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Inspection on 21/06/05 for Shawside Nursing Home

Also see our care home review for Shawside Nursing Home for more information

This inspection was carried out on 21st June 2005.

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

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

Residents said they liked living in the home and were complimentary about the staff. Care staff were described as `caring` and willing to do anything to help. One visitor said she was made welcome at the home.The home has a committed core group of staff that are enthusiastic and motivated to do a good job. One visitor said he and his family were made welcome in the home.

What has improved since the last inspection?

Issues around the safety of medication practices had been addressed. Fire safety issues identified by the fire safety officer were reported to have been addressed.

CARE HOMES FOR OLDER PEOPLE Shawside Nursing Home 77 Oldham Road Shaw Oldham OL2 8SP Lead Inspector Tracey Rasmussen Announced 21 June 2005 st 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 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. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Shawside Nursing Home Address 77 Oldham Road Shaw Oldham OL2 8SP 01706 882290 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.bupa.com BUPA Care Homes (CFH Care) Limited Mrs Verity Taylor Care Home 150 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (57), of places Physical Disability (120), Physical Disability over 65 years of age (120) Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The manager is supernumerary at all times. 2. No more than 90 places to be used for nursing care. 3. No service users under 55 years of age to be admitted into the home. 4. One named service user above 39 years of age may be accommodated in the home. 5. A minimum of 630 nursing staff hours must be provided each week. 6. A minimum of 630 care hours must be provided on Beech House each week. 7. No service user under the age of 65 years to be admitted to Beech house. Date of last inspection 9 December 2004 Brief Description of the Service: Shawside is a care home that provides 24 hour residential and nursing care for up to 150 service users. The home is owned by Care First Health Care Limited which is a part of BUPA. Shawside is situated on the outskirts of Shaw and is approximatley three miles from Oldham town centre. Local shops, libraries, GP surgeries and pubs are available in Shaw centre which is about a ten minute walk away. Bus services are available close by. The home provides accommodation in five separate units or ‘houses’. Car parking facilities are provided close to each house and garden areas are accessible both at the front of the home and at the rear of each house. All bedrooms are single and none have en-suite facilities. Accessible toilets are situated close to bedrooms and communal areas. Some of the bedrooms have patio windows that open onto the garden areas, all bedrooms overlook the grounds. Each house has its own assisted bathing facilities and walk-in showers are also available. Communal lounge and dining areas and a small servery are available in each house. Kitchen facilities and laundry facilities are located within the main reception buildings. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over ten hours on the 22nd June 2005 by two inspectors. A tour of the five houses of the home took place and care and staff records were seen. Nineteen of the 150 residents, two visitors (close relatives), one GP, one tissue viability nurse and five staff were spoken to. Three resident questionnaires and one relative questionnaire had been returned to the CSCI and these were generally positive. Eleven GP comment cards have been returned, six contained positive responses but five contained details of a number of areas of concern which included frequent requests for GP visits, poor communication between nursing staff teams and poor English language skills of some of the staff. The manager was shown these comments and did state that the home cared for 150 people many with complex nursing needs. She stated that each house arranged their own GP visits in response to resident need and that GPs who visited regularly on a planned visit did not have a problem with the home. One GP visiting the home confirmed this and stated that it was “one of the best in the area”. The manager did say she was unaware that some GP’s had concerns as these had not been discussed with her. A complaint was also investigated at this inspection and this was in relation to the standard of care one resident received whilst living in Beech House. Some aspects of the complaint in relation to poor medical and physical care were not proven. However, aspects of the complaint relating to family members being informed of all significant incidents and staffing levels not being consistently maintained when staff were sick were substantiated. Problems with the control of odours on Beech House were also identified. Verbal feedback of the findings from the inspection was given to the manager at the end of the visit. What the service does well: Residents said they liked living in the home and were complimentary about the staff. Care staff were described as ‘caring’ and willing to do anything to help. One visitor said she was made welcome at the home. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 6 The home has a committed core group of staff that are enthusiastic and motivated to do a good job. One visitor said he and his family were made welcome in the home. 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. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4 Residents needs are assessed before they move into the home. The home can confirm they can meet the needs of the resident on admission. EVIDENCE: Before admission to the home residents were visited at home or in hospital by the house manager or senior care assistant so that an assessment of the potential new resident’s needs could be completed. Resident’s case files examined in the home on the different houses also contained community care assessments, which detailed the resident’s needs. The resident or their relative was informed after assessment if the home could meet the resident’s needs. Copies of the home’s service user guide were available in each resident’s room. One resident confirmed she had read this. