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Inspection on 28/02/06 for Shawe House Nursing Home Ltd

Also see our care home review for Shawe House Nursing Home Ltd for more information

This inspection was carried out on 28th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

At this inspection the atmosphere within the home felt and the residents appeared settled and content. The staff and manager showed they were sensitive to the individual care needs of the residents accommodated. The staff were clearly knowledgeable of the residents and their care needs.

What has improved since the last inspection?

Since the last inspection the home had increased the activities provided for residents including aromatherapy massages, visits by a music therapist, musicians and arts and crafts. Improvements to the environment had been made in relation to the deep cleaning and replacement of bedroom carpets. A no smoking policy has been introduced and a programme of staff supervision. Improvements had been made in the maintenance of the resident`s financial records. Following the last inspection the manager has increased the frequency of staff meetings and have now three staff members who are moving and handling trainers. The home had updated and developed some of its policies and procedures since the last inspection. The home had received the Investors in People Award since the last inspection.

CARE HOMES FOR OLDER PEOPLE Shawe House Nursing Home Ltd Pennybridge Lane Flixton Manchester M41 5DX Lead Inspector Elizabeth Holt Unannounced Inspection 28th February 2006 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.V278613.R01.S.doc Version 5.1 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.V278613.R01.S.doc Version 5.1 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.V278613.R01.S.doc Version 5.1 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. 17th November 2005 Date of last inspection Brief Description of the Service: Shawe House is a Nursing Home providing care for 33 older people with a dementia type illness. It is a converted large Victorian house with modern extensions including a conservatory. The home is located in Flixton near Flixton golf course. There are good bus links to nearby towns and the city centre. Accommodation is provided in 27 bedrooms (21 single and 6 double rooms). Bedrooms are situated on the ground and first floor. There is a passenger lift available for the residents to use. Shawe House has two large lounge/dining areas. The home overlooks green open space and has a spacious parking area at the front of the house. Shawe House Nursing Home Ltd DS0000064072.V278613.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on the 28th February 2006. During the inspection time was spent talking to the registered manager, several of the residents, and staff. In addition residents files, records and other relevant documentation were examined. As this inspection only looked at a limited number of standards the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the people living there. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that it follows its recruitment policies and procedures and ensures the appropriate information is held on file for each staff member. Shawe House Nursing Home Ltd DS0000064072.V278613.R01.S.doc Version 5.1 Page 6 Care plans and risk assessments must include the appropriate detail to demonstrate the actual care given. To ensure staff check the temperature of the bath water prior to a full body emersion. 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.V278613.R01.S.doc Version 5.1 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.V278613.R01.S.doc Version 5.1 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): These standards were not assessed on this inspection. EVIDENCE: The core standards were assessed during the previous inspection. Shawe House Nursing Home Ltd DS0000064072.V278613.R01.S.doc Version 5.1 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 The care planning process is detailed and provides staff with the information required to meet the residents needs however some shortfalls have the potential to place residents at risk. EVIDENCE: Following a review of a sample of care plans they were generally personalised, detailed and developed from comprehensive assessments however shortfalls were noted in the following areas. The daily statements used phrases such as “satisfactory day or quiet day” which gave little indication of the actual care given. The care plans lacked some continuity and follow through of the care provided. Some risk assessments were not fully completed. For one resident a nutritional risk assessment had been completed however this did not indicate the guidance for staff to carry out if the assessment was a high score. One resident nursing needs assessment had not been fully documented. These shortfalls must be addressed to demonstrate that residents are having their health care needs met. Staff spoken to had a good understanding of the care needs of the residents. Shawe House Nursing Home Ltd DS0000064072.V278613.R01.S.doc Version 5.1 Page 10 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): These standards were not assessed on this inspection visit. EVIDENCE: All the core standards were assessed during the previous inspection. Shawe House Nursing Home Ltd DS0000064072.V278613.R01.S.doc Version 5.1 Page 11 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): 18 An appropriate response has been taken by the home following an allegation of abuse. EVIDENCE: Following an allegation of poor practice/abuse in January 2006 this is being investigated under the Adult Protection procedures. This investigation in its early stages highlighted some serious concerns in relation to the home’s recruitment procedures. Action has been taken by the home to improve its recruitments procedures. Other agencies are currently involved in this investigation. Shawe House Nursing Home Ltd DS0000064072.V278613.R01.S.doc Version 5.1 Page 12 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): Theses standards were not assessed on this inspection visit. EVIDENCE: The core standards were assessed during the previous inspection. Shawe House Nursing Home Ltd DS0000064072.V278613.R01.S.doc Version 5.1 Page 13 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 and 29 The numbers and skill mix of the staff appeared to be sufficient to meet the needs of the residents. The homes recruitment procedures must be reviewed in order to protect and safeguard the residents. EVIDENCE: At the time of the inspection the home accommodated 30 residents in receipt of nursing care, plus one resident was in hospital. The numbers and skill mix of the staff appeared to be sufficient to meet the needs of the number of residents accommodated. Staff spoken to were clearly enthusiastic and enjoyed their role and responsibilities. The staff clearly knew the residents well. A sample of staff files examined showed these did not contain all the information required in Schedule 2 of the Care Homes Regulations 2001. A requirement was made for these shortfalls to be addressed. Shawe House Nursing Home Ltd DS0000064072.V278613.R01.S.doc Version 5.1 Page 14 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): 38 Some shortfalls in the monitoring of the temperature of the water in the home may put residents and staff at risk. EVIDENCE: There was no record of staff checking the water temperature in the bathrooms prior to the residents receiving a bath. There was evidence of the maintenance man carrying out weekly checks. It was pleasing to note that following the hot feeling hot to touch the manager instructed the plumber to check the boiler system. Following a recent incident where the home appropriately notified the Commission for Social care Inspection of a resident who had gone missing. It was pleasing to see following this that the manager carried out a full and detailed review of the homes policy and procedure of a resident going missing. Shawe House Nursing Home Ltd DS0000064072.V278613.R01.S.doc Version 5.1 Page 15 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Shawe House Nursing Home Ltd DS0000064072.V278613.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 13 Requirement All residents care plans must set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and care needs are met. A full audit of staff files must be carried out to ensure they contain all the information and documents listed in Schedule 2 of the Care Homes regulations 2001 Staff must check and record that the bath temperature is satisfactory prior to the full body emersion of residents. Timescale for action 26/05/06 2 OP29 19 26/05/06 3 OP38 13 05/05/06 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.V278613.R01.S.doc Version 5.1 Page 17 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.V278613.R01.S.doc Version 5.1 Page 18 - 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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