Inspection on 18/12/07 for Sheldon Lodge

This inspection was carried out on 18th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Sheldon Lodge 16/10/06

Sheldon Lodge 23/02/06

Sheldon Lodge 15/09/05

Sheldon Lodge 12/01/05

Sheldon Lodge 05/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Sheldon Lodge 150 Sheldon Road Chippenham Wiltshire SN14 0BZ Lead Inspector Elaine Barber Unannounced Inspection 18th December 2007 10:55 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 Lodge DS0000028697.V354817.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 Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sheldon Lodge Address 150 Sheldon Road Chippenham Wiltshire SN14 0BZ 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) 01249 660001 Mr Sateeam Arithoppah Mrs Jayne Arithoppah Mr Sateeam Arithoppah Care Home 9 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (9) Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th October 2006 Brief Description of the Service: Sheldon Lodge is registered to care for nine older people, two of whom may have dementia or associated illnesses and three of whom may have a mental disorder. It is a detached property which is located within a residential area of Chippenham and is close to a public house and convenience store. The home is privately owned and the proprietors are Mr and Mrs Arithoppah who live on the premises and undertake many shifts. The home offers five single and two shared bedrooms, which are located on the ground and first floor. A stair lift is installed to access all parts of the building. There is a large, well developed garden and on-street parking is available. Information about the service is available in a statement of purpose, a service user guide and a brochure with photographs. Inspection reports are available in the home and can also be downloaded from the CSCI website, www.csci.org. The fees range between £337 and £394 a week. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home on 18th December 2007. During the visit information was gathered using: • • • • • Observation Speaking to nine people who lived in the home Discussion with the owners. Discussion with two members of staff. Reading records including care records. Other information has been received and taken into account as part of this inspection: • • An Annual Quality Assurance Assessment (referred to as the AQAA). The AQAA is the owner’s assessment of how well they are performing. It also provides information about what has happened during the last year. Comment cards that were returned by eight people who lived in the home, five relatives, four staff members, a social worker and a GP. The judgements contained in this report have been made from all this evidence gathered during the inspection. What the service does well: Information about the home was available in different formats including a statement of purpose, a service user guide, a brochure with pictures and comments from residents and a letter. This ensured that people had the information they needed to make an informed choice about whether the home could meet their needs. People’s needs were assessed when they moved into the home to ensure that their needs would be met. Each person had a contract or a statement of their terms and conditions so that they knew what to expect from the service. Each person had a care plan which included their health, personal and social care needs to ensure these needs were fully met. People had access to health care and saw the GP and other health professionals. They were generally protected by the home’s medication policies and procedures. Care was taken to ensure that people’s privacy and dignity were respected so that people felt they were treated with dignity and respect. People were offered activities, which suited their individual interests and capabilities. These included singing, music, art therapy and bingo. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 6 People also had contact with the local community. They were taken out individually and in groups, for example to garden centres. Representatives from a church visited and one person was supported to go to church. People were encouraged to follow their preferred routines and make their own choices. They got up and went to bed when they chose and chose where to spend their time. People could have as much or as little contact with family and friends as they wished, and were supported to do so by staff. There was a varied menu and people were offered a choice of meals. People received a wholesome, appealing, balanced diet. There was a complaints procedure and all the relatives and people who lived at Sheldon lodge knew how to make a complaint. People’s views were listened to and acted upon. There were policies and procedures and staff training about prevention of abuse, which ensured that people were safeguarded from abuse and harm. The home was in a residential area of Chippenham. There was a large lounge, with a separate dining room and a garden where people sat out in the summer. People lived in safe, comfortable surroundings with access to shared indoor and outdoor space. They had sufficient toilet and bathroom facilities. People had safe, comfortable bedrooms with their own things around them. Many had brought their own things and the owners provided all the required furniture and fittings. They also had provided new fans for everyone and a television in each of the rooms. The home was clean and hygienic. There were usually two staff on duty during the day time and one of the owners would also be present. The owners slept in at night. A range of training was provided so that all staff had the training that they needed to do the job. This ensured that people’s needs were met by the numbers and skill mix of staff who were trained and competent to do their jobs. The owners are both registered nurses and one holds the relevant managerial qualifications. They keep their training up to date by undertaking the same training as the staff. There are systems for reviewing the quality of care, to ensure that the home is run in the best interests of people who live there. The owners do not manage people’s money and relatives ensure that people’s money is safely managed. There are systems for servicing of equipment and health and safety checks to ensure the health, safety and welfare of people and staff are maintained. What has improved since the last inspection? The risk assessment format had been changed so that risks were identified individually and cross refernced with the care plan to ensure people were protected. