Inspection on 11/09/07 for Sheldon House

This inspection was carried out on 11th September 2007.

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.

Other inspections for this house

Sheldon House 02/06/09

Sheldon House 19/06/08

Sheldon House 15/01/08

Sheldon House 20/09/06

Sheldon House 20/03/06

Sheldon House 29/09/05

Sheldon House 08/02/05

Sheldon House 09/09/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sheldon House Sea View Road Falmouth Cornwall TR11 4EF Lead Inspector Kerensa Livingstone Key Unannounced Inspection 11th September 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 Sheldon House DS0000008894.V346312.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. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sheldon House Address Sea View Road Falmouth Cornwall TR11 4EF 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) 01326 313411 01326 317902 sheldon@comfortcaregroup.co.uk Mr Charles Barry Libby Mrs Anne Louise Libby, Mr Darren Libby Mrs Doreen Ann Peters Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (34) Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2006 Brief Description of the Service: Sheldon House is a long established care home and is registered to provide nursing care for up to 34 people who experience dementia or enduring mental illness. The current owners have run the home since November 2000. The current accommodation is a former hotel that was initially converted around 1994 and since then has undergone further structural changes. It is located on a quiet residential road close to the town and beaches of Falmouth. It is easily accessible on foot and by transport from the town, this results in frequent visits to the home by relatives and friends. There is a car park at the front of the home and an attractive garden area. The accommodation is provided over three floors and is accessible to people who experience a disability by two shaft lifts. The building is not the best design to provide the care and support required by residents. The layout does not easily lend itself to meeting the needs of residents. The bedrooms are for both single and shared occupancy. There are three communal areas are provided on the ground floor. There is no designated dining room. There is a small patio area to the rear of the home, which is accessible to residents. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that was undertaken by one inspector over two full days. The inspector looked at records, care documentation, Policies and Procedures and inspected the environment. The inspector met and talked with the Residents, Registered Manager, staff, relatives and professionals visiting the home. The registered providers were visiting the home during the first day of the inspection. The Inspector made direct observations of the care and support and the manner in which the staff interacted with residents. An Annual Quality Assurance Assessment (AQAA)) was completed by the Registered manager prior to the inspection. Questionnaires were made available to relatives and professionals by the home as part of the inspection process. The current fees range from £450.00 to over £650.00 depending on client need. What the service does well: What has improved since the last inspection? Residents have their needs assessed prior to moving into the home, the needs of existing residents requires more consideration. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 6 The medication records have improved since the last inspection. There has been increase in the training that is provided for staff. The activities coordinator is working hard to improve the level of stimulation and activity available for individuals. What they could do better: Prospective residents are not provided with written information to enable them to make an informed choice of home. The Statement of Purpose provided at inspection did not contain the necessary information, this document is being finalised. The plan of care is not adequate to lead and direct the care to meet individual needs. Residents and/or their representatives must be enabled to make decisions about their lives. Medicines must be administered safely, as per the home’s policies and procedures. The residents value the activities provided, however these must be extended and developed to meet the needs of all the residents. Mealtimes were observed to be extremely busy, staff worked very hard to meet resident’s needs, but this was compromised by the numbers of staff on duty. Some of the individual’s privacy and dignity needs are not safeguarded by the existing arrangements in the home. The current environment is unsuitable and does not meet the needs of the resident. Individual accommodation could be made more homely and comfortable. There is not adequate storage for equipment. There are areas of the home, which require tidying up, cleaning or redecoration. The lack of a dining room reduces the quality of life for residents. The room used for the storage of medicines is not suitable as it is currently arranged. The numbers of staff on duty are not adequate to meet the needs of the residents. The training provided must include post registration, induction and specific training to the client group. Feedback is sought from users of the service, this information needs to be analysed as part of an annual development plan for the home. Residents do not have direct access to their own money. Risk assessment practices require improvement. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 7 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. Sheldon House DS0000008894.V346312.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 Sheldon House DS0000008894.V346312.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): 1, 3 & 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Prospective residents are not provided with written information to enable them to make an informed choice of home. Residents have their needs assessed prior to moving into the home, the needs of existing residents requires more consideration. EVIDENCE: A new brochure style Resident’s guide is currently being printed and has been updated. All prospective residents must be provided with a Resident’s Guide, which includes the required information. The inspector was informed that this does not take place and has not done for a considerable period of time. The Statement of Purpose is dated September 2005, the information is not up to date or inaccurate. At the time of the inspection this document was being updated and the inspector was informed it would include all the required information. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 10 Given the challenging and potentially complex nature of the user group detailed assessments are required in order that the appropriate care and support is both available and provided. Since the last inspection, there is evidence that new residents are being admitted to the home following an assessment by a qualified nurse. Additional information is gathered as required. There is evidence that the collective needs of the existing residents need greater consideration when assessing a prospective resident. On the day of the inspection a prospective resident and their family visited the home and were shown around. Intermediate care is not provided at this home, there are no designated facilities or staff. Sheldon House DS0000008894.V346312.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 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The plan of care is not adequate to lead and direct the care to meet individual needs. Residents and/or their representatives must be enabled to make decisions about their lives. Medicines must be administered safely, as per the home’s policies and procedures. Some individual’s right to privacy and respect is compromised. EVIDENCE: The resident’s plans do not clearly detail the actions that staff need to take to ensure that all aspects of the health, personal and social care needs of the person are met. New person centred care plans are being introduced although staff seemed unsure about what is expected. There is little evidence of resident and/or representative involvement in the planning or reviewing of the care plans. One new resident did not have a care plan and several were incomplete. All residents are registered with a General Practitioner. There is clear evidence that advice is sought from the General Practitioner and Mental Health Services as required. The dentist was visiting the home on the day of the inspection. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 12 Nutritional screening is being undertaken and there was evidence that action is taken where there is concern about weight loss. A qualified mental health nurse is on duty at all times. Advice is sought from the District Nurse team on general health issues. No continence assessments are undertaken, evidence must demonstrate how continence is promoted. Care plans must detail the actions required to ensure that individual health care needs are met, this should be based upon clear detailed information. All medication is administered by qualified nurses and a Monitored Dosage system is used. The administration of medication was observed. The trained nurse on duty must administer medication directly from the medication trolley to the resident individually to reduce the risk of an error being made. Medication administration records were inspected and found to be accurate. A record of staff signatures are kept, photographs are not kept on the medication sheet. Records of medication received and disposed of are being kept. The room designated for the storage of medicines is very small and difficult to manoeuvre in. There is a designated member of staff responsible for ordering the medicines. There are policies and procedures in place; these were not inspected in detail at this inspection. There is a designated fridge to store medication that requires this facility, temperatures are checked daily. There are two Controlled Drugs (CD) cupboards and a CD register, an audit of this medication showed that it was correct. Some items were overstocked. The Pharmacist was due to visit on the following day to check the medicines. Staff were observed to treat residents with respect. The inspector observed that the privacy and dignity of some residents was compromised. Some examples of this are as following; uninvited guests entering their bedrooms, communal toiletries in the bathrooms, unwarranted attention from other residents and how some people were dressed. No lockable facility is provided in each resident’s room and residents are actively discouraged from having any money or valuables in the home. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 13 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, & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents value the activities provided, however these must be extended and developed to meet the needs of all the residents. Visitors are welcomed to the home at anytime. Mealtimes were observed to be extremely busy, staff worked very hard to meet resident’s needs, but this was compromised by the lack of a dining room and staffing numbers. EVIDENCE: The care staff work hard to try to be flexible in meeting the individual lifestyles of the residents, their ability to do this is restricted by the number of staff on duty. Resident’s interests are recorded. There is a part time (18 hours) activities coordinator who has been in post for a couple of months. A record is kept of the activities undertaken. In the last month the activities included escorted walks, manicure, spending time reading/ writing/talking one to one. Entertainment included a singer and a group of local churches coming into the home to deliver a service. There are plans to commence a physical activity group. Some individuals are given opportunities for stimulation through leisure and recreational activities in the home; this must be extended to include all residents. Due to the complexity of needs of the individuals, the current Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 14 staffing hours provided are inadequate to meet their needs. One resident commented that they would like to go out a bus trip to see the sea, but there is no bus. A relative commented that it would be nice if the residents could go out into the garden more often or they were able to take their relatives out in a motorised wheelchair. During the inspection, residents were observed sitting outside under umbrellas accompanied by staff. Care staff organise