Inspection on 22/09/06 for Shawe House Nursing Home Ltd

This inspection was carried out on 22nd September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 28/02/06

Shawe House Nursing Home Ltd 18/11/05

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 22nd September 2006 9:30 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 Shawe House Nursing Home Ltd DS0000064072.V298256.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. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 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.V298256.R01.S.doc Version 5.2 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. 28th February 2006 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 large Victorian house that has been appropriately converted and extended. The home is located in Flixton in an area that is close to Flixton gold course. There are good bus links to nearby towns. There are 27 rooms of which 6 are ‘shared’ rooms, 12 bedrooms have en suite toilets. The rooms are situated on the ground floor and first floor and a passenger lift is available for the residents to use. Shawe House has two lounges, one of which was used as a lounge/dining area and the other was used for quieter pursuits. There are 3 bathrooms with toilets, a shower room with toilet and 3 single toilets. There is a large and well-maintained garden that overlooks green open space and a large parking area at the front of the house. Fees charged by the home were £499. 50 per week. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit that took place on 22 September 2006. To establish what the home was like for residents living there, time was spent talking to residents, some staff on duty including the manager and relatives who visited the home during the inspection visit. Information was gathered as part of the inspection process, which included a questionnaire completed by the manager, which gave information about the residents, the staff and the building. A limited tour of the premises was undertaken and resident and staff files were also examined. The last visit to the home in July 2006 identified a number of areas that the home needed to improve. The home forwarded information to the Commission for Social Care Inspection showing how they had addressed those issues. What the service does well: What has improved since the last inspection? Since the last inspection the Registered nurses had received training in care planning. Staff spoken to had found this useful and the paperwork relating to care planning had been reviewed and updated. It was also seen that improvements had been made in the risk assessments carried out and how these were recorded. There was evidence that improvements had been made to the environment to make it more homely. The conservatory/lounge had been redecorated and new furniture and flooring had been provided. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 Page 6 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.V298256.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 Shawe House Nursing Home Ltd DS0000064072.V298256.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 at least once during a 12 month period. 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. Procedures are available to ensure that the needs of prospective residents are fully assessed before they are admitted to the home. EVIDENCE: The files of two residents recently admitted to the home were examined and were found to contain detailed pre-admission assessments that had been carried out. It was confirmed that the manager or a senior nurse on duty would complete the pre-admission assessment forms. Intermediate care was not provided by the home. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 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. The care needs of the residents were recorded and staff treated residents with respect and promoted their independence. Medication procedures were in place that protects the residents. EVIDENCE: At the last visit to the home in July 2006 a number of requirements were made to ensure that care plans were appropriately recorded. This was following a concern that had been raised to the local authority under the Protection of Vulnerable Adults (POVA) procedure. A random sample of care plans were examined during this visit that showed appropriate improvements had been made. Evidence was available to show that care plans were discussed with relatives where possible. A new format for the recording of falls risk assessments had been developed and was in use. Staff were clearly aware of the individual risks and needs of each resident. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 Page 10 Information relating to the social activities individual residents may wish to participate in was not included in the care plan. This could prevent some residents’ social needs not being fully met. There was evidence of the home making improvements in the nutritional support provided to residents in line with current guidelines. Improvements had also been made in the recording of wound care management. Observations during the inspection visit indicated that the residents were treated with dignity and respect. One of the visiting relatives said, “I can rely on the staff to tell me of any changes in my wife’s care and they are very kind and caring.” There were policies and procedures in place for the safe handling and administration of medication. Examination of the medication administration records showed that these had been appropriately completed. A requirement made following the visit in July 2006 regarding the administration of ‘morning medication’ was found to have been addressed. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 Page 11 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 and 15 Quality in this area outcome is good. This judgement has been made using available evidence including a visit to this service. Activities were provided and residents were encouraged to maintain contact with family and friends. Residents could exercise some choice over their lives and residents received a balanced diet. EVIDENCE: Information relating to the type of social activities that an individual resident may like to be involved in had not been recorded in their care plans. However, there was evidence of a number of social and recreational activities being made available for residents to participate in. Some residents had been on an outing to a local steam engine fair and attended trips to local pubs. Examples of in house entertainment included singing along to music, music therapy, artwork, and special occasion parties. During the inspection staff were observed assisting residents in an appropriate and dignified way. One resident was encouraged to complete a jigsaw puzzle and another resident was looking at a magazine with a staff member. It is recommended that appropriate information regarding social activities be recorded in the individual residents’ care plan. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 Page 12 The home had an open visiting policy and relatives and other visitors could be received into the residents’ own room or any of the communal areas of the home. From discussions with staff it appeared that residents are able to exercise choice over their lives. One staff member who was relatively new to the team described how he would promote choice in relation to the clothes the resident wore each day. Mealtimes were being promoted as a social occasion and attempts to encourage residents to sit together where possible were being made. The menu included choice for the residents. Residents who could express a view said the meals were very good. Staff were observed to appropriately assist those who required some help and encouragement at mealtime. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has the systems and procedures in place to protect residents from abuse and that allows people to express their complaints/concerns. EVIDENCE: A policy was in place for the protection of vulnerable adults and staff spoken to were aware of how to put the policy into practice. Relatives spoken to were clear about how to make a complaint and they felt confident that a complaint would be dealt with appropriately. The home had a record of any complaints made. Following concerns that had been raised under the Protection of Vulnerable Adults the local authority had carried out investigations supported by the management of the home in relation to alleged poor practice. During this inspection visit the opportunity was taken to follow up the requirements that had been made following that investigation process. These requirements were found to have been appropriately met. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are safe, homely and comfortable. EVIDENCE: On arrival at the home it was evident that there was some odours, however this appeared to be well managed and ongoing cleaning routines meant that the home was free from odour and was well ventilated as the morning progressed. Residents’ bedrooms were seen to be homely, comfortable and personalised. During a limited tour of the building, which included communal areas, toilets and a number of resident’s bedrooms, it was noted that bedroom 7 requires redecorating. Décor and furnishings were generally acceptable and there was evidence of a programme of redecoration in place. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and deployment of staff appeared sufficient to meet the residents’ assessed needs. Recruitment and selection procedures were in place to safeguard and protect the residents. EVIDENCE: On the day of the inspection the staffing numbers and skill mix appeared appropriate to meet the needs of the residents accommodated. Staffing levels included the manager, 3 Registered nurses and 7 care assistants. Staffing rotas were available to indicate how many staff was on duty at any particular time. The manager was present in the home on the day of the inspection. The home employs 18 carers, 8 of the staff members have successfully completed National Vocational Qualification level 2. The senior staff in the home encouraged Training and development and staff said they found study days useful. A training list of all study days/courses attended was provided showing training available to staff. Evidence was seen that newly appointed staff went through a structured induction process. A staff member spoken to said he had found the induction period a positive experience. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 Page 16 The home had recruited a number of new staff since the last inspection in an attempt to minimise the use of agency staff. The manager stated that the use of agency staff had been exceptionally high however this had been due to a number of staff on long term sickness. Policies and procedures were available to ensure the correct procedures are carried out when staff are recruited to the home. A sample of staff files were examined. All relevant pre-employment checks had been carried out. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A system was in place to monitor the quality of the service provided by the home. The health, safety and welfare of the residents and staff were promoted by the home. EVIDENCE: The manager demonstrated that he knew each resident well and had a detailed knowledge of his or her care needs. A questionnaire was available to seek the views of residents/relatives. A quality audit had also been sent out to visiting professionals. Information provided in the home’s pre-inspection questionnaire provided confirmation that all health and safety checks were current and up to date. Policies and procedures had been reviewed and updated. Staff commented Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 Page 18 they did read these and were made aware when new policies and procedures were introduced. The home was maintaining an accurate fire log book with the required checks and fire drills. Procedures were in place for the safe keeping of residents’ finances. Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 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 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 Page 20 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. 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 Refer to Standard OP12 Good Practice Recommendations It is recommended that all residents are consulted about their social interests, and arrangements made to enable them to engage in local, social and community activities. It is recommended that room 7 is re-decorated as part of the rolling programme of maintenance. 2 OP19 Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 Page 21 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 Shawe House Nursing Home Ltd DS0000064072.V298256.R01.S.doc Version 5.2 Page 22 - 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. 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