Inspection on 30/05/07 for Shawcross Care Home

This inspection was carried out on 30th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Shawcross Care Home Bolton Road Ashton-in-Makerfield Wigan Lancashire WN4 8TU Lead Inspector Val Bell Unannounced Inspection 30th May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 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. Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shawcross Care Home Address Bolton Road Ashton-in-Makerfield Wigan Lancashire WN4 8TU 01942 276628 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) shawcross@fshc.co.uk Tameng Care Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Lesley Wilson Care Home 50 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (26) of places Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 50 service users to include: up to service users in the category of OP (Older People) (including 3 non-nursing places) up to 24 service users in the category of DE (E) Dementia over 65 years) for residential care only The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. New service 2. Date of last inspection Brief Description of the Service: Shawcross is a purpose-built care home providing care for 24 people over 65 with Dementia and 26 people over 65 years of age who require residential or nursing care. The home is located in Ashton-In-Makerfield and is close to shops, churches, and local social clubs. Main bus routes serve the home. The nursing and dementia care units are both split into two smaller units situated on the ground and first floors. On each floor of the nursing and dementia care units are lounge and dining areas. All bedrooms are single with en-suite toilet facilities. Shawcross was re-registered on 05/10/06 under the name of Tameng Care Limited, which is a wholly owned subsidiary of Four Seasons Health Care Limited. The home makes the following charges over and above the weekly care and accommodation fees that are listed after this section: Chiropody £ 8.00 Hairdressing From £ 4.50 Newspapers As charged Fees charged by the home provided in June 2007 are in the range of: £338.07 to £490.00 Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the home was registered in October 2006. Site visits to the home form part of the overall inspection process and the inspector conducted two visits to the home during daytime hours on 30th May and 14th June 2007. The opportunity was taken to look at the key standards of the National Minimum Standards (NMS). This inspection will also be used to decide how often the home needs to be visited to make sure that the required standards are being met. During the visit, time was spent talking to six people living in the home, three visitors, five members of staff on duty, the administration assistant and the manager. The registered manager was present on the second day’s visit. Additionally, time was spent sitting in one of the lounges on the dementia care unit to observe the care being given to a small group of people. This was followed up with conversations with the staff on the unit and examination of records. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken to assess the quality of the environment. What the service does well: Shawcross was commended for best practice in the areas of staff training and quality assurance monitoring. The staff training programme enables staff to develop their knowledge and skills so that they can competently and confidently meet the assessed needs of people living in the home. The quality assurance programme provides the people living there with a service that they can rely on. The people living in Shawcross benefit from the efficient way in which the home is managed. The needs of the people using this service are placed first and they receive good quality health and personal care. The atmosphere in the home is relaxed and people receive the right amount of help with their daily living activities. People are encouraged to express their views on the quality of the service they receive and the manager and staff team work hard to ensure that continual improvements are made for the benefit of the people living there. A visitor commented that the home provides a, ‘hotel-type service.’ Meals are important to the people at Shawcross and three people said that they enjoyed the food. Robust systems are in place to make sure that only people with the right personal qualities are employed to look after people living in the home. Procedures for protecting people from harm and for dealing with their Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 6 complaints offer reassurance that they will be safe living in the home. Similarly the building is regularly maintained and this provides a safe, pleasant and comfortable environment in which to live. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 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 Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People admitted to the home can be confident that their needs will be fully assessed to ensure that the home can provide the support and care that they need. EVIDENCE: Five files examined contained care manager assessments of need. When the home receives a referral the manager goes to visit the person to undertake an in-house assessment that will determine if that person’s needs can be met by the service. The dependency assessment tool used is comprehensive and together with care manager assessments provides the manager with the information she needs to make a decision on whether to offer the person a place. The person being referred and their relatives or representatives are fully involved in the process and wherever possible are invited to visit the home before they decide if they want to accept the offer of a place. The manager said that some of the people referred lack capacity to be fully Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 9 involved so involving their representatives is crucial to understanding a person’s background and current needs. The home did not provide an intermediate care service. Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples health and personal care needs are met in a respectful and private way. EVIDENCE: Five care plans were examined during the first visit to the home. The care received by two of these people was monitored to see if they were receiving support and care as stated in their care plans. Signed care plan agreements were in place to demonstrate that people living in the home and/or their representatives had participated in the process. Care plans had been reviewed every month and updated if a person’s needs had changed. Written records provided evidence that people had access to the full range of healthcare professionals, such as dieticians, speech therapists and specialist hospital services. Health monitoring was good and where concerns had been identified prompt referrals had been made to the relevant healthcare professional. There was also written evidence that healthcare advice was followed up consistently. The manager said that staff had developed very good Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 11 working relationships with health personnel and that this was a useful resource that resulted in positive healthcare outcomes for the people living in the home. At the time of the visits new care plan formats were being introduced for people newly admitted to the home and some gaps were noted in the records. For example, one person had been assessed as high risk for developing pressure ulcers although no care plan for pressure relief was in place. This had been addressed by the time of the second visit to the home. This person had been admitted three weeks prior to the inspector’s first visit. His daily records detailed that he had sustained a cut to his face from a bed rail that had not been covered with a protective bumper pad. The member of staff making the recording had failed to complete an incident report. It is important that incident and accident reports are consistently completed so that the manager can monitor and take action to remedy such risks in the future. Such shortfalls were not found in the older style care plans still in use. It is acknowledged that the organisation required the implementation of the new care plan formats, although no specific training had been provided for the manager or staff. This appeared to cause difficulties for staff in becoming accustomed to the new format in use. The manager had identified this and confirmed that she would be providing training for all staff and had set a three-month timescale to implement the new care plans for all people living in the home. The systems for administering, recording and storage of medication were assessed on the unit providing care to people living with dementia. All medication was securely stored in a locked medicine trolley located in a locked room. Medication received into the home had been carefully checked by staff to ensure that it was correct and all returns to the pharmacy had been recorded. Medication records were clear and legible and a sample of medication in stock agreed with the balances recorded. The senior care assistant on duty was asked to describe how medication is administered to people living in the home. She was confident in her answer and demonstrated good practice in this area. Three visitors were asked if they thought the staff were respectful and if they promoted dignity for the people living in the home. The three visitors confirmed that their relatives were treated with utmost respect and in a dignified way. One of the visitors said, “I come here a lot and have never seen any of the staff being anything less than respectful. They are a kind and caring bunch of staff and have the residents’ best interests at heart.” This was further confirmed during an observation session in one of the dementia unit lounges where staff were seen to address people by their preferred names and discreetly escort people to their own rooms if they needed support with personal care. Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home eat healthy diets, maintain regular contact with family and friends and generally engage in regular activities of interest. EVIDENCE: The home employs an activities co-ordinator whose role involves planning and organising activities that provide stimulation and interest for people living in the home. Examples of people’s craftwork were seen displayed in the home and staff provided verbal examples of the range of activities that were offered. These included armchair exercises, music, TV and video, memory games, a pen-pal project with children at a local school, manicures, shopping and meals out. It was generally accepted among the staff team that more one-to-one activities were needed with people who suffered mental and physical frailty and one member of staff commented that more staffing during daytime hours would facilitate this. Staff generally seemed unsure of the type of activities that people suffering such frailties could participate in and this was discussed at length with the manager. This is an area that could be developed and it was recommended that the manager undertake some research into this area to determine current good practice in providing regular stimulation for the people living in the home. Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 13 Time was spent in the afternoon observing a small group of people in one of the lounges on the unit that provides care to people living with dementia. The atmosphere in the lounge was relaxed as people listened to the music of the 1930’s. It was evident that this was an enjoyable experience as most people were tapping their feet and keeping time with the music. Throughout the observation, staff were seen to interact well with people, referring to them by their preferred names and treating them with respect. It was pleasing to see that staff took special care to talk to people on their level and to maintain good eye contact with people who had hearing impairments. The manager added that a lady living in the home has sight impairment and uses a sensory board to aid communication. One of the people in the lounge had three visitors and staff provided them with tea and biscuits. Staff demonstrated that they had developed good relationships with these visitors and took time to engage in meaningful and inclusive conversation. Two of the visitors to the dementia unit and a visitor to the nursing unit were asked their views about the quality of care provided by the home. One of the visitors commented that her relative was very well cared for and felt that a hotel type service was provided. Another visitor confirmed that staff always telephone if they have any concerns about the welfare of her husband. All three visitors praised staff for being kind and caring and said that they were completely satisfied with the way their relatives were cared for. The visitors said they were always made welcome in the home and that staff were approachable and