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Inspection on 07/11/06 for Shawside Nursing Home

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

This inspection was carried out on 7th November 2006.

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.

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

On the whole the home was peaceful and offered a relaxed pleasant atmosphere. Staff were friendly and good humoured with residents and visitors to the home and they undertook their caring duties in a professional manner. One resident said, `I`m alright they have been wonderful with me.` And another resident explained how moving into Shawside from another home had improved her health and wellbeing. Residents appeared well cared for with attention to hair, nails and clothing coordination. Residents said staff did their job well and comments such as staff are `pleasant and polite` and `staff are very nice-there`s not one of them you couldn`t say you didn`t like` were made. Residents said that staff listened and respected their wishes in relation to personal care and socialisation. Care plan records were detailed and medication practices safe. Visitors were welcome into the home. Meals and food was described as good, although one resident said easy access to a menu was not available.Complaints were treated seriously and investigated properly as the home`s procedures requires. Staff had had training to ensure residents were safeguarded as far as possible from abuse and they knew what to do if they suspected abuse. Employment recruitment practices were safe so staff who may have posed a risk to residents were not employed. Staffing levels in the home were appropriate to meet the needs and dependency levels of the residents. Staff had had a wide range of training and almost half the care staff team had a NVQ 2 qualification. Quality assurance systems were established which means standards of service were monitored and improved when issues were identified.. Resident`s personal monies were maintained safely and health and safety practices were safe.

What has improved since the last inspection?

The home continues to ensure staff are NVQ trained.

What the care home could do better:

Records of activities that residents joined in should be recorded and information about whether the resident enjoyed or benefited from these noted. This would help the staff to continue to organise activities which residents enjoyed and wanted to join in with. One resident reported that no one told her what the menu was for the day. Therefore, it may be beneficial to review how easy residents can see or have access to the days menus, or whether staff inform residents on a regular basis. Refurbishment in the home is being followed in accordance with a business plan. This should continue and bathrooms pipe work should be boxed in. This will ensure the home remains well maintained and safe. Employment application forms should contain the full working history of all staff wishing to work in the care home. This will allow the manager to fully be aware of staff experience not only in the care industry but also skills from other jobs which may be put to good use in the home for the benefit of residents.