themed days, where staff dress up in costume and activities are arranged. The hairdresser was visiting the home at the time of the inspection. Visitors are able to visit at anytime. The main door to the home is locked, however regular visitors are provided with a pass key, so they do not need to be allowed in. One relative commented how they were able to visit at anytime and often had a cup of tea. No written information is being given to relatives currently about the home’s policy on maintaining relatives involvement with residents at the time of moving into the home. This is due to be addressed when the Resident’s guide is finalised. Residents are able to bring in personal affects to the home. No advocates are utilised regularly. Managerial staff are due to attend Mental Capacity Act training, which may help clarify some issues where due to capacity, consent is being obtained from a third party. Some individual accommodation was observed to be impersonal. The menu on the first day of the inspection was Tagliatelli with bacon and cheese sauce or Cornish pasty followed by Semolina. Vegetables were not served with this meal or on the menu for the whole day, they were noted to be generally lacking from the menu. The Chef/cook works from 09.30 until 6pm and is supported by a kitchen assistant. Breakfast is provided by the care staff, which is porridge, boiled egg, cereals or toast. The menus operate a three-week rotation and have been recently reviewed. Residents are offered a clear choice of main course, but not pudding although there are alternatives in the kitchen. Fresh fruit is readily available and a fruit salad offered at teatime mid afternoon. Special diets are provided as required. No food records are kept. There is no designated dining room, so care staff have to serve food to individual rooms and the three lounges as well as assist thirteen individuals to eat their lunch. The lunchtime was observed to be rushed and noisy with meals being served at all different times. The inspector was informed that this is usually the case. The current arrangements are not conducive to a relaxing unhurried mealtime, where independence is encouraged. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 15 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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are listened to and acted upon. Residents are not safeguarded by the existing arrangements in the home. EVIDENCE: There is a complaints procedure, this should state that the complainant can contact the Commission for Social Care Inspection or Department of Adult Social Care at anytime. A record is kept of any complaints with the investigation details and outcome. The home has received one complaint, which was resolved. The Commission has not received any formal complaints since the last inspection. There is a protection of vulnerable adults procedure in place. Any allegations or concerns have been reported to the Department of Adult Social Care as required. There is a whistle blowing policy. A rolling training programme about the protection of vulnerable adults is in place for staff. Training records must be kept up to date so that there is evidence of who has attended this training. Discussion with staff demonstrated that they were aware of the action to take. However, the number of incidents within the home over the last month are high, these include aggression and inappropriate behaviour. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 16 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, 20, 22, 24 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The current environment is unsuitable and does not meet the needs of the resident. Individual accommodation could be made more homely and comfortable. There is not adequate storage for equipment. There are areas of the home, which require tidying up, cleaning or redecoration. The lack of a dining room reduces the quality of life for residents. Specialist equipment is provided based on individual need. EVIDENCE: The home is a three storey building with the communal areas located on the ground floor. The layout of the home has significant limitations in providing good quality services and facilities. This has been recognised by the providers who are also aware the layout of the building does present certain limitations and challenges in creating a homely and comfortable setting for residents. Previous timescales to address the unsuitable environment have not been met and no immediate work is due to start. Several relatives have concerns about Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 17 the suitability of the environment, one commented that a ‘purpose build premises would help the home improve’. The outside areas to the rear of the building require tidying up. There are parts of the home including bathrooms that would benefit from redecoration and to be made more comfortable or homely. There is no designated dining room. There are three lounge areas where the majority of the residents were observed to spend all their time. These areas are comfortable. The outdoor space to the rear of the home is enclosed, it is small and requires some attention to make it pleasant for the residents. Lighting and furnishings are homely, floors are not carpeted which results in sounds being echoed. Furniture and equipment was observed stored in corridors and bathrooms. Bathrooms were observed to house communal toiletries, jugs, urinals, trolleys, commodes and pads. Rubbish bins were observed to have no lids. Some chairs and mats were soiled and required washing. Specialist equipment is obtained on an individual basis, hospital beds and pressure relieving mattresses are provided for people who need them. Some resident’s rooms were observed to need repairs or redecoration e.g. curtains rehanging. Tiles were observed to be missing in a bathroom and a new carpet is required in the hall. The call bells do not have extension leads to enable residents to use them, they are used for plugging in alarmed mats to alert staff. This practice should be reviewed and based upon a risk assessment. The use of linoleum in bedrooms should be based upon risk assessment and dependant on individual need. No lockable storage or lockable doors are provided. One room was observed not to have a chest of drawers, table or mirror. There were odours in several areas of the home including individual’s rooms. Some areas were observed to need cleaning and dusting in the home. The laundry is a large room separate from the main building. There are two industrial washing machines and two dryers. Red disposable bags are used for soiled laundry. All bed linen and towels are sent out to be laundered. Clothes are all labelled, however on the day of the inspection there was a large rack of unclaimed items of clothing. There is a designated member of staff working in the laundry every day of the week. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 18 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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty are not adequate to meet the needs of the residents. The recruitment procedures are robust to safeguard residents. Training is actively encouraged and facilitated, this must incorporate induction, post registration training and training specific to the people who live at Sheldon House. A high percentage of staff have achieved their National Vocational Qualification level 2 and/or 3. EVIDENCE: On the first day of the inspection there were two nurses and five carers on duty all day (the inspector was informed that the staffing levels identified as minimum for the home are two nurses and six carers). Thirteen residents required assistance to eat their meals. There were no designated housekeeping staff on duty on day one of the inspection due to sickness. The lack of housekeeping cover was raised at the last inspection. On day two there were only five carers on duty in the morning, this increased in the afternoon. Senior carers have been appointed and were observed to manage the delivery of care and allocation of staff resources during the inspection. The care staff were observed to be under considerable pressure during the inspection to complete the work required. The inspector also was concerned that there were inadequate housekeeping or catering hours to meet the needs of the residents. This placed an additional unreasonable burden on the care staff. The maintenance person and activity person are shared between this home and the Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 19 sister home. Relatives were very positive about the staff, one stated ‘they really do care about the residents’ and another relative said ‘the staff are really good’. The catering and laundry staff must be recorded on the rota, as well as the Registered Manager. All staff are encouraged to participate in training including their National Vocational Qualification (NVQ) level 2 or level 3 training. Eight staff have achieved their NVQ level 3 and seven have NVQ level 2. A thorough recruitment procedure was evident at the home, files examined contained a completed application, health declaration, at least two written references, Criminal Records Bureau checks and a record of the interview. All staff receive a contract. No volunteers work in the home. There is a structured three day induction training course provided internally which incorporates fire training, moving and handling, infection control, POVA and food handling. End of life care is going to be added at the end of the year. Two days are compulsory and the third day is optional, this day includes end of life care and introduction to dementia care. One staff member is a Moving and Handling trainer, currently there is no trained Fire Officer, so it is planned to arrange for a local Fire Officer to attend to provide additional training. Staff are provided with an in-house induction, however this does not comply with the Skills for Care induction and must be completed within twelve weeks. Training records must be kept up to date. Registered nurses must be supported to undertake training to ensure that they remain up to date. There is limited evidence of training specific to the needs of the residents, all staff must be provided with training to ensure that they can meet the specific needs of the residents. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 20 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager has the skills to manage the home. Feedback is sought from users of the service, this information needs to be analysed as part of an annual development plan for the home. Formal supervision of staff takes place regularly. Staff and residents or their representatives have opportunities to contribute to the running of the home. Residents do not have direct access to their own money. Risk assessment practices require improvement. EVIDENCE: The registered manager is Registered Mental Nurse and has completed her National Vocational Qualification level 4 in Management. The registered manager has been in post over two years. Staff at the home described the Registered Manager as accessible and supportive. It is evident that the Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 21 registered manager is committed to providing high standards of care. Staff meetings are held. There are regular senior management meetings. A comprehensive quality assurance audit took place in May of this year taking account of the views of staff, relatives or representatives, residents and professionals visiting the home. At the time of the inspection due to workload pressures this information was yet to be analysed, opportunities for improvement identified and a suitable action plan established. A copy of this report has been forwarded to the Commission for Social Care Inspection since the inspection. Three monthly residents forums are held, one was due to be held on the 13th of September. The Registered persons conduct regular visits to the home; the written report of this visit shall report on the conduct of the care home and demonstrate how an opinion can be formed about the standard of care provided in the care home The inspector was informed that resident’s monies are not held in the home and that no monies are received on behalf of the resident. There is no lockable facility for residents to keep money. Staff were observed using their own funds to buy refreshments for a resident going out for a walk. Staff informed the inspector that a mentor system existed and all staff receive regular supervision, which includes all