responsive. Care plans examined contained evidence that people admitted to the home had their nutritional needs assessed and their weights were regularly monitored. Food hygiene was not assessed on this occasion as the home had recently undergone a food inspection. A copy of the Environmental Health Officer’s report was shown to the inspector and this confirmed that food hygiene regulations had been met. The inspector joined two people in the dining room for their lunchtime meal. A choice of two hot meals and a dessert was provided in line with that day’s displayed menu. During lunch three people confirmed that the meals provided were of good quality and sufficient quantity. Drinks and snacks are available twenty-four hours a day. People needing assistance to eat were helped in a relaxed and unobtrusive way by staff. It was very pleasing to note that one of the people admitted to the home five weeks before this visit had made such good progress that he no longer needed a soft diet. He said that he had thoroughly enjoyed his meal. Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems in place and staff training ensure that people living in the home are afforded protection from harm and their concerns are listened to and action will be taken to put things right. EVIDENCE: Policies and procedures for dealing with complaints were in place and people referred to the home had been given written details on how to make their concerns and complaints known. The most recent complaint was received in June 2006. Records provided evidence that this complaint had been substantiated following a detailed investigation. It was pleasing to note that an action plan had been developed to prevent similar shortfalls happening in the future. The complainant had been provided with full written details of the outcome of the investigation. Two visitors to the home confirmed that they knew whom to contact if they had any concerns. It was pleasing to note that action had been taken to comply with the requirements of the Mental Capacity Act 2005, the second part of which will come into force in October 2007. The manager said that people living in the home would be assessed to determine their capacity to consent to treatment and other important life decisions. However, some people may also lack capacity to make the more usual decisions associated with their daily living and if decisions need to be taken on their behalf this should be recorded in Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 15 detail as part of the assessment process. A recommendation was made to this effect. The organisation had developed policies and procedures for safeguarding adults from abuse and these had been implemented. Additionally, copies of safeguarding adults’ procedures developed by Local Authorities that the home contracted with had been obtained. Two care staff said they had received training in this area and they were able to clearly demonstrate the appropriate knowledge of what they would do if there were any allegations or suspicions of abuse. These systems and staff training afford protection to the welfare and safety of people living in the home. Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Redecoration, renewal and refurbishment of the home’s facilities and equipment ensure that people are provided with a safe, comfortable and pleasant living environment. EVIDENCE: Shawcross provides people living there with accessible, attractive, and safe accommodation. The dementia care and nursing units are located in separate buildings, linked by an office and reception area. Both units are on two floors and each floor has its own lounge and dining area. Ample off road car parking spaces are situated at the side of the home. A tour of the home and examination of maintenance records provided evidence that the home has been regularly maintained. All areas were found to be clean and hygienic and no unpleasant odours were present. Ramped access was provided to the front door and level access throughout each of the two floors. Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 17 A passenger lift was provided and handrails fitted to corridors throughout. People living in the home and staff spoken to, said that the domestic staff did an excellent job of keeping the home clean. Grounds were seen to be safe, tidy and accessible to people living in the home. One person spoken to said that he enjoyed sitting outside in the nice weather. People admitted to the home were able to bring their personal possessions in with them, such as family photographs and ornaments and bedrooms were seen to reflect individual’s interests and personalities. The manager and another member of staff had been booked on a training course to update their skills and knowledge in how to control infection safely. The manager said that they would then roll out the training to the rest of the staff. Clinical waste was being disposed of according to good practice guidelines. The laundry was sited away from the food preparation areas and suitable facilities had been provided to meet the needs of people living in the home. Laundry equipment had been regularly maintained. Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that staff have the personal qualities, skills, knowledge and experience to meet the assessed needs of people living in the home. EVIDENCE: The dementia and nursing units were each split into two smaller units staffed by separate teams. A qualified nurse and two care assistants were on duty on each of the nursing units and unit managers had been employed to take responsibility for the day-to-day management. Day-to-day management of the dementia unit was the responsibility of a senior care assistant supported by two carers. An activities co-ordinator was also employed. These staffing resources appeared to be sufficient to meet the assessed needs of the people living in the home. However, as mentioned earlier on in this report care assistants working on one of the nursing units said that they would like more time to be able to become involved in meeting the social needs of the people they cared for. This is an area that can be developed by utilising the skills of the staff team to provide increased interaction with people living in the home. A recommendation was made for some research to be undertaken in this area. The personnel file belonging to the most recently recruited member of staff was assessed for evidence that the required pre-employment checks had been undertaken. This person’s file contained