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 The care planning documentation was sufficient to meet the health, personal and social care needs of residents. Residents stated they were treated with respect and dignity. Medication practices did pose a potential risk to one resident. EVIDENCE: Residents interviewed in each of the ‘houses’ were very positive about living at the home. One resident said ‘she couldn’t fault the staff’ and another resident said the staff were ‘smashing’. Another resident said the ‘staff worked very hard and they are nearly always short staffed’. Residents also said that they felt that their rights to privacy were respected in the home. One resident said she was aware of what was in her care plan because she had discussed it with the nurses. Residents also knew who their key worker was. The quality of information recorded in the resident’s care plans was of a good standard. Risk assessments had corresponding care plans and these were detailed. Information was recorded which detailed the individual medical and physical needs, including regular weighing and observations. Social care needs were recorded. Care plan interventions provided good guidance to staff and Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 11 Beech House care plans had person centred interventions, which is good practice. References were also made to resident’s rights to privacy, dignity and choice. Records were available for GP, podiatry, optician and other community medical support services. A GP at the time of the visit was positive about the home and a tissue viability nurse did say that concerns regarding pressure area care were being addressed with the home. One house did have a number of residents with pressure ulcers, some of which were hospital acquired and some acquired at the home. The tissue viability nurse was providing a support service in the management of some of these. The nurse in charge of this house stated that both nursing and care staff were waiting to attend further training in care and management of pressure sores.. The home’s medication practices had improved since the last inspection and the requirements identified had been addressed. One resident spat out her medication frequently and this was recorded in the resident’s daily records but this information had not been transferred on to her medication administration sheet, this omission could potentially pose a risk to other people. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15 Residents social needs are not consistently met. Life style choices are available and resident’s family and friends are welcome in the home at any time. The quality of food provided to residents is good, although mealtime presentation was poor in some areas. EVIDENCE: A number of residents were spoken to in Shaw house and they all stated that they were very satisfied with the service they received. In conversation residents detailed the recent activities they had been involved in and these included easy chair exercises, singing songs, bingo, VE Day celebrations, a trip to see Half A Sixpence. Residents on Royton House were also very positive and said they felt like part of a family. Beech house has their own dedicated ‘Hobby Therapist’ and at this visit she encouraged and assisted residents to paint using watercolours. One lady was sewing cross-stitch and one gentleman was reading the paper. Other residents said they didn’t want to be involved in the planned activities. An activity plan was also available on Oldham and Miller house but this did not seem particular inspiring nor were residents overly complimentary about the level of acticities that were provided. Discussion with staff and the manager Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 13 indicated the ‘Hobby Therapist’ was shared between houses so provided limited opportunity on a daily basis for each house to have daily planned activities. A number of residents did say they preferred to stay in their own room. One resident had her own cockatiel, another resident had patio plants outside her patio doors. Visitors were seen coming and going all day. Residents bedrooms were made personal with possessions and mementos and resident’s said that routines in the home were flexible. Residents were complimentary about the meals provided in the home and said they could request alternatives. Compliments such as ‘the foods very good’ and ‘food is lovely’ were heard frequently. The home offers a cooked breakfast, a lighter lunch and a main evening meal. Menus were available and choices were offered to residents. One relative did say she was concerned about the variety of foods provided to residents who required pureed diet. She stated that it frequently appeared to be the same pureed meat and vegetable. Residents were provided with assistance at mealtimes in a discreet manner. It was noted that the presentation of the dining tables at breakfast on Beech was not of a high standard. There was no table clothes, condiments and cups were given to residents without saucers. . Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Residents are protected from abuse and can be confident that complaints will be treated seriously. EVIDENCE: Residents were clear who they could complain to if the need arose. A copy of the complaints procedure was available to each resident and the complaints the home had received were documented in detail. Nursing staff on each houses also ensured they dealt with complaints on a daily basis. All staff have undertaken an ‘induction’ training programme and this included the established staff. Staff understood the issues around abuse and were clear in describing the action they would take if they suspected abuse. Staff in each of the houses stated that they responded to resident and relatives complaints and tried to address the areas of concern. Records seen in three of the four houses indicated that concerns and actions in response to the concerns were recorded. The manager had investigated two complaints since the last inspection. The inspector also investigated one complaint at this visit and this was in relation to the care a resident received on Beech House. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26 Residents live in a safe, well-maintained and comfortable home which has aids and adaptations to meet their needs. Some refurbishment is required. The standard of housekeeping and hygiene in two of the houses needs to be improved. EVIDENCE: Three of the houses were clean but Beech house had an odour of urine at the entrance to the house and Oldham house had several areas that were dirty. One visitor on Oldham house said that cleaning had deteriorated recently and she pointed out layers of dust and debris lying around her relative’s bedroom. One resident on Oldham House said she missed the old cleaners –‘the new cleaners popped in and popped out again with a flick of a cloth’. Both house managers of Beech and Oldham were aware of their specific problems and were trying to address these. The manager of Oldham house had had a meeting with housekeeping staff to highlight the concerns. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 16 The manager acknowledged that she was struggling to employ enough housekeeping staff in the home due mainly to unexpected sickness absence. Following this visit the manager supplied an action plan to the CSCI to address the issue of cleanliness in the home. The home was maintained safe, and maintenance records were available however these were not viewed at this inspection. Some areas of the home do need refurbishing and the manager of Oldham house said refurbishment was planned for later this year. Parts of the home that had been refurbished (Royton and Beech) still hadn’t had their bathrooms up graded and bare pipes were visible. Various types of equipment was available. Residents bedrooms had been made homely with their possessions. Garden areas were pleasant. Beech House has a secure and pleasant garden with raised beds. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 30 Staffing levels were insufficient to meet resident’s needs in some houses. Staff are trained to do their job. EVIDENCE: Residents were complimentary about the staff, comments like “the staff will do anything for you” were heard in most of the Houses. Residents knew who their key worker was. Staff at interview were cheerful and enthusiastic. Some staff members did express concern about the home’s recruitment problems and said recently they had been short of staff. A comment was made that agency staff were rarely used, although on agency worker was on duty at this visit. The manager agreed that the home was struggling to recruit suitable people to different jobs in the home and that a major recruitment campaign had been commenced to address this. Only one employment file was briefly checked and this was okay. The care staff on duty demonstrated knowledge and insight to the needs of the residents and could identify the gaps in their own skills and abilities particularly in relation to managing challenging behaviour. Staff had received some training in this area, but one member of staff said that this had been theory based and she would benefit from practical training in breakaway techniques. The manager did say that additional training in this area was on the home’s training plan. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 18 The manager also stated that staff whose first language wasn’t English had all had English language lessons and had passed the course requirements. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 38 The management of the home promotes the health, safety and wellbeing of the residents. Residents have some say in how the home is run although recording of staff supervision could be inproved. Communication with relatives could be better. EVIDENCE: The home has a management structure, which enables the manager to have a overview of the situation on each of the houses. Staff and residents and relatives were aware of the systems in place to discuss any issues and concerns on each of the houses and they knew how to access the manager if required. Investigation of a complaint did identify that relatives were not always kept informed about incidents involving their loved one. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 20 Each of the houses had regular meetings, with residents and staff and minutes of these were available. Staff supervision was being undertaken although some of the records seen contained little information. The home employs a maintenance person and fire safety and maintenance records were available. Not all these records were seen. Staff at interview said they had had training in safe moving and handling of residents and fire safety. The home had had a fire safety inspection last November, where a number of requirements were made. The manager stated that these had been addressed and a request made to the fire safety officer to return to check this. This had not occurred. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 2 2 STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 2 x x 2 x 2 Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 22 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 9 Regulation 13 Requirement The registered person must ensure that MARS sheet reflect all relevant information about the resident. The registered person must ensure that dining tables are presentable at mealtimes to promote the social aspect of meal times. The registered person must ensure that all areas of the home are maintained clean and odour free. The registered person must ensure that there are sufficient staff on duty at all times to meet the needs of the residents. The registered person must ensure that residentsare kept informed of any significant events that affect the residents wellbeing. Timescale for action 31/07/05 2. 15 12 31/07/05 3. 26,38 13 31/07/05 4. 27,38 18 31/07/05 5. 33 24, 12 31/07/05 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 Good Practice Recommendations F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 23 Shawside Nursing Home 1. Standard 12 2. 3. 4. 19 25 30 5. 36 The registered person should ensure that each house has its own dedicated ‘hobby therapist’ who can provide activities on a daily basis in accordance with resident’s needs and preferences. The registered person should ensure that refurbishment of the home is continued. The registered person should ensure that all exposed pipe work is covered and refurbishment of the bathrooms and toilets is completed. The registered person should ensure that all staff who work with residents that may present with challenging behaviour receive practical training in the management of the residents behaviour. The registered person should ensure that supervision records are recorded in detail. Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 2nd Floor Heritage Wharf Portland Place Ashton under Lyne OL7 0QD 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 Shawside Nursing Home F54-F04 Shawside S25453 V224915 210605 Stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!