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 7 Recent training had included equality and diversity which helped staff to understand why they were promoting choice and equality and how to put it into practice. There was also dementia training which had given the staff a better understanding of the illness and how to promote choice and dignity for people. Improvements had been made to complaints handling. The owners had introduced a book for those who may not feel comfortable raising issues, although very little had been put in it. People who were known to be reticent about making a fuss were being asked their opinions more. The dining room had been redecorated and furnished and a new floor had beeen laid. People were very pleased with the result. The shower room had also been refitted and retiled. This made the environment more pleasing and comfortable for people. A new hoist had been fitted in the bathroom to ensure that people were kept safe when being assisted to bathe. The call bell system had been repaired and the call panel had been clearly labelled to ensure that people could call staff at all times when they need assistance and receive help promptly. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sheldon Lodge DS0000028697.V354817.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 Lodge DS0000028697.V354817.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, 2, 3, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People had the information they needed to make an informed choice about whether the home could meet their needs. People’s needs were assessed to ensure that their needs would be met. Each person had a contract or a statement of their terms and conditions so that they knew what to expect from the service. EVIDENCE: There was a statement of purpose, which included full detail about the care that was provided. There was also a service user guide, which contained a summary of the statement of purpose, and there was a brochure with pictures and comments from residents, relatives and staff. The owner said that each person was given a brochure and a service user guide. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 10 There was information in each person’s bedroom telling them that the service user guide was kept in a drawer for them to refer to. The information contained in the service user guide was summarised in a letter, which was laminated and kept on each person’s bedroom wall for ease of reference. The eight people who completed comment cards said that they received enough information about the home before they moved in to decide whether it was the right place for them. The care records of three people were read. Each of these people had had an assessment of their needs when they were admitted to the home. The assessments contained all the information identified in standard 3. Each person had a care plan developed from this assessment information. People whose care was paid for by social services had a social services contract. People who paid for their own care had a statement of terms and conditions, which they and the owners had signed. All the people who completed comment cards said that they had received a copy of their contract. Sheldon Lodge DS0000028697.V354817.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 good. This judgement has been made using available evidence including a visit to this service. People have all their health, personal and social care needs set out in care plans to ensure their personal and health care needs are fully met. They are generally protected by the home’s medication policies and procedures. People feel they are treated with dignity and respect. EVIDENCE: The care records of three people were read. Each person had a care plan, in a new format, which covered all aspects of standard 3.3. These plans were reviewed every two months and a record was made of any changes with the date. People had not signed these plans although they had signed their previous plans. All the people who completed comment cards said that they received the care and support that they needed. The five relatives said that their relatives’ needs were met. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 12 Each person also had a series of risk assessments. A recommendation was made at the last inspection that the format of the risk assessment is changed so that each risk is on a separate sheet and is linked to care plan. This had been done. Each risk was now recorded on a separate sheet and cross referenced with the care plan. One person said that they went out independently. They said that measures were taken to keep them safe. They always told staff when they were going out and where they were going. They carried a mobile phone so that staff could phone them to check they were all right, or they could phone home. The manager said that she believed it was appropriate for people to take risks to promote their independence but risks must be managed. Health care needs were recorded in the care plans. Any nutritional needs, skin care needs and risks of falling were assessed. Each person who wanted one had a pressure-relieving mattress. Appointments with health care professionals were recorded in the care records. Each person was registered with a GP. There were links with the community team and mental health team. One person said that the nurse visited them every three months. Everyone who wanted one had a flu vaccination. One person who was spoken to and all the people who completed comment cards said that their health care needs were met. The social worker and GP who completed comment cards said that people’s health care needs were met. There was a medication policy. A monitored dosage system was used for medication and the owners had developed their own administration record sheets. Any changes were recorded on the record sheets with information about who authorised the changes. They were then signed and dated by the owner. The owners both checked in the medication and signed the records to say that they were received and correct. The medication record sheets were on the whole well maintained except there was a gap when no signature or symbol was recorded. The owner stated that this had occurred at the time of the Christmas party and the person did not have their sleeping tablet. When medication is not given a reason must be recorded. All the staff but one new member had received training about medication administration