CARE HOME ADULTS 18-65
Shassab 144 Manchester Road Chorlton Manchester M16 0DZ Lead Inspector
Steve OConnor Unannounced 23 August 2005
rd 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 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 Stationary 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 F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Shassab Address 144 Manchester Road Chorlton Manchester M16 0DZ 0161 860 4596 Telephone number Fax number Email 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 Mohammed Iqbal Mr Mohamed Iqbal Care home only (PC) 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD) 7 of places Old age, not falling within any other category (OP) 1 Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1 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). 2 The care home provides a separate room where service users can meet visitors in private. 3 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). 4 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. 5 The service should, at all times,employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 6 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). Date of last inspection 7 December 2004 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 F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 22nd August 2005. 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. The majority 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 Commission for Social Care Inspection (CSCI) had to make three additional visits to the home as a result of concerns raised by other professionals visiting the home. The first was on the 22nd April 2005 due to concerns about the way that staff were moving and handling people who needed lifting with a hoist. As a result the home were required to change the unsafe moving and handling practice and to provide staff with refresher training. On the 5th May 2005 the home was visited again due to concerns raised by the local environmental health department of breaches in health and safety regulations. The environmental health department and the CSCI issued the home with a considerable list of actions needed to meet the required standards. The environmental health department made an additional visit on the 7th July 2005 and found that although the majority of the work had been completed, some was still outstanding and needed further action to be taken. On the 4th July 2005 the CSCI had to visit the home again as a result of concerns raised by the community physiotherapy service of poor moving and handling practice in the support of a named person. During the visit poor practice was observed that was unsafe for the person and the staff. It was also found that there was no clear moving and handling assessment, support guidelines, poor recording and that staff had not had any recently updated moving and handling training. This was despite the need for training being raised not only on the visit of the 22nd April but previously, in response to concerns of moving and handling practices raised in August 2003. As a result, immediate requirements were made to make sure that the person was supported safely.
Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 6 The home’s response to the issues will be highlighted in the rest of this report. What the service does well: What has improved since the last inspection?
Since the last inspection, in December 2004, some additional visits were made to the home in response to concerns about the way staff move and handle people, the home has worked with the local physiotherapy service and took their guidance and support to change the poor practice seen. Clear and detailed guidance was provided by the physiotherapy service and the staff have undertaken moving and handling training. The support given to the named person is now also clearly recorded and monitored. Another visit was made to home in response to the local environmental health department concerns of breaches in health and safety regulations found at the home. The home had taken the actions required of them to improve the premises and health and safety systems and practices. These included replacing/repairing worn or damaged fixtures and fittings, furniture and flooring. Also cleaning, decorating and repairs to communal areas such as toilets, the laundry and kitchen. The home had also to introduce better systems and/or training for the food handling and storage, safe hygiene and reporting accidents. Although most of these areas had been addressed the home has to make sure that standards are maintained and so both the environmental health department and the CSCI will be monitoring the situation. All care homes have to develop a set of written policies and procedures that describe how they will run and manage the home to protect people’s safety and wellbeing. These policies explain to management and staff what they do and how they should do it. The home has made improvements over the past two inspections in developing clear policies and procedures in areas relating to
Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 7 health and safety, protecting people from harm and how to support people. This means that the management and staff now have clear guidelines in the way they run the home and work with people in the best way to support their needs. 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.
Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 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 standard(s) 1, 2 and 5 Information about the service was available to people and their needs are assessed before they come to live at the home. EVIDENCE: The home had developed a Statement of Purpose, Service User’s Guide and Service Users Contract that contained all the information required from the National Minimum Standards and regulations. These actions met the requirements issued at the previous inspection. The most recent person to come to live at the home had a full and detailed Care Programme Approach (CPA) assessment from the purchasing local authority. Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 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 standard(s) 6 and 9 The home had identified the risks people come across in their day-to-day lives and the support needed to address those risks. The home had not fully developed a care plan reviewing system that shows people’s changing needs and progress. EVIDENCE: Care plans have been developed for each person that sets out the support they require to meet their needs. Care plans are reviewed on a regular basis and the home had developed a new care plan review format as a result of a requirement from the previous inspection. However, the review documentation is at times inconsistent and does not look at all the person’s identified goals and does not clearly show the progress made in achieving those goals. Another requirement in relation to the care plan review system was made. As a result of the recent concerns regarding moving and handling practices the home has, with the help from the community physiotherapy service, developed new moving and handling risk assessments. The most recent person’s CPA assessment contained a detailed risk assessment and it is recommended that the home further develop its own service risk assessments. The home had
Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 11 developed a Risk Assessment and Management Policy as required from the previous inspection. Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12 and 13 The home was not able to fully show that it had offered people with the opportunities to participate in appropriate social, leisure and community based activities as set down in its Statement of Purpose. EVIDENCE: Several people were independent in being able to access their community and could participate in local amenities and places of worship. Several people had a daily programme of support that included personal and healthcare tasks and activities. One person accessed local specialist day care services although the home was not fully clear what the person did at this service. It was recommended that the home liaise more fully with the day service to establish the person’s programme of activities and to see how they can be incorporated into the person’s daily routines. The Statement of Purpose states that the home aims to offer people opportunities to access a wide range of social and leisure activities, access to public services and lifelong learning and taking on responsibilities within the home. However, the care plans, care plan reviews or the daily recording does not show clear evidence that people are being offered the opportunities
Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 13 (whether they agree to them or not) to participate in such activities. The home must ensure that the aims of the home stated above are fully reflected and evidenced in people’s care plans, care plan reviews, daily programme and daily recording. Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 18, 19 and 20 The home supports people’s personal and healthcare needs and has the medication administration systems in place to support people to manage their medication safely. EVIDENCE: The concerns raised by the community physiotherapy service had been addressed with their support and guidance. The situation was still being monitored to ensure the examples of bad practice did not return. People’s personal care and healthcare needs and support were identified in the individual care plan. Some additional guidance was provided on how to meet these needs. The home works alongside general and specialist healthcare providers in supporting and accessing the health services needed. The medication administration system was seen and the MAR sheets were found to be accurate. Medication prescribed ‘as required’ (PRN) had guidelines for administering. This action met the requirement issued at the previous inspection. A person’s medication was being stored in the domestic fridge. All medication that requires refrigeration must be stored according the Royal Pharmaceutical
Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 15 Society guidelines for Care Homes and be in a separate, dedicated and lockable refrigerator. Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 16 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 standard(s) 23 The home does not have the financial systems in place that fully protects people from the risk of abuse. EVIDENCE: The home had adopted the Manchester Multi-Agency Adult Protection Policy and Procedures as its own operational procedures. This met the requirement issued at the previous inspection. The home had developed a policy and procedure for managing people’s personal finances as required from the previous inspection. The policy and procedure did not set out the monitoring and auditing system to be used to ensure that records and people’s funds were accurate, although the manager did check the balance of people’s money. A requirement was made. The finance records of people showed that the home was not following its own policy in that not all people’s actual spending had been recorded accurately and a person had their money held in a bank account under the manager’s name. In addition receipts for spending had not been kept and the signatures of both the person and staff had not been recorded. These issues were discussed with the home and issues of good practice and alternatives to the manager being the appointee and bank account holder were raised. The home must ensure that it follows its own policy and procedures and records all transactions accurately and receipts were kept. Large amounts of people’s cash must not be kept on the premises unless agreed through the persons representative and alternative ways of managing a named person must be developed.
Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 17 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 standard(s) 24 and 30 The home provided people with a safe environment to live in but did not fully have the procedures and systems in place to ensure that the home is safe from cross infection. EVIDENCE: The home was found to be clean and there was evidence that some recent maintenance work and redecoration had been carried out. In addition the work required by the Environmental Health Department had been completed. An audit of all the furniture in people’s bedrooms had been undertaken and a decoration programme showing when areas had been decorated and the costs involved. These actions met the requirements issued at the previous inspection. The home supports people who are at risk of cross infection due to their needs and health. The home does have an Infection Control Policy and there were signs around the building reminding staff to wash their hands. However, the home did not provide staff with specific infection control training or step-bystep practical guidance.
Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards were not assessed during this inspection. Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards were not assessed during this inspection. Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 3 Standard No 22 23
ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 x x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 2 2 x x x x Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Shassab Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 21 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 6 Regulation 15 Timescale for action The review of peoples care plans 30th must include all the persons November identified goals and must clearly 2005 show the progress/changes made in a persons needs and the support that the home provides. 1st The home must ensure that the aims of the home relating to, September accessing a wide range of social 2005 and leisure activities, access to public services and lifelong learning and taking on responsibilities within the home are fully reflected and evidenced in people’s care plans, care plan reviews, daily programme and daily recording. All medication that requires 1st refrigeration must be stored September according the Royal 2005 Pharmaceutical Society guidelines for Care Homes and be in a separate, dedicated and lockable refrigerator. The Finance policy and 1st procedure must set out the September monitoring and auditing system 2005 to be used to ensure that records and people’s funds were accurate.
Version 1.40 Page 22 Requirement 2. 12/13 16 3. 20 13 4. 23 13 Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc 5. 23 13 6. 30 13 The finance policy and procedure must be followed and, (a) all people’s actual spending must have been recorded accurately. (b) A named persons money must not be held in a bank account under the manager’s name. (c) All receipts for spending must be kept and the signatures of both the person and staff must be recorded. (d) Large amounts of people’s cash must not be kept on the premises unless agreed through the persons representative. Infection control training and step-by-step practical guidance must be provided for all the staff team. 1st September 2005 30th November 2005 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 9 12 Good Practice Recommendations It is recommended that the home enures 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 person’s programme of activities and to see how they can be incorporated into the person’s daily routines. Shassab F55 F05 s55957 Shassab V245843 D230805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 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
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