CARE HOMES FOR OLDER PEOPLE Shawside Nursing Home 77 Oldham Road Shaw Oldham Lancashire OL2 8SP Lead Inspector Tracey Rasmussen Unannounced Inspection 7th and 8th November 2006 11:00 07/11/06 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 Shawside Nursing Home DS0000025453.V318947.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. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shawside Nursing Home Address 77 Oldham Road Shaw Oldham Lancashire OL2 8SP 01706 882290 01788 816940 taylorve@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Limited 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) 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 DS0000025453.V318947.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. The manager to be supernumerary at all times. No more than 90 places to be used for nursing care. No service users under 55 years of age to be accommodated into the home. One named service user above 39 years of age may be accommodated in the home. A minimum of 630 nursing staff hours must be provided each week. A minimum of 630 care hours must be provided on Beech House each week. One named service user under the age of 65 years to be admitted to Beech house in the category DE(E). The home is registered for a maximum of 150 service users to include: *up to 57 service users in the category of OP (Old age not falling within any other category). *up to 120 service users in the category of PD (Physical disability under 65 years of age). *up to 120 service users in the category of PD(E) (Physical disability over 65 years of age). *up to 30 service users in the category of DE(E) (Dementia over 65 years of age). 5th January 2006 Date of last inspection Brief Description of the Service: Shawside is a care home that provides 24 hour residential and nursing care for up to 150 service users. Care First Health Care Limited, a part of BUPA, owns the home. Shawside is situated on the outskirts of Shaw and is approximately 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 Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 5 bedrooms are single, 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. A copy of the home’s last inspection report was available from the main reception of the home. 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. The current weekly fees range from £313.66 to £595 dependent on the package of care required. Further details regarding fees are available from the manager. Additional charges are made for hairdressing, newspapers and other personal needs. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced key inspection site visit on the 7th and 8th November 2006. The inspection included a review of all available information received by the Commission for Social Care Inspection (CSCI) about the service provided at the home since the last inspection. At this visit four out of the fire houses were in use and each of the four houses were visited. All key inspection standards were assessed at the site visit and information was taken from various sources which included observing care practices, talking with residents; speaking with visitors; interviewing the manager and other members of the staff team. A tour of the home was also undertaken and a sample of care, employment and health and safety records seen. The inspector also checked to see if the manager had done what she was asked to do following the last inspection. This related to ensuring at least 50 of staff have NVQ 2. This had almost been completed. What the service does well: On the whole the home was peaceful and offered a relaxed pleasant atmosphere. Staff were friendly and good humoured with residents and visitors to the home and they undertook their caring duties in a professional manner. One resident said, ‘I’m alright they have been wonderful with me.’ And another resident explained how moving into Shawside from another home had improved her health and wellbeing. Residents appeared well cared for with attention to hair, nails and clothing coordination. Residents said staff did their job well and comments such as staff are ‘pleasant and polite’ and ‘staff are very nice-there’s not one of them you couldn’t say you didn’t like’ were made. Residents said that staff listened and respected their wishes in relation to personal care and socialisation. Care plan records were detailed and medication practices safe. Visitors were welcome into the home. Meals and food was described as good, although one resident said easy access to a menu was not available. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 7 Complaints were treated seriously and investigated properly as the home’s procedures requires. Staff had had training to ensure residents were safeguarded as far as possible from abuse and they knew what to do if they suspected abuse. Employment recruitment practices were safe so staff who may have posed a risk to residents were not employed. Staffing levels in the home were appropriate to meet the needs and dependency levels of the residents. Staff had had a wide range of training and almost half the care staff team had a NVQ 2 qualification. Quality assurance systems were established which means standards of service were monitored and improved when issues were identified.. Resident’s personal monies were maintained safely and health and safety practices were safe. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 9 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 Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 10 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. Resident’s needs were assessed before they moved into the home and the home confirmed they could meet the needs of the resident on admission. EVIDENCE: Five resident care files, at least one from each ‘House’ were looked at to see if information about the care and support needs of each resident had been assessed by the home before the ‘new’ resident moved into the home. All the care files had a ‘pre-admission’ assessment of care needs. More than one ‘House’ manager said that they went out to visit the ‘new’ person before they came into the care home. Visitors confirmed that they visited the home before their loved one was admitted into there. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 11 The quality of the pre-admission assessment information was generally good and four out of the five care files also had further information available in the form of a social work or nursing assessment. Residents spoken with were positive about the home and comments included; ‘I’ve been here for 3 weeks now’ and “I’m alright they have been wonderful with me. It’s not like home but you can’t expect that”. Another resident and family member had moved from another care home and stated she was getting much better care at Royton House. Intermediate care (standard 6) is not provided at Shawside. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 12 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 were treated with respect and dignity. The care planning documentation was sufficient to enable staff to meet personal and health care needs of residents. Medication practices in place were safe. EVIDENCE: The home provides nursing, care and support across a range of care needs. Shaw House provides a residential care service where personal care needs are met. Beech House provides a residential dementia care service, whilst Royton and Miller Houses provide, on the whole, nursing care services. Residents were spoken to in all four houses and visitors views were also sought where possible. All provided positive feed back about living in the home. One resident from Royton House stated that she ‘liked it here’; a relative from Miller said it was ‘smashing here’ and resident in Shaw House said ‘I can’t fault anything here’. Residents on Beech House were unable to comment on the Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 13 service, however the atmosphere in the house was relaxed and peaceful the house was relaxed and peaceful and residents were settled. Each house was calm and peaceful and residents were presentable and dressed according to their preference, clothing co-ordinated, hairs were set and fingernails were manicured. Staff chatted with residents in a calm relaxed manner and there was good camaraderie observed between some residents and staff. In some of the houses some residents were also cared for in bed and this was reported to be in response to their care needs. One resident spoken with said she preferred being in bed –‘I can’t get comfortable in chair.’ And another resident said staff respected her requests; ‘I sit out in the lounge in a morning and have a lie down in the afternoon then get back up for tea’. Staff were respectful, attentive and caring in their approaches and interactions with residents. Staff spoken with both care and nursing staff were knowledgeable about the residents living in ‘their’ house and all could list the various training courses they had attended. Care planning records were available in each of the houses for all residents and five care files were looked at to assess the quality of the information recorded about each resident’s care needs and the care to be provided. Care plans seen contained assessment information based on the activities of daily living, moving and handling, nutrition, falls, skin and pressure area assessments. Where a risk or need was identified then a care plan was recorded. The majority of the care plans seen had very good care plan interventions which explained how care was to be given according to the diverse needs and wishes of the resident (person centred care). They also included references to promoting privacy and dignity and offering choices in routines and personal care. Care plans on Beech House were very detailed and comprehensive. One care plan on Royton House had not been updated sufficiently to provide an accurate record of care needs. However the home did undertake quality monitoring of a sample of care plans on a monthly basis and missing or out of date records were returned to the relevant care worker to be up dated. It was noted that various recording formats for example risk assessments were being used and this should be reviewed to ensure a consistent care planning format is used in all houses. Records of contact with community health services such as GP, tissue viability speech therapy and optical support were available. One resident was very positive about the quality of care she had received and said the home had helped her get better. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 14 Care plans were recorded for the social aspects of the service however these could be developed further to include person centred preferences and evaluations of the social activity or stimulation. Medication was briefly reviewed in three out of the four houses. Each house has a dedicated treatment room for the storage of medication. All three treatment rooms were clean and tidy and stocks of medication appeared appropriate. Controlled drug records and medicines needing refrigeration were satisfactory. Medication recording practices were safe; administration records were accurate and records of receipt and disposal of medication were available. It was noted on Beech House that medications had not been delivered for the first day of the new medication month. The manager of the home stated that the home’s pharmacist was coming in later that week and this would be discussed. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 15 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. Life style choices are available and resident’s family and friends are welcome in the home at any time and most resident’s social needs are met. The quality of food provided is good ensuring residents receive a balanced diet. EVIDENCE: The home employs two hobby therapists who undertake social activities in each of the houses through the week. The manager stated she had requested as part of the home’s business plan, further staff hours to employ another hobby therapist thereby increasing the number of hours of planned activity in each house. Records of activities were available and resident’s care plans did contain information about their social background and preferences but it was unclear what activities each resident had joined in and if they had benefited or enjoyed Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 16 this. One resident said there wasn’t any activities but then qualified it with ‘– a women did snakes and ladders . I didn’t enjoy. It’s not for me’. One resident said ‘I go into Shaw sometimes’ and other residents said they preferred to stay in their bedrooms. Residents were seen sitting and walking outside. Care plans for the social aspect of the service should be developed further and this should include types of stimulation and preferences of residents who remain in the room or are required to remain in bed. Care plans for day to day living did refer to seeking the resident’s view or choice with regards clothing and cleansing. One resident confirmed her wishes were respected. During this visit many relatives and visitors called at the home and they made themselves ‘at home.’ One resident spoken with did say they went out regularly with family members. Residents said ‘my husband comes at least once a day’ and a relative said ‘I am here every day 1.30 –4.30 and family visit every evening.’ The lunchtime meal and evening meal was observed in different houses during this visit. Tables were set appropriately with tablecloths, cutlery and salt and pepper. Residents were assisted discreetly to enjoy their meal and many relatives were seen providing their loved ones with assistance. A written menu of the meals served in the home was available, however one resident said ‘food is on the whole very good but there are two things - I don’t know what my meal is until it comes and there is a menu but no one reads it to us’. The resident did say if she didn’t like what was offered she could choose an alternative. Staff spoken too said that residents were asked the day before for their meal preference and this was recorded and sent to the kitchen. The home offers a lighter lunch and the main meal is served in the evening. Food served at both meal times was plentiful and nutritious. It was reported that the home’ chef had just won the Heartbeat Award and received the Chef’s Best award. It was also reported that menus had been adapted to ensure the government’s nutrition guidelines was complied with. Discussion with Beech unit manager indicated that good practice of fortifying foods to increase the nutritional content for people with dementia was undertaken. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 17 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 can be confident that staff are trained to respond appropriately to suspected abuse. Residents can also be confident that all complaints will be treated seriously. EVIDENCE: Since the last inspection visit the manager had received a number of concerns and issues and had addressed these through the home’s complaints procedure. Records were available of all complaints and issues and the actions undertaken in response to each complaint was recorded. Residents spoken with said they had no complaints and felt able to discuss their concerns with the manager or the nurse. Staff said that they would inform the manager or nurse if they received a complaint. Staff reported that they had received training in abuse and the protection of vulnerable adults and were able to discuss the content of their training and relate it to the home environment. Records were available of staff training and one staff member had a folder of training certificates and this included Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 18 certificates for training in abuse. Staff also confirmed they had undertaken NVQ training and this also included information and training in abuse. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 19 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. Residents live in a safe, well maintained home that was clean and odour free. EVIDENCE: The home was clean and odour free and domestic staff were observed to be thorough in undertaking their duties. Each house has it’s own team of domestic staff and cleaning programmes were avialable. A head housekeeper provides leadership of the whole domestic team. It was reported that Beech House does have an odour problem on occasions and both the house manager and home manager have and continue to look for ways to combat the problem. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 20 Residents bedrooms had been made homely with their possessions. Garden areas were pleasant. Beech House has a secure garden with raised flower beds and residents were seen walking independently outside. Some resident’s rooms benefited from patio doors that had enabled the resident to personalise the space outside their room. Other residents had had bird feeders placed in front of the windows so they could watch garden birds feeding. One resident said, ‘I get all sorts of birds finches, coal tits’. A business plan setting out a three year plan for on going refurbishment was being undertaken. Both Royton and Beech had been refurbished and Shaw and Miller had benefited from some refurbishment Pipe work in bathrooms was exposed and unsightly. These would benefit from being boxed in. The kitchen and laundry areas are situated next to the main entrance building. These were not seen at this visit. The maintenance man was observed working in different houses attending to day to day repairs and general maintenance. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 21 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. Recruitment vetting practices, staffing levels, training and skill mix were appropriate to meet residents’ needs and promote their health and safety. EVIDENCE: The home had a pleasant relaxed atmosphere and all staff spoken with were good humoured and at ease. Staff were positive about working in the home. Comments from resident included ‘staff are very nice, there’s not one of them you couldn’t say you didn’t like’; and “Staff alright. ‘I like’ em here. You can have a laugh and joke’.” Three employment files for newer staff to the home were seen and these contained the required pre-employment checks such as Criminal Record Bureau (CRB) disclosures, PovaFirsts and references. This means that the home has ensured as far as possible that new staff working in the home do not have a history of abusing people. In accordance with the recent amendments of the care home regulations the manager should ensure a full working history is obtained before the employment commences. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 22 Records were available to indicate that the home did train staff from the start of employment with induction training to on going training and NVQ. Completed induction training folders were available on three out of the four houses and these were comprehensive. Nursing and care staff were spoken with in all houses and they listed various training courses they had attended. These included abuse, challenging behaviour, break away techniques, dementia, diabetes, health and safety and moving and handling. Observation of care practices indicated staff did follow procedures for moving and handling and one resident confirmed that ‘staff do use the hoist properly’ A staff member was able to provided a folder of certificates of all the training she had undertaken and the home manager provided a copy of the large database of training staff had completed. The staffing rotas were available and indicated that staffing levels were maintained at appropriate levels to meet resident’s care needs, although one care staff member felt Beech house was on occasion understaffed. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 23 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): 31,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home promotes the health, safety and wellbeing of the residents. Residents do have a say in how the home is run so they are provided with opportunities to contribute to the daily routines of the home and arrangements are in place to ensure resident’s money is safe. EVIDENCE: The manager is a registered nurse and has completed her NVQ 4 in management. Her style of management both within the home and dealing with other professionals has been one of openness. This means that incidents, Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 24 concerns or issues have been dealt with openly and in accordance with the home’s policy and procedures. The home has well established quality monitoring systems which include monthly auditing of various aspects of the service provided and visits by a BUPA operational manager to ensure service standards are maintained. Residents and relatives meetings had been held on each of the houses and records were available of these. Annual resident questionnaires had been sent out and a report from last year’s questionnaires was available. Each house is required to develop it’s own action plan in response to the outcomes from the questionnaires. Minutes of staff meetings were also available and records of staff supervision were also available. Although not reviewed directly at this visit, the home’s administrator confirmed that the safe systems for handling resident’s personal monies, as previously inspected, were still in place. The operations manager of the company audits these regularly. Fire safety records and maintenance records were available in each house and these were up to date and indicated regularly monitoring and checks were undertaken in the home. Practices observed in the home followed health and safety guidelines. Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 25 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 2 3. Refer to Standard OP7 OP15 OP19 Good Practice Recommendations The registered person should ensure care plans contain more person specific activities and evaluations of the social aspects of the service are relevant to the resident. The registered person should ensure that resident’s are aware of the home’s menus and assistance provided to those residents who may not have ready access to them. The registered person should ensure that refurbishment of the home is continued and that all exposed pipe work is covered and refurbishment of the bathrooms and toilets is undertaken. The registered person should ensure that the NVQ training programme continues. The registered person should ensure a full working history is obtained before the employment commences 4 5 OP28 OP29 Shawside Nursing Home DS0000025453.V318947.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Shawside Nursing Home DS0000025453.V318947.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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