through a distance learning course. One member of staff said that it was a good course and they had learned a lot about medication. The medication was stored in a locked cupboard in the kitchen. Some of the medication stored was sensitive to heat and steam. The owner said that it did not get hot near the cupboard and they had not had problems with medication deteriorating. There were two shared rooms. The owners had taken care to ensure the privacy of the people who shared the rooms by screening each person’s area with thick curtains. Staff were seen to knock on people’s doors and ask permission before going in. There was a mobile phone so that people could receive calls in the privacy of their rooms and people were provided with their own phones if they wanted one. People could receive visitors in their own Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 13 rooms or in the quiet end of the lounge. People were all wearing their own individual clothes. The owner stated that the training had included equality and diversity which trained staff to understand why they were promoting choice and equality and how to put it into practise. They also said that there was dementia training which had given the staff a better understanding of the illness and how to promote choice and dignity to a less able person. One member of staff said that this training had helped them to understand why people were behaving in certain ways and how to meet their needs more effectively. Five relatives stated in their comment cards that the home always met their relatives’ different needs. One person commented that their particualr needs were dealt with sensitively. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were offered activities, which suited their individual interests and capabilities. They were encouraged to follow their preferred routines and make their own choices. People could have as much or as little contact with family and friends as they wished, and were supported to do so by staff. People received a wholesome, appealing, balanced diet. EVIDENCE: All the people who completed comment cards said that there were activities in the home that they could take part in. These included bingo, art therapy, music, singing, reflexology, and cooking. Representatives from the local Methodist church came once a month and had recently held a church service. One person went out to church. The owner said that in the summer there were garden parties and people had been taken to the church garden party. The previous week there had been a Christmas party for relatives and people spoken to said that they had enjoyed this. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 15 Two people said in their comment cards that they liked to help around the house with washing up, setting the table and the laundry. One person said that they liked to sit in the garden and the owner said that people used the garden a lot in the summer. One person said that they went out independently. On the day of the inspection they went out for a manicure. The owner said that they took people out individually and in small groups. The manager took one person out on their own to get their hair cut. In the summer there had been trips to horse world and a garden centre. There had been a trip to another garden centre at the beginning of December. People also went out with their relatives. All the relatives who completed comment cards said that the home helped their relative to keep in touch with them. One said that the home also encouraged their mother to keep in touch with other relatives and friends. In the Annual Quality Assurance Assessment (AQAA) the owners said that the routine at Sheldon Lodge was flexible. For example breakfast was between 7:30am and 9:30am and people could choose to have their breakfast in their own room or the dining room. People could get up and go to bed when they chose. Although most people did not generally stay up after 9 pm, records showed that some did not actually go to sleep until quite late, and preferred to watch TV in their own rooms. People had brought items of furniture and personal possessions to make their bedrooms more homely. They could choose how and where to spend their time, and what activities to participate in. People were able to meet with their visitors within the main communal areas or in private accommodation as required. All the relatives who completed comment cards said that people were supported to live the life they chose. There was a satisfactory and varied menu, which provided a choice at breakfast and at teatime with the option of a cooked breakfast at weekends. The main meal of the day was at lunchtime. Drinks and snacks were available at other set times of the day. Healthy eating was positively encouraged and a good selection of fresh fruit and vegetable is made available. Lunch during the inspection took account of people’s tastes. Although a main meal of meat, potatoes and vegetables was being served everyone had slightly different combinations and two people were offered a ploughmans lunch. People who were spoken to said that they enjoyed the food and they were given meals that they liked. One person said that alternatives were always offered and they were never given food they did not like. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s views were listened to and acted upon. The policies and procedures and the staff training about prevention of abuse ensured that people were safeguarded from abuse and harm. EVIDENCE: There was a complaints procedure and everyone had a copy of this in their service user guide. In the Annual Quality Assurance Assessment (AQAA) the owners said that they had introduced a book for those who may not feel comfortable raising issues, although very little had been put in it. They also said that people who were known to be reticent about making a fuss were asked their opinions more. Thay said that they had ensured staff were aware of getting feedback from people and informing them about any issues raised. Five relatives who completed comment cards knew how to make a complaint. One commented that staff were conscious of explaining the procedure. Eight people who completed comment cards knew how to make a complaint. All said that the staff listen and act upon what they say. One said that ‘The staff do listen to what I have to say and try their best to carry out my wishes.’ There had been no complaints since the last inspection. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 17 The home has copies of the “No Secrets” document, as well as the organisational policy and procedure on responding to allegations of abuse. Staff spoken to confirmed that they had received training in the protection of vulnerable adults. All staff members are encouraged to report any incidences of poor practice, and a “Whistle Blowing” procedure is also available. There have not been any incidents requiring a vulnerable adults’ referral. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People lived in safe, comfortable surroundings with access to shared indoor and outdoor space. They had sufficient toilet and bathroom facilities. People had safe, comfortable bedrooms with their own things around them. The home was clean and hygienic. EVIDENCE: The home was in a residential area of Chippenham and the building was in keeping with others in the road. Communal areas consisted of a sitting room and separate dining room. ‘Dor guards’ had also been fitted to all doors on the ground floor so that they can be safely held open as required. Radiator covers were fitted. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 19 At the front of the building there is a large, well-maintained garden. The owners carried out a risk assessment of the home and grounds on a regular basis and kept a record of what is found and actioned. Any problems noted at any time were dealt with immediately. Since the last inspection the dining room had been refurbished and a new wood floor had been laid. New light wood tables and chairs with leather seats had been provided. There were also matching leather look place mats. The dining room was well presented and homely. People said that they liked the new décor and furniture. The kitchen was domestic in style and people had easy access so that they could make drinks when they chose. There was a downstairs toilet and upstairs there was a bathroom with toilet, shower room with toilet and a separate toilet. Since the last inspection the shower room had been refitted with a new shower tray and been retiled. A new hoist had been fitted in the bathroom and the flooring needed to be replaced as a result. The seal around the bath also needed attention. The owner said that they planned to refit the bathroom in a similar way to the shower room in the new year. There were two twin and five single bedrooms, which were on the ground and first floors, with a stair lift, which people used with staff assistance. People’s bedrooms were homely and each contained individual personal items. The double rooms had screening with curtains to ensure privacy. Each person had an individual lockable safe for valuables. New electric fans had been fitted in the bedrooms and all but one of the rooms had a new wash hand basin. A television was provided in each room and some rooms also had freeview boxes and DVD recorders. There were policies and procedures for the maintenance of the building and infection control. Staff were receiving training about infection control through a distance learning course. All areas were provided with anti bacterial soap for residents, families and staff use. There was a separate laundry room with a large washing machine, with a sluicing facility, and a tumble drier. Two people said that they liked to help with folding the laundry. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is generally good although improvements need to be made to recruitment practices. This judgement has been made using available evidence including a visit to this service. People’s needs are met by the numbers and skill mix of staff. They are not wholly supported and protected by the home’s recruitment policy and practices. People are cared for by staff who are trained and competent to do their job. EVIDENCE: The home provides the minimum levels of staff, which comprises of two care staff on duty throughout the waking day and commences at 08:00 and finishes at 21:00. A cleaner is employed for five afternoons a week and a music therapist and an art therapist also provide support for activities in the home. The owners are usually present in the home, sometimes as members of staff on duty and sometimes in addition to the staff. There are no waking staff employed at night but the owners provide the necessary sleeping in duties. They make regular checks during the night, and a monthly review of people’s night time needs is recorded. Each person has access to a call bell and is encouraged to ring for assistance if required. The call would then be heard within the owners’ private accommodation. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 21 All five of the relatives and friends who completed comment cards said they were satisfied with the overall care provided. Six out of eight people who completed comment cards said that staff were always available when they needed them and two said that they usually were. Five staff had a national vocational qualification (NVQ) at level 2. Three new staff had yet to start their NVQ although one had completed the underpinning knowledge. All new staff had induction training using the skills for care common induction and foundation standards. Training includes required courses, such as first aid, manual handling, food hygiene, and health and safety, and NVQ training. Other training included dementia, Protection of Vulnerable Adults, medication administration, and advanced first aid. Seven staff members, as well as the two owners had done a VRQ in Dementia Care. There had also been a course on Conflict Management. One of the owners had become a distance learning tutor with a college so that they could deliver the courses more effectively to the staff and have better access to courses available. All four staff who completed survey forms said that they received training that was relevant to their role, helped them to understand people’s needs and kept them up to date with new ways of working. One of these staff said that they had worked in the home for four years and had received on-going and varied training. There was a recruitment procedure. All four staff who completed survey forms said that their employer carried out checks such as a Criminal Records Bureau CRB check and two references before they started work. The records of two new staff were seen. Each had completed an application form, which included a declaration that they had no convictions. One of these staff had two written references and a Protection of Vulnerable Adults (POVA) first check before they started work. They spent the first few days training and then worked under supervision as they are permitted to do as long as the CRB check has been applied for and all other checks are complete. Their CRB check came through a few days after they started. They also had a birth certificate and photo driving license as proof of identity. They had completed a medical questionnaire to confirm that they were physically and mentally fit. The second member of staff had two written references, a birth certificate and marriage certificate as proof of identity and a medical questionnaire. However, they had a CRB check from their previous employment dated 28th February 2006. Their start date was 7th September 2007. CRB checks cannot be used for different jobs and a new check should have been completed. The owner said that they thought they could use recent CRB checks and they would apply for a new one straight away. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 22 A recommendation was made at the last inspection that one member of staff who did not have a POVA check signs a declaration that they had not been placed on the POVA register and that the owner completes a risk assessment regarding the continued employment of this individual with vulnerable people. The owner confirmed that they had signed a declaration. Sheldon Lodge DS0000028697.V354817.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, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a registered nurse who, has been in post for many years, and holds the relevant managerial qualifications. There are systems for reviewing quality of care, to ensure that the home is run in the best interests of people who live there. People’s money is safely managed. People are cared for by staff who are supported. There are systems to ensure the health, safety and welfare of people and staff. EVIDENCE: The owners are both registered nurses and have many years experience. The manager has the Registered Manager’s Award. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 24 One of the owners has had training to undertake the testing of portable electrical appliances and to facilitate training within the home. He also takes responsibility for the home’s medication systems. Both have obtained their VRQ in Dementia Care. One of the owners has recently become a distance learning tutor with a college so that they could deliver the courses more effectively to the staff and have better access to courses available. The owners did the same training as the staff to keep their training up to date. The views of people who lived at Sheldon Lodge had been sought as part of the annual consultation. Last year the questionnaire had also been sent to families/friends, staff and visiting professionals. The replies had been collated and the owners’ responses had been sent to all the people who had responded. An annual plan was produced last year although few areas were identified by people for action. Despite this the owners have identified areas for improvement themselves. These have been referred to earlier in the report. The owners had just sent out the questionnaires again last year and planned to write a report. The home does not have any involvement with residents’ finances. Residents are encouraged to manage their own financial affairs with the assistance of their family members or representatives. The owners were not appointees for any one and did not look after money. Relatives paid the hairdresser direct and the owners paid for chiropody and the families paid them back. All four staff who completed survey forms said that they had regular meetings with their manager to give them support and discuss how they were working. One was more specific and commented that they had two monthly professional development meetings with one of the owners. One member of staff who was spoken to said that they discussed their training needs in supervision. The owner confirmed that supervision meetings occurred every two months. They also said that the staff reviews (6 times a year) had been redeveloped as they were becoming predictable without the staff really taking any interest or input. Every two months a different area of working was assessed with some level of self assessment required by the staff. There was a heath and safety policy and staff had training about health and safety. Health and safety checks were made in the home every six months. In addition the owner said that staff observe people’s rooms on a daily basis and if anything needs attention this is done promptly. There were individual fail-safe devices to all hot water outlets. Those on the wash hand basins in rooms had been cleaned and checked when the basins were replaced. Radiator covers were fitted. Risk assessments addressed key areas. Items of equipment such as the boiler, stairlift, washing machine and tumble drier were under service contract. The hot water system was checked for legionella in June 2007. A new bath hoist was fitted in September 2007. Staff had training about fire safety and there was a fire risk assessment. Checks of the fire safety measures were carried out at the recommended intervals. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 25 Two requirements were made at the last inspection that all call bells are maintained in good working order, so that residents or staff are able to summon help in an emergency, and that the emergency call bell panel is clearly labelled, so that staff might immediately identify in which room assistance is needed. The call bell system had been repaired and was serviced and the call bell panel was clearly labelled. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 26 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 3 3 3 X X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 27 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. 1. Standard OP29 Regulation 19 (1) Requirement The registered person must ensure that a new Criminal Records Bureau check and a Protection of Vulnerable Adults check are obtained for the member of staff who has a CRB brought from a previous job. Timescale for action 18/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The temperature of the medication cupboard should be monitored to ensure it does not exceed the limits identified in the patient information leaflets. If a problem is identified the medication cupboard should be relocated out of the kitchen. Sheldon Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Lodge DS0000028697.V354817.R01.S.doc Version 5.2 Page 29 - 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!