed.
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 17 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, 39, 42 The registered manager has the qualifications and experience to run the care home. The home does not have the systems in place to assess the quality of the service it provides and has not undertaken all the practices required to ensure people’s health and safety are maintained. EVIDENCE: The registered manager is also the owner of the home that has been in operation for around 12 years. They have undertaken the NVQ level 4 in Care and Management. They have full responsibility for all decisions affecting the running of the home and implementing the National Minimum Standards. The home has no informal or formal system for quality assurance that is based on people’s views and/or other relevant people. This is a requirement that has been raised through other inspection reports. A Quality Assurance system must be developed to assess the quality of the service based on people’s views and of other relevant people. An action plan must be developed as a result of this process and submitted to the CSCI within the set timescale.
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 18 The fire log was seen and found that the required checks were being made. The home had not undertaken its own fire risk assessment. Evidence was seen that electrical and fire equipment had been annually serviced and environmental/safe work practice risk assessments had been completed. There was no evidence of an up-to-date gas safety certificate. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.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 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 X 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 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43
DS0000055957.V278892.R01.S.doc X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X 2 X X 2 X
Version 5.1 Page 20 Shassab, 144 Manchester Road, Chorlton, Manchester Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Timescale for action The review of peoples care plans 01/05/06 must include all the persons identified goals and must clearly show the progress/changes made in a persons needs and the support that the home provides. (Previous timescale of 30/10/05 not met) Requirement 2. YA12 16 The home must ensure that the aims of the home relating to, accessing a wide range of social and leisure activities, access to public services and lifelong learning and taking on responsibilities within the home are fully reflected and evidenced in peoples care plans, care plan reviews, daily programme and daily recording. (Previous timescale of 01/09/05 not met) 01/05/06 Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 21 3. YA20 13 4 YA20 13 5. YA23 13 6. YA23 13 7. YA30 13 8 YA32 19 All medication that requires refrigeration must be stored according the Royal Pharmaceutical Society guidelines for Care Homes and be in a separate, dedicated and lockable refrigerator. (Previous timescale of 01/09/05 not met). The home must seek the guidance of the CSCI Pharmacy Inspector and put into place all requirements and actions set by her. The Finance policy and procedure must set out the monitoring and auditing system to be used to ensure that records and peoples funds were accurate. (Previous timescale of 01/09/05 not met) The finance policy and procedure must be followed and, (a) all peoples actual spending must have been recorded accurately. (b) All receipts for spending must be kept and the signatures of both the person and staff must be recorded. (c) Large amounts of peoples cash must not be kept on the premises unless agreed through the persons representative. (Previous timescale of 01/09/05 not met) Infection control training and step-by-step practical guidance must be provided for all the staff team. (Previous timescale of 30/11/05 not met) An action plan must be submitted to the CSCI setting out how the home is to meet the target of 50 of its staff completing the NVQ Level 2.
DS0000055957.V278892.R01.S.doc 01/03/06 01/03/06 01/05/06 01/04/06 01/04/06 01/04/06 Shassab, 144 Manchester Road, Chorlton, Manchester Version 5.1 Page 22 9 YA34 19 10 YA35 19 11 YA39 24 12 YA42 12 The home must ensure that all staff have applied and received a CRB disclosure certificate and POVA check before they start employment. The home must undertake an audit of all the staff training and develop individual staff training plans that set out what training staff have undertaken, what training was required and when refresher training was needed. A Quality Assurance system must be developed to assess the quality of the service based on people’s views and of other relevant people. An action plan must be developed as a result of this process and submitted to the CSCI within the set timescale. a) An up-to-date gas safety certificate must be provided to the CSCI. b) An up-to-date fire risk assessment must be provided to the CSCI 01/03/06 01/05/06 01/07/06 01/03/06 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. Refer to Standard YA9 YA12 Good Practice Recommendations It is recommended that the home ensure that it further develops its own risk assessments from the assessment information provided by the purchasing authority. It is recommended that the home liaise more fully with the day service to establish the persons programme of activities and to see how they can be incorporated into the persons daily routines. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V278892.R01.S.doc Version 5.1 Page 24 - 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!
