Inspection on 28/12/07 for Shawe House Nursing Home Ltd

This inspection was carried out on 28th December 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

Shawe House Nursing Home Ltd 29/07/09

Shawe House Nursing Home Ltd 30/01/09

Shawe House Nursing Home Ltd 22/09/06

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 28th December 2007 10:00 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.V339997.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.V339997.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 www.shawehouse.co.uk 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.V339997.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. 22nd September 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 golf 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 £524 50p per week. Additional charges are made for hairdressing, chiropody and outings. Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a site visit, took place on Friday 28th December 2007. The manager of the home was not told beforehand of the inspection visit. All key inspection standards were assessed at the site visit and information was taken from various sources which included observing care practices and talking with residents who live at the home, visitors, members of the staff team and the home owner who was present during part of this site visit. We sent the manager a form called an Annual Quality assurance assessment (AQAA) before the site visit to tell us what they thought they did well, and what they need to improve on. We considered the responses and information the manager provided and have at times referred to this in the report. Before the site visit residents, relatives, staff and health professionals were sent surveys asking them to comment on the service. A number of survey reports were returned and where possible some of the information has been used in the report. A tour of the building was conducted and a sample of care and staff records was looked at, including employment and training records, staff duty rotas and resident’s care plans. The Commission had been informed the Registered Manager was leaving his position and the new manager was due to commence on the 3rd January 2008. Temporary arrangements were made for an experienced nurse to take on the management role during this period of absence of a manager. Information provided by the manager of the service prior to the inspection showed that no complaints had been made directly to the home since the last visit. One allegation of poor care practice was not upheld following an investigation under Trafford Council’s adult safeguarding procedures. What the service does well: The internal and external appearance of the home provides a clean, pleasant and comfortable environment for residents to live in. Residents were seen moving around the home in a purposeful way and they were encouraged to spend time in the dining and day areas. Relatives and visitors spoke favourably about the environment in which the residents lived and those residents, who could express a view, liked their bedrooms and felt the Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 6 standard of cleanliness in the home was always good. The atmosphere in the home during the visit was relaxed, friendly and welcoming. The home carries out detailed assessments of each prospective resident before they are admitted to the home and this information was used to develop the care plans. Residents were registered with a General Practitioner (GP) and were supported to receive professional input from other health professionals as needed. Staff showed their skills in communicating with residents and their representatives. The relationships between the staff and the residents/relatives were friendly and it was evident they knew them well. From the observations during the inspection it was evident the residents were treated with respect and dignity and their right to privacy was upheld. Relatives spoken to during this inspection visit said they were satisfied with the way staff treated them. Relatives spoken to felt involved in the care and were generally kept informed of changes in their relatives’ healthcare needs. Comments from relatives included, “I visit here regularly and the staff are always kind and helpful”, “The staff are lovely, I have never seen anyone be sharp or short with a resident, they are very caring and patient”. The staff were heard talking to residents in a kind, sensitive manner and supported them appropriately during meal times. The meals provided looked appetising and relatives were complimentary about the food provided to their family members. The programme of staff recruitment protected the residents. The maintenance and refurbishment programme is ongoing to keep the environment pleasant for the residents. What has improved since the last inspection? Since the last inspection the care plans were audited more regularly to ensure that all the residents identified needs are met. There was an improvement in the recording of the social and recreational activities provided in the individual residents’ care plans. Since the last visit the home have employed an activities co-ordinator, and purchased multisensory equipment to stimulate, entertain and create a peasceful environment in the lounge where this is setup. Training in the End of Life Care has been provided to staff since the last inspection and staff have found this to be most worthwhile to improve the quality of care provided to residents. Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 7 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. Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 8 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.V339997.R01.S.doc Version 5.2 Page 9 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. Prospective residents needs are fully assessed prior to them moving into the home. EVIDENCE: Three residents were case tracked. Pre-admission assessments had been carried out for all three and the assessments were comprehensive. The assessments included activities of daily living, mini-mental score, and a tool to identify risk and a family history where possible. Care managers from the funding authority carried out assessments and copies of these assessments were available. The representative from the home then carried out further assessments. Information in the assessments was used to generate a working care plan. Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 10 The information in the Annual Quality Assurance document (AQAA), the selfassessment completed by the manager of the home prior to the inspection, provides evidence that the manager and the staff value the assessment process as important. Following the assessment, admission is arranged on a trail basis of six weeks, giving the opportunity to the resident/advocate/social worker to stay at the home or to transfer to another establishment. When being placed on the waiting list, the resident is encouraged to visit, if this is not possible it is essential that the advocate visit. Information is taken and given to ensure clarity of expectation, choice and detailed information regarding the home. Whilst visiting the home advocates are encouraged to talk with other visitors and relatives to ascertain their opinion of the home. It is only after comprehensive information that advocates can make an informed choice of home. An up to date Statement of purpose was not available during this visit. Shawe House does not provide intermediate care. Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 11 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. Residents are supported appropriately so their health, personal and social care needs are met. EVIDENCE: Three residents were case tracked. The care plans were generally well detailed to enable the staff to understand the care they needed to provide to support the residents. Specific detail was in place for staff to monitor the mental health needs of resident’s however some of the plans of care were not always clearly written for the staff to be able to monitor the progress of the residents’ healthcare needs. A named nurse and key worker are allocated to each resident and these staff contribute to the care plans. There was documentary evidence to show that Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 12 residents had access to a range of medical services available in the community. Entries in the care plans showed records of professional visits and evidence of the monitoring of patients. The staff had approached the consultant psychiatrist in relation to a resident whom the staff had noted as being labile in mood throughout the day. Care plans showed detailed evaluations of the planned care and there was evidence of the likes and dislikes of individual residents, for example, “…prefers showers and likes them regularly.” Throughout the visit the residents appeared relaxed and generally settled and happy in their environment. For one resident there was a detailed risk management strategy and a behavioural risk assessment. The notes included evidence of the staff having explored with the resident and his family reasons for changes in their behaviour. Moving and handling risk assessments, pressure sore prevention, falls and nutritional assessments are included in the care plans. Information provided in the self-assessment highlighted that since the last inspection staff had received training in End of Life Care (Liverpool Palliative Care Model), which has become a feature of the home’s care provision. Residents, after full consultation have ended their life in an environment that is tailored to meet their needs which takes into consideration their individual wishes and preferences. Families are supported at this time and whilst a resident is receiving palliative care, the home has totally open visiting times and will cater for the needs of relatives for example, providing meals, allowing the family to stay and help in the care of their relative. All disciplines work in a co-ordinated fashion to maximise a peaceful passage to death. Training is underway to attain the gold standard framework for care homes with dementia, which will develop further the skills of the staff and enhance end of life care. Information provided before the visit showed the home is using the Malnutritional Universal Screening Tool to enhance the dietary needs of the residents, ensuring that weight loss is recognised early and intervention can be implemented immediately. The home is working closely with community dieticians, firms supplying food supplements and the speech and language team to reverse under nourishment common within care settings. Two care plans showed evidence of close monitoring of these residents weight and nutritional status. Observations during the inspection visit indicated that the residents were treated with dignity and respect. Staff were seen sitting and chatting to Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 13 residents on a one to one basis and where one resident was seen to be tearful, the staff member pulled up a chair to sit next to them and engage with them and offer support. The home uses a pre-dispensed monitored dosage system. A sample audit of the medication administration records (MAR) showed these were generally adequately maintained, however staff must sign when the drugs have been administered and if charts have to be handwritten, the staff must sign and countersign these. The storage for Controlled Drugs was very small and a controlled drugs cupboard, which is compliant with current regulations, The Misuse of Drugs (safe custody) Regulations 1971 must be planned for particularly in light of the potential for the need to hold more Controlled Drugs if residents are on the End of Life Care pathway. Records for the receipt of medications into the home and of medication for disposal were maintained. Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 14 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. The lifestyle experienced in the home matched the expectations and preferences of the residents and family/representatives. EVIDENCE: An activities organiser is employed at the home and works for 30 hours per week. During the inspection staff were observed assisting residents in an appropriate and dignified way. One staff member was seen having a memory game with a resident before their morning cup of tea. A discussion with the activities organiser and staff at the home highlighted that the activities provided for example, arts and crafts, collage work, sessions with multisensory equipment to stimulate, entertain and create tranquility, parachute game and table tennis, highlighted that this work is very much on the day with the residents as their attention span and compliance can be very low. Residents are focused and supported to achieve realistic and meaningful goals and time was spent establishing the residents mental capacity during Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 15 activities. Recordings in the care plans showed this. 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 some choice over their daily lives. Mealtimes were promoted as a social occasion and attempts to encourage residents to sit together where possible were being made. The dining areas in the two lounges were used and some residents sat at small tables with other residents whilst other residents ate alone. Staff were observed to appropriately assist those who required some help and encouragement at mealtime. A resident’s son who visited every day said during the visit, “My Mum is so well cared for here, I do not have any worries about her because they do such a good job. The home held a family buffet on Xmas Eve, which was very well attended and an entertainer who came too.” Another relative replied saying, “The only slight niggle that I have is that when I arrive at 12.00 as the canteen opens, some of the staff go off to have their own meals and as a result there do not often seem to be enough staff around to help the many residents who need assistance with eating. A few residents who appear to require help are left to fend for themselves. But I can also see the problem as the staff have to eat sometime. I have always been impressed with the standard of the mid day meal. It looks like superb quality meat whether for casseroles or the roast on Sunday and is really well cooked. This is a tribute to the butcher but also to the cooks. I am also always impressed with the standard of dress of all the residents, excellent laundry and ironing and no one ever looks unkempt. Good attention also to haircutting and foot care etc.” 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. A discussion with the chef showed that he was enjoying a degree of flexibility in managing the daily menus. There main meal at lunchtime looked appetising and there was a homemade thick vegetable soup for the evening meal. A brief tour of the kitchen showed that there were good stocks of fresh and frozen food including meat and vegetables. One of the relatives responded in the survey as follows, “Staff continuously interact with patients at appropriate levels and are always mindful of their needs. Good food, preparation, presentation and quality. Good entertainment, which stimulate the patients well. Excellent care is given by the staff here under what I would call very difficult circumstances.” Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse and people can 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. Information provided to the CSCI indicated that staff had completed training in the Protection of Vulnerable Adults in the last twelve months. 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. A residents husband responded in the relatives survey saying, “My wife, though understandably very confused, displays the same equable temperament and placid disposition that has always been a feature of her behaviour and I have to assume that this is due to the understanding care and attention that she receives from the nursing and care staff. Even when a relatively small accident occurs, I am phoned and given an assessment serious or otherwise. This is a reassuring practice as no news is good news.” Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 17 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 unknown bruising and alleged poor practice, which were not found to be upheld. Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 18 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. The home provides a clean, homely and comfortable environment for the residents to live in. EVIDENCE: A partial tour of the home was carried out that included nine resident’s bedrooms. The home was found to be generally clean and tidy and with minimal odour. Bedrooms were personalised with photographs and some had small pieces of furniture, which families or residents had chosen to bring. The environment is spacious which allows residents to move freely around the home and the staff were seen to support residents who chose to wander. Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 19 Equipment was available in the home to make sure the physical care needs of the residents could be appropriately met. Bedrooms on the ground floor had been repainted and had new furniture since the last inspection and these looked homely and pleasant for the residents. The corridors had paintings on the walls, which were textured so that residents could feel these as they wandered around the home. Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 20 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 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. Residents were protected by the recruitment and selection procedures. EVIDENCE: At the time of the visit there were 28 residents accommodated at the home. The staff team includes a mix of Registered nurses and Registered mental nurses and care workers who were supported by domestic, laundry and catering staff. The staffing levels appeared appropriate to meet the needs of the residents and there had been an increase in domestic staff employed since the last inspection to keep the home clean for the residents. There has been some use of agency staff over the past month to cover for sickness and vacancies, however the duty rotas showed the use of regular agency staff over a period of time. The home employs 11 full time carers and 4 part time carers, 80 of these staff members have successfully completed National Vocational Qualification level 2. The senior staff in the home encouraged the training and development needs of the staff who said they valued study days. A training matrix was not available during this visit however individual staff files did show some of the Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 21 training courses the staff had attended. One staff member had recently had training on epilepsy, dementia care, a moving and handling instructors course and a recent course on food hygiene. Staff spoken to clearly knew the care needs of the resident’s well and this was evident in their practice. A sample of staff files were looked at. These contained the required documentation and checks to ensure the staff are safe to work with residents. The one staff member who returned a comment card said they were given training which they felt was relevant to their role and helped them to understand and meet the individual needs of residents. A relative spoken to who visits the home every day said she was very happy with the care her husband received and she felt the staff communicated quite well with her. She stayed for Xmas dinner and tea and said, “everything I see that goes on involves the staff being kind and attentive to the residents, everybody here looks very well cared for too. My husband is always well presented and if he needs attending too the staff never moan or make him feel a nuisance.” Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 22 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, 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. The health, safety and welfare of the residents and staff were promoted by the home. EVIDENCE: The home’s Registered Manager was absent from the home at the time of this visit and was due to leave his position. The new manager was due to start on the 3rd January 2008 and the responsible individual for the home held a residents/relatives meeting to introduce the new manager earlier in the month, which had been well attended. The manager is not yet registered with the CSCI but is awaiting her Criminal records Bureau check before submitting her application for registration. An experienced nurse was taking on the role as Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 23 the lead nurse during this period of time to ensure the smooth running of the home. Arrangements were in place for close communication with the responsible individual for the service. There was evidence of a Resident Satisfaction Survey completed in June 2006 where the evaluation of the results showed that 83.33 of respondents claimed the care given was very good. This however should be sent out on an annual basis and should include the opinions, comments and suggestions from health and other professionals who visit the home. Records were kept of the management of resident’s pocket monies and a clear audit trail was possible for resident’s monies. The Commission was notified under Regulation 37 of the Care Homes Regulations 2001 of any notifiable incidents that had taken place since the last inspection. This included a resident requiring hospital treatment under the Mental Health Act 1983 whereby the home acted appropriately. The fire safety checks were being carried out in line with the appropriate guidance and other maintenance checks including, gas heating certificate dated 19/09/07,and the hoist and lift certificates was available. Accident records were held, however these must be recorded in an appropriate book in line with the requirements of the Data Protection Act 1998. From the ones held it was difficult to establish these were being monitored. For a resident who had 4 accidents/incidents over four days the care plan showed staff had taken remedial action to make sure the resident had appropriate footwear on, that any spills are cleaned up immediately and that the resident’s mobility and presentation were assessed regularly. Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 24 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.V339997.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 Requirement To allow the safe storage of Controlled Drugs a controlled drugs cupboard, which is compliant with current regulations, The Misuse of Drugs (safe custody) Regulations 1971 must be provided. Timescale for action 30/03/08 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 OP1 Good Practice Recommendations Sufficient information must be provided to prospective residents/relatives for them to make an informed decision about the home. This includes updating the Statement of Purpose and the Service User Guide. It is recommended that the home should make sure any handwritten entries on the medication administration charts are signed by the member of staff making the entry and countersigned by a second member of staff to check the accuracy. The manager should make sure that the training matrix is up to date and a training and development plan is DS0000064072.V339997.R01.S.doc Version 5.2 Page 26 2. OP9 3. OP30 Shawe House Nursing Home Ltd 4. OP33 5. OP38 developed and followed. To allow people and or their representatives to express their views on the quality of the service a system must be sent out annually to provide the basis for any improvement. Accident records should be recorded in a book in line with the Data Protection Act 1998 to enable an accurate audit trail of these is possible and they are accurately recorded and reported. Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 27 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 Shawe House Nursing Home Ltd DS0000064072.V339997.R01.S.doc Version 5.2 Page 28 - 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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