two written references and evidence Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 19 of a current Criminal Record Bureau disclosure along with evidence that confirmed the person’s identity. This member of staff had also completed an induction programme. Induction programmes for new staff were in the form of a workbook that was linked to the National Minimum Standards for Older People. A mentor who was an experienced member of staff oversaw completion of the workbooks. New employees had completed case studies and supervised tasks that demonstrated their learning and competence in meeting the needs of people living in the home. This was identified as an area of best practice and was commended. The manager was focussed on ensuring that staff had regular opportunities to develop good practice through regular and ongoing access to training. At the time of the visit, training records were being separated from personnel files so that each member of staff could have access to their individual training records. These records contained staff development plans, workbooks and National Vocational Qualifications (NVQ) and training certificates. Staff development needs had been identified during regular supervision sessions and the manager said that staff were encouraged to also identify their own learning needs. It was pleasing to be told by two care assistants that they had recently identified that it would be useful to have more knowledge of the conditions associated with diabetes so that they could recognise if people were becoming unwell. A suitable course had been provided and the two members of staff said that this had increased their knowledge and skills in this area. The 50 target for care staff to achieve a level 2 NVQ in care had been exceeded and domestic staff employed by the home had achieved NVQ level 2 in housekeeping. Currently, seven members of staff were working towards achieving NVQ level 2 in care. Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality assurance systems ensure that the home is managed in the best interests of the people living there. EVIDENCE: The registered manager was suitably qualified and experienced in the care of older people and since the last inspection she had completed the Registered Managers Award. During conversations with the manager it was evident that she was forward thinking and required the best possible outcomes from the staff for the people using this service. Staff spoken to said that the manager was approachable and always ready to listen to innovative ideas and suggestions to improve the quality of the service provided. The manager had been in post for the previous two years and previous inspection reports provide evidence that the standard of service provision has consistently been improved Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 21 and maintained. The manager expressed her view that quality assurance monitoring is crucial to this improvement process and a robust system has been implemented during her period in charge. A professionally recognised quality assurance programme is conducted by an organisation named RDB. RDB conduct annual audits of the home’s care provision, which takes up to three days, the most recent one being in October 2006. The service achieved a four-star rating following this audit, which was an improvement on the three stars achieved the year before. RDB’s accreditation report commended the service for its focus on person-centred care provision. The manager stated that she is aiming for the maximum five-star accreditation this year. In addition to this formal quality assurance programme the manager has implemented robust systems to assess quality on an ongoing basis. Satisfaction surveys are issued to stakeholders (people living in the home, their representatives and interested professionals) every year. Data from the surveys is analysed and a quality report and action plan are produced to inform the home’s business plan. The manager adopts a hands-on style and works a late shift every week and a Saturday or Sunday every month. This gives her the opportunity to work with all staff employed by the home to assess their performance and the outcomes experienced by people living in the home. The manager also holds ‘open clinics’ once a month to make herself available for discussion with relatives and visitors to the home. In adopting this approach the manager has up to date information on peoples views on how well the home is operating and it gives her the opportunity to address any issues that are brought to her attention. Furthermore, the organisation’s regional manager visits the home at least monthly to report on how well the home is being managed. Detailed action plans are produced with timescales for improvements needed and these are monitored and reviewed by the regional manager at each months visit. This robust system of quality assurance is considered to be an example of best practice and is commended. Seven people living in the home have appointed power of attorney’s to deal with their personal finances. The manager said that the home’s staff do not deal with appointee-ship for benefits purposes. The home’s administrator looks after small amounts of day-to-day spending money and accurate and up to date records are held of all transactions made. In conversation with staff on duty it was confirmed that mandatory health and safety training was up to date and regular refresher training was available. A sample of the home’s health and safety records was examined. It was evident that the homes electrical and gas equipment had been serviced and maintained regularly and the required health and safety checks were being done at the prescribed intervals. Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 OP12 OP14 Good Practice Recommendations Incidents and accidents occurring in the home should be recorded so that the manager can monitor and take remedial action to manage risks effectively. Research should be undertaken to establish the range of opportunities available for people with mental and physical frailties to engage in stimulating and interesting activities. In line with the Mental Capacity Act 2005 steps should be taken to ensure that all decisions taken on behalf of people that lack capacity should be recorded in detail during the assessment and care planning processes. Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Shawcross Care Home DS0000068317.V337475.R01.S.doc Version 5.2 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!