aspects of work. One member of staff informed the inspector that they found their supervision sessions useful. The registered manager undertakes staff appraisals six monthly. The format used appeared very comprehensive and a self-assessment is part of the process. Staff are subject to performance related pay. Some environmental risk assessments have been compiled since the last inspection as required, some areas or equipment have not been assessed e.g. unregulated hot water in resident’s room, freestanding radiators. The inspector was informed that servicing of equipment and checks are undertaken as required. The portable appliance testing was commenced in May and is yet to be completed. Hot water checks are undertaken by a plumber, however no evidence was available at inspection. Regular fire training is undertaken and statutory fire checks by a named person. Staff questionnaires are circulated three monthly in relation to fire prevention. Regular reviews of aggressive incidents and inappropriate behaviour is required to reduce the risk to residents and staff. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 22 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 2 X 2 X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 1 Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 5 Requirement The registered person shall produce a written guide to the care home, which shall include the information detailed in this regulation. A copy of this document must be supplied to the Commission and each resident. The registered person shall compile in relation to the care home a written statement which shall consist of the matters listed in Schedule 1. A copy of this document must be supplied to the Commission. The registered person shall after consultation with the resident or representative prepare a written plan as to how the resident’s needs in respect of his health and welfare are to be met. The resident’s plan must be made available to the resident and kept under review. Previous timescales not met Timescale for action 01/12/07 2. OP1 4, Sch.1 01/12/07 3. OP7 15(1) 01/12/07 4. OP10 12(4) 30/12/06 The registered person shall make 01/12/07 suitable arrangements to ensure that the care home is conducted in a manner, which respects the DS0000008894.V346312.R01.S.doc Version 5.2 Page 24 Sheldon House 5. OP12 16(2) 6. OP15 16(2i) 7. OP15 17(2) Sch.4 8. OP18 13(6) 9. OP19 23(2) 10. OP19 23(2)(b)( d) privacy and dignity of residents. The registered persons shall make arrangements for residents to engage in local, social and community activities. They will provide facilities for recreation and activities, having regard to the needs of the resident. The registered person shall provide suitable, wholesome and nutritious food, which is varied, to residents. The registered person is required to keep records of food in sufficient detail to enable any person inspecting the record to determine that the diet is satisfactory, in relation to nutrition or otherwise and any special diets. The registered persons shall make arrangements to prevent residents being placed at risk of harm or abuse. The registered person shall not use the premises for the purposes of a care home unless the physical design and layout of the premises to be used as the care home meet the need of the residents e.g. dining space. The registered person shall ensure that the premises used are of sound construction and all parts of the care home are kept clean and reasonably decorated. Previous timescales not met 01/12/07 01/10/07 01/10/07 01/10/07 01/02/08 01/02/08 11. OP20 13(4) 23(2) 12. OP22 23(2l) 30/03/07 The physical design and layout of 01/02/08 the premises to be used as the care home meet the needs of the residents and activities that residents participate in are so far as practicable free from avoidable risks. Previous timescales not met 30/03/07 The registered person shall 01/12/07 DS0000008894.V346312.R01.S.doc Version 5.2 Page 25 Sheldon House 13. 14. OP26 OP27 15. OP30 16. OP31 17. OP38 provide suitable storage for the purposes of the care home. 16(2k) The registered person shall keep the care home free from offensive odours. 18(1a), The registered person shall 17, Sch.4 having regard to the size of the home, the number and needs of the resident ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of the residents. These must be recorded on the duty rota. 18(1c) The registered person shall ensure that staff are provided with the training appropriate to the work they are to perform e.g. Skills for care induction, post registration training, specific role training. 37 The registered person shall give notice to the Commission without delay of the occurrence of any event in the care home, which adversely affects the wellbeing, or safety of any resident and any allegation of misconduct by the registered person or any person who works at the care home. 13(4)(a-c) Satisfactory risk management and risk assessment arrangements must be put in place. Previous timescales not met 30/11/06 01/12/07 01/10/07 01/12/07 01/10/07 01/12/07 Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 26 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. 4. 5. 6. 7. Refer to Standard OP1 OP1 OP8 OP9 OP15 OP24 OP38 Good Practice Recommendations For the statement of purpose to include the physical environmental information detailed in National Minimum Standard 1. For the resident’s guide to include resident’s views of the home and qualifications of all staff. For assessments to be undertaken by a suitably qualified person to promote continence. For the room used for the storage of medicines to be rearranged or reprovided to meet the needs of the staff. For residents to be offered a clear choice of pudding at mealtimes. For an audit of each room to be conducted to ensure that they are provided with the fittings and furnishings that the resident requires as detailed in NMS 24. For evidence that the portable appliance testing has been completed to be forwarded to the Commission on completion. Sheldon House DS0000008894.V346312.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Sheldon House DS0000008894.V346312.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. 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. 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