Inspection on 18/11/05 for Shawe House Nursing Home Ltd

This inspection was carried out on 18th November 2005.

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

Shawe House Nursing Home Ltd 29/07/09

Shawe House Nursing Home Ltd 30/01/09

Shawe House Nursing Home Ltd 28/12/07

Shawe House Nursing Home Ltd 22/09/06

Shawe House Nursing Home Ltd 28/02/06

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

CARE HOMES FOR OLDER PEOPLE Shawe House Nursing Home Ltd Pennybridge Lane Flixton Manchester M41 5DX Lead Inspector Elizabeth Holt Unannounced Inspection 18th November 2005 12:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shawe House Nursing Home Ltd Address Pennybridge Lane Flixton Manchester M41 5DX 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) 0161 748 7867 0161 748 7920 Shawe House Nursing Home Ltd Mr Bernard Leslie Evans Care Home 33 Category(ies) of Dementia - over 65 years of age (33) registration, with number of places Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 33 older people requiring nursing care as a result of an organic mental illness can be accommodated. Service users shall not be subject to detention under the terms of the Mental Health Act 1983. Staffing levels as specified in the Section 13 Notice dated 30 December 2002 shall be maintained. Date of last inspection Brief Description of the Service: Shawe House is a nursing home providing care for 33 older people with dementia. It is a converted large Victorian house with modern extensions. The home is located in Flixton near Flixton golf course. There are good bus links to nearby towns. There are 27 rooms (21 single rooms and 6 double rooms). The rooms are situated on the ground floor and the first floor. There is a passenger lift available for the residents to use. Shawe House has two lounges and one was used as lounge/dinning area. The other lounge was used for quieter pursuits. There are 2 bathrooms with toilets, a shower room with toilet, and 3 single toilets. The home overlooks green open space and it has a spacious parking area at the front of the house. There was a large and well-maintained garden. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on 18 November 2005. Time was spent talking to the line manager, the manager of the home and staff. The opportunity was taken to talk to some of the residents and their relatives during the inspection. The paperwork kept at the home was looked at. 32 residents were accommodated at Shawe House at the time of the visit. Most of the improvements needed at the last inspection had been carried out. Other areas were identified as requiring improvements during this inspection. Not all the standards were inspected and this report should be with previous reports to get a good picture of the services being provided by Shawe House. What the service does well: The home had a warm and friendly feel to it. The atmosphere was calm and relaxed. The residents and their relatives felt that they could talk to any member of staff and they will be listened to. The manager arranged family meetings every 2 months for the residents and their relatives to talk about any issues they may have. The residents and the relatives that we spoke to during the inspection said that the Home arranged for someone to visit them to talk about their needs before they made a choice whether to use the services of the Home. They said that the manager encouraged them to visit the home and to meet those who were already accommodated at Shawe House before they made a choice. The bedrooms were nicely decorated and were decorated in the way in which the individual residents preferred. Other areas of the home were being decorated at the time of the inspection. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 6 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. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6. Prospective residents received all the necessary information to make a decision whether to use the services of Shawe House. All residents were assessed before being offered a place. EVIDENCE: The manager ensures that all prospective residents are assessed and issued with the homes Statement of Purpose and the Service User Guide. The manager or a qualified member of staff visits the prospective resident to assess them before they are offered a place. This is evident in residents’ records. The home liaised with the prospective resident’s relatives, social worker, and representatives to ensure that the resident’s interests are safeguarded. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 9 Prospective residents were given the opportunity to ‘test drive’ the home before they are offered a permanent place. All new residents were given a four weeks trial of the home to help them make a final decision whether to accept the services of Shawe House. Shawe House does not provide intermediate care. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. The health, personal and social care needs of the residents was documented in the care plans that enabled staff to meet the assessed needs of the residents. The medication procedures were suitable to meet the needs of the residents. The staff treated each resident as an individual and worked hard to ensure they promote their independence. EVIDENCE: The care plans examined were detailed. They included admission assessments, Trafford’s multi-disciplinary assessments, risk assessments, and monthly mental health reviews. The care plans were personalised and well maintained. Staff spoken to had a good understanding of the care needs of the residents. 2 relatives spoken to stated how good the care being provided was. 1 lady who visited regularly said, “I see a lot and these staff are very kind to these old people”. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 11 There were procedures in place for the administering and handling of medication. None of the residents accommodated at the home managed their own medication. Observations during the inspection indicated that the residents were treated with respect. The staff spoke to the residents in a dignified and respectful manner. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. The home continues to support the residents to maintain contact with their relatives, friends and advocates. Individual lifestyles are met. However, there were little leisure activities being organised. The home provides a wholesome and appealing balanced diet. EVIDENCE: The home continues to support the residents to maintain contact with their relatives and friends. Visitors were welcomed at anytime of the day. There was a plan of leisure activities in place but the evidence seen indicated that the home could do better by organising more leisure activities and entertainment. A Halloween party was organised and some of the relatives said that it was enjoyable. There was a menu in place that included choice. The residents that we spoke to said that the meals were nice. Residents on special diets were catered for. This included diets for residents with diabetes, allergies to certain foods or ingredients, and soft diets. Some of the residents requested meals that were not on the menu when unwell and the home was able to cater for their preference. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Policies and procedures for dealing with complaints were in place. The policies and practices of the home ensure that residents are safeguarded from abuse and harm. EVIDENCE: The complaints procedure was displayed in the hallway and it was visible to the residents and their relatives. The complaint policy and the complaints logbook were also available in the office. The relatives spoken with were clear about how to make a complaint. The staff that we spoke to were also aware of the complaints policies and procedures. There were policies and procedures in place regarding the Protection of Vulnerable Adults and Whistle Blowing. All staff spoken to had a full understanding of potential indicators of abuse and what to do when they became aware of an allegation of abuse. They confirmed that they had received training for this. There was a display which included a telephone number at the hallway headed ‘Adult Abuse’ that asked any person to contact the adult abuse team when they had any concerns. Trafford Borough council issued this. In addition, there was a leaflet explaining what abuse was and the forms of abuse. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. The home appeared safe, well maintained, clean, and nicely decorated. However, there was unpleasant urine odour in some bedrooms. EVIDENCE: There was evidence of a programme of redecoration and improvement. Windows and some floors have been replaced. The residents enjoyed a well maintained home and it was in a good decorative order. All the bedrooms were personalised and decorated nicely. The residents live in a clean and hygienic home. The home is cleaned on a regular basis, although some of the bedrooms had an unpleasant urine odour. The current management of this must be reviewed and the appropriate measures taken. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. The home makes sure the right staff are employed to look after vulnerable people. This means that residents are safeguarded by the robust employment practices of the home. EVIDENCE: The duty rosters indicated that the numbers and skill mix of staff would be adequate to meet the needs of the residents accommodated at Shawe House. Staff members had individual files that contained all the necessary required information. The home had a robust recruitment procedure, which ensures that the staff were suitable to work with vulnerable residents. Staff files examined revealed that thorough pre employment checks were carried out. All staff received induction training and the staff that were spoken to said that the induction training they received equipped them with the necessary skills to carry out their role confidently. Each staff had an individual training profile that clearly showed they had received specialist and mandatory training. New starters were issued with a folder containing all the policies and procedures required to carry their duties appropriately. One member of staff said, “I am very happy with my job”. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 16 Although one of the staff members said they received supervision from the senior members of staff there were no records to indicate that this was being carried out. The manager said that he intends to carry out regular supervisions with all his staff. This must be carried out on a regular basis and a record kept on staff personal files. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. The home is well run by the manager. The manager listened to the views of the residents and their relatives. Policies and procedures were in place to ensure that the well being of the staff and residents are protected. There are financial procedures in place however, it was not adequate to protect the interest of the residents. EVIDENCE: The manager was undertaking NVQ Level 4 Managers award and hoped to complete it by next year. The manager had made efforts to put all the necessary systems and arrangements in place to enable the home run smoothly. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 18 Questionnaires are sent to the residents and their relatives at least once a year to find out whether the home is providing a good service. Residents’ finance records were examined and were found to be inadequate to protect them from financial abuse. The balances were not being checked on a regular basis. Regular checks must be carried out. Two people must sign all entries. There were health and safety policies and procedures in place to promote and protect the residents from harm. Fire tests are carried out on a weekly basis. Moving and handling training was offered to the staff and was ongoing. Equipment tests were not being carried out at suitable intervals and must be addressed. An accident logbook was in place and the accidents were audited on a regular basis. Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 19 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 3 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 2 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 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 20 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. 1 Standard OP12 Regulation 16 Requirement There was little evidence of leisure activities and the registered person must ensure more activities are organised for the residents. The registered must ensure that the offensive odours in some of the bedrooms are eradicated to enable the home meet its aims and objectives set out in the Statement of Purpose. The registered person must ensure that all staff received regular supervisions. The registered manager must ensure that there are safeguards in place to protect the financial interest of the residents, and maintain records specified in Schedule 4 (9). The registered person must ensure that fire equipment are tested and maintained at suitable intervals. Timescale for action 15/12/05 2 OP26 23 15/12/05 3 4 OP30 OP35 18 17 01/01/06 15/12/05 5 OP38 23 15/12/05 Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shawe House Nursing Home Ltd DS0000064072.V262747.R01.S.doc Version 5.0 Page 22 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. 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