CARE HOME ADULTS 18-65
Sheldon Ridge Nursing Home 1/3 Bierley Lane Bradford West Yorkshire BD4 6AB Lead Inspector
Steve Marsh Key Unannounced Inspection 9th March 2007 09:00 Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 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 Ridge Nursing Home DS0000019895.V323748.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 Adults 18-65. 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 Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Sheldon Ridge Nursing Home Address 1/3 Bierley Lane Bradford West Yorkshire BD4 6AB 01274 688029 01274 684320 sueroberts@hotmail.com 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) Brunel & Family Housing Association Limited Ms Susan Linda Roberts Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: Sheldon Ridge is registered to provide long term nursing care for thirteen adults with challenging behaviour, physical needs and learning disabilities. The home is situated in the village of Bierley and is close to local amenities and a main bus route into Bradford City centre. The home was originally two purpose built bungalows; an extension now links the bungalows, and creates additional communal space. All bedrooms are for single occupancy. Spacious communal areas include lounges, dining areas, a multi-sensory room, and an activity room. The home has an attractive enclosed rear garden, with level access from the lounges. Specified parking areas are available for visitors to the home. Nursing staff, health care assistants, cooks and domestic staff are employed at the home. The home is a joint venture between Brunel Support Works and Bradford District Care Trust. Fees for the service are currently £467:46 per week. Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care homes are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home, Health and Personal Care etc. An overall judgement reflects how well the home delivers outcomes to the people using the service. The judgement categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded in the body of the report. More detailed information about these changes is available on website – www.csci.org.uk This unannounced inspection was carried out between the hours of 9:00am and 5:30pm. Mr Andrew Moran was appointed acting manager on the 4 October 2006. Mr Moran is a Registered Nurse Learning Disabilities and has achieved a National Vocation Qualification at level four in management. The last key inspection was in June 2006 and sixteen requirements were made at that time. A random inspection was carried out on 11 December 2006, which looked at the following areas of concern: • • • • • • • Medication Financial Procedures The Environment Management Staffing Levels Staff Training Staff Meetings The purpose of this inspection was to assess what progress the service has made in meeting requirements and to assess the impact of any changes in the quality of life experienced by people living at the home. The methods I used included looking at records, watching staff at work and seeing how care was given to the service users, talking with service users and staff and looking round the home. Questionnaires were left at the home for service users and relatives so that they could share their views of the service with the Commission. Unfortunately no questionnaires were returned before this report was completed. Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection?
The home is moving away from providing “institutional” type care to a more person centred approach where everyone is treated as an individual and given the opportunity to make the most of their potential. More emphasis has been placed on providing the service users with a range of activities and outings suitable for their needs, which is improving their quality of life. A new care planning system has been introduced and risk assessments are now completed as part of the care planning process. When fully operational this should provide staff with information they require to provide the care and support each service user needs. New systems have been put in place to protect the service users from financial abuse and their personal money is now held securely. The lounges and dining rooms have been decorated and new furniture, pictures and soft furnishing have either been purchased or are on order, which will make the home a more pleasant and comfortable place for the service users to live.
Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 7 With the exception of a weekend cook and cleaner the home is now fully staffed, therefore service users are receiving continuity of care as agency staff are only used as a last resort. A staff training audit has been carried out and the manager is committed to making sure the service users are cared for by a skilled and experienced staff team. The home has started to consult with relatives and carers about the service and started to introduce quality assurance monitoring systems. However, further work is required before the system is effective and benefits the service users. There is now a commitment by both Brunel Housing and Bradford District Care Trust to work with the Commission to improve standards at the home and provide the service users with quality care. What they could do better:
The home must make sure that all care plans accurately reflect the service users present circumstances and are reviewed on a regular basis to ensure they receive care and support in line with their assessed needs. To safeguard the service users the staff must be vigilant when signing the Medication Administration Record (MAR) sheets and two staff must always sign the controlled drug register. The home must make sure that all investigations into complaints are recorded appropriately if relatives are to have confidence in the way their complaints and concerns are dealt with. The home needs to make sure that all staff receive up dated mandatory training to make sure that they have the skills and competences required to meet the residents’ needs. Staff employment files must contain sufficient evidence to show that a thorough recruitment and selection procedure has taken place, so that relatives can be sure that service users are being cared for by staff that are suitable to work with people with learning disabilities. The home still needs to appoint a permanent manager who has the leadership skills to motivate the staff team and provide the service users with quality care. Quality assurance monitoring systems need to be developed further to make sure the views and opinions of the service users, relatives and other healthcare professional are sought about the service provided. Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 8 Some areas of the home including a number of bedrooms need refurbishing to make them more pleasant for the service users. A new nurse call alarm system needs to be installed. The system must be fitted with sounders that can be heard in different parts of the building or staff provided with bleeps so that they can respond quickly. The locks fitted to bedroom doors must be reviewed to make sure the service users are not able to accidentally lock themselves in their rooms and that staff are able to gain entry at all times. 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 Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Relatives are provided with sufficient information to enable them to make an informed decision about the home. The admission procedure is thorough and relatives can be sure that service users will not be admitted unless staff are able to meet their needs. EVIDENCE: The manager confirmed that there have been no changes to the home’s service user guide. The document is available to relatives, which will assist them when choosing a home. The manager confirmed that the information can be made available to service users in a pictorial format if required. However, service users admitted to the home are generally unable to understand information provided either in the written word, on audiotape or in pictorial format. No new service users have been admitted to the home for about two years. The form used for pre-admission assessments was seen and found to be basic, Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 11 but if completed correctly should provide enough information about prospective service users to determine if they would be suitable for admission. The admission procedure for the home is thorough and all referrals are initially presented and discussed at the regular allocation meetings held for disability services to make sure a suitable placement is found. If a service user is allocated a place, they are offered a minimum of two teatime visits, a full day visit and an overnight stay, which helps them and their relatives decide if the home can meet their needs. Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some care records do not provide accurate and up to date information, which means that service users may not receive the support and care they need from staff to meet their health, personal and social care needs. EVIDENCE: The home is currently in the process of introducing new person centred care plans, which covers all areas of the service users’ health and social care. The format for the new care plans is good but staff must remember to date all records. There is evidence to show that relatives are involved in the care planning process and the manager confirmed that they are always invited to attend review meetings so they can air their views and opinions of the care provided. Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 13 Risk assessments are included in the care plans and where specific areas of concern have been identified action is taken to minimise potential risks without restricting the resident’s freedom of movement or choice. Unfortunately not all care plans have yet been changed to the new system and at least four plans looked at were not up to date and therefore did not accurately reflect the present level care or support required by the service users. The care plan for one service user with severe behavioural problems had not been looked at for a considerable period of time even though staff had serious concerns about her welfare. Care plans should be clearly written giving direction to staff about what care and support each resident needs and how they prefer their care needs to be met. The care plans must be kept up to date and should be used by staff as working documents so that the residents can be sure that they will receive consistent and appropriate care. Staff confirmed that more emphasis is now being placed on encouraging service users to make as many decisions and choices as possible within the limitations of their disability thereby improving their quality of life. Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged and supported to participate in a range of activities, which helps to improve their quality of life. Meals are nourishing and take into account the likes and dislikes of the service users. EVIDENCE: The manager confirmed that no service users are capable of seeking paid employment or attending further education classes although one service user does attend a day centre one day a week. The home does however employ both a full time and part time activities coordinators who are responsible for arranging activities and outing for the service users. Care staff also said that more emphasis and time is now being
Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 15 placed on encouraging service users to develop daily living skills and providing activities rather than having a very rigid daily routine. There is multi sensory room available for the service users to use although it requires refurbishing if the they are to benefit from the facility. Funding has been requested to refurbish this room and it is anticipated that work will start in the near future. The home is fortunate to have two mini buses available to use and trips out to places of interest are organised on a regular basis. Staff are also looking at taking some service users on a weekend break later in the year. This will provide the service users the opportunity to develop their social skills and mix with people who do not have a disability. Through discussion with the activity co-ordinators it is apparent that they are trying hard to develop the range of activities available to make sure that service users lead a full and active life. Service users presently visit the shops, pubs and other local amenities on a regular basis. However, it was recommended that staff also look at ways involving residents more in community events, which would again enable them to meet and make friends with people who do not have a disability. Service users are encouraged to maintain strong links with family and friends and are able to receive visitors in the privacy of their own rooms if they wish to do so. A full time cook is now employed at the home to provide the service users with a varied and balanced diet. Through discussion with the cook it is apparent that he is aware of the individual service users’ dietary needs and on the day of the visit the meals prepared looked appetising and were well presented. The mealtimes on the day of the visit were relaxed and unhurried and service users needing assistance to eat their meals were helped in a discreet and sensitive manner. Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Records and reports about the service users welfare show that their healthcare needs are met, and personal care is provided in a discreet and sensitive manner. However, to safeguard the service users, staff must be more vigilant when administering prescribed medication. EVIDENCE: During conversations with staff it was evident that they had a good understanding of the individual needs of the service users. There is a key worker system in place, which allows staff to focus on individual service users and develop positive relationships with relatives and other professionals. Staff said that the daily routines at the home were flexible and are now less task orientated, giving them more time to spend with the service users. Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 17 The manager confirmed that service users are supported by the staff team in accessing healthcare services, and accompany them on visits to see their general practitioner or outpatient appointments. The input of other healthcare workers is recorded and shows that staff are seeking professional help if they have any concerns. During the inspection I had a brief discussion with a speech therapist who said she worked with the staff team to maintain and improve the residents quality of life. The home continues to use a monitored dosage system of administering medication (blister pack), which is securely stored on the premises. The stock control system for PRN (as and when required) medication was checked and found to be in order, which shows that it is being held and administered safely. However, a number of gaps were seen on the Medication Administration Record (MAR) sheets where staff had not signed for medication. On checking the controlled drug register it was also noted that on four occasions medication had been given but not witnessed by two staff. This is not safe practice and therefore steps must be taken to address this matter. Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home must make sure that all investigations into complaints are recorded appropriately if relatives are to have confidence in the way their complaints and concerns are dealt with. To safeguard the service users from any form of abuse all staff must receive adult protection training. The service users’ personal money held in safekeeping by the home is now protected by the policies and procedures in place EVIDENCE: The manager said that to the best of his knowledge only one complaint had been received since the last inspection visit and this had been referred to the Adult Protection Unit to investigate. This matter has now been resolved and it is not anticipated that any further action will be taken. However, the manager confirmed that the number of complaints received might be inaccurate, as he had found some records including the record of complaints to be out of date on taking up post. Adult protection policies and procedures are in place and the manager has recently attended a two-day training course. There is also an ongoing adult protection training programme in place, however at present only about a third of the staff have received appropriate training. The manager is aware of this and is addressing the matter.
Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 19 Improvements have been made in the way the service users’ personal finances are held and dealt with, which makes sure they are protected from financial abuse. Transaction sheets are available for all money held in safekeeping showing income, expenditure and a balance and receipts are obtained for all items purchased by staff on behalf of service users. Bank accounts have also been opened for service users, which means that large amounts of money are no longer kept on the premises. Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the home continue to require refurbishment to provide the service users with a pleasant and comfortable environment. EVIDENCE: The home is situated in the village of Bierley and is close to local amenities and on a main bus route. The home was originally two purpose built bungalows; an extension has linked the bungalows, and created more communal space. Internally some areas including a number of bedrooms still require refurbishing and it is anticipated this work will start in the near future. However, it was noted that all service users had furnished their rooms with personal belongings making them look individual and homely. Some concerns were raised about the practice of leaving keys in the bedroom doors has there would be now way for staff to enter the room if the key went
Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 21 missing and the service user locked the door from the inside. At present no service users are able to use a key therefore there is no practical reason for them to be left in doors. However, risk assessments must be carried out for new admissions and a key offered if appropriate. To safeguard the service users the locks fitted to bedroom doors must be reviewed to make sure they are not able to accidentally lock themselves in their rooms and that staff are able to gain entry at all times. The communal areas including lounges and dining rooms have recently been decorated and carpets replaced with new laminate wood effect flooring, which has eliminated the odour problem noticed at the last key inspection. At present the lounges and dining rooms although clean, look sparse and unwelcoming, however new furniture is on order and pictures are to be purchased to generally brighten up the rooms. Bathrooms and toilet facilities are located throughout the building and there is an assisted bath available for more dependent service users. There is also a shower room although funding has recently been requested to refurbish this area to make it easier for service users to use. At present the home has no effective nurse call alarm and therefore other than by shouting out staff are unable to summon assistance if they require help to care for a service user. Funding has been requested to install a modern nurse call system, however this as not yet been agreed. To ensure the health and safety of the service users and staff it is important that this matter is resolved as soon as possible. The alarm system must be fitted with sounders that can be heard in different parts of the building or staff provided with bleeps so that they can respond quickly. Externally there is a pleasant garden and patio area to the rear of the home, which service users are encouraged to use during the better weather. Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff recruitment records do not provide sufficient evidence to show that service users are being cared for by staff that are suitable to work with people who have a disability. There is a genuine commitment to provide staff with the training they require to meet the needs of the service users. EVIDENCE: Brunel and Family Housing and the Bradford District Care Trust have a thorough staff recruitment and selection procedure, which is based on equal opportunities and ensuring the protection of the service users. However, the main employment files for all staff employed by the Trust are held by the Human Resource Department and there is insufficient information held at the home to show that service users are protected by a safe recruitment and selection procedure. In two of the three staff files looked at no application forms were available and only one written reference could be found
Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 23 for a recently appointed staff. This matter is currently being addressed by the Trust. Improvements have been made in the way staff information is held and employment files are now less bulky and contain only relevant information. At present the home has no nursing or care staff vacancies, which makes sure service users receive continuity of care. However, they are in the process of recruiting a weekend cook and cleaner to ensure dietary needs are met and the home is kept clean and free from offensive odours. Since taking up post the manager has carried out a full staff-training audit, which showed that much of the training completed by care staff was out of date. A number of courses have already been arranged and it is anticipated that mandatory training will be up to date by the end of June 2007. Additional training will then be identified through formal staff supervision and appraisal system, which has recently been put in place. It is important that all staff receive updated mandatory training such as moving and handling and adult protection as soon as possible so that service user’s are cared for safely by skilled and competent staff. At present seven care staff have achieved a National Vocational Qualification (NVQ) at level two and a further three are studying for the award. Staff confirmed that training is now encouraged at the home and felt that morale had generally improved since the appointment of the new manager. Staff now felt valued and are working as a team, which is vital if service users are to receive the best possible care. Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and the manager provides good leadership to the staff team and ensures the service users’ rights are protected. EVIDENCE: Mr Andrew Moran was appointed manager of the home in October 2006, however the post is only temporary until the end of March 2007. It is important that a permanent manager is appointed as soon as possible if the home is to move forward and provide the service users with a safe, comfortable and stimulating environment in which to live. Mr Moran is a Registered Nurse Learning Disabilities and has achieved a National Vocational Qualification (NVQ) at level four in management.
Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 25 Staff said that the manager had an open and approachable management style and listened to their views and opinion on how they felt the service could be improved, which had not happened in the past. Staff also said that the manager was changing the emphasis of the home from providing “institutional” type care to a more person centred approach where everyone was treated as an individual. Regular staff meetings are now held to keep staff informed of any changes in policies and procedures or work practices, which makes sure care is provided in a consistent way. Some work has started to put quality assurance monitoring systems in place and it is anticipated that survey questionnaires will be sent out to relatives and other healthcare professionals in the near future. The manager has also held a relatives meeting and although it was poorly attended is planning to arrange further meetings as part of the quality assurance monitoring process. Policies and procedures are in place at the home to ensure the health and safety of the service users, visitors and staff, and are reviewed on a regular basis to ensure they comply with present legislation. The home is supported by a number of different departments within the two organisations, and the manager confirmed that there are now clear lines of accountability with external management. Brunel and Family Housing and Bradford District Care Trust are responsible for the overall management of the service and for ensuring that suitable financial procedures are in place. Sheldon Ridge Nursing Home DS0000019895.V323748.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 Adults 18-65 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 3 2 X X 3 3 Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15 Requirement The Registered Provider must make sure that all service users have an up to date plan that covers social, personal and health care needs. The plans should be followed to make sure service users’ needs are met. Previous timescales 31/12/05, 31/03/06, 01/12/06 and 01/03/07 not met. To safeguard the service users the Registered Provider must make sure that when controlled drugs are given a witness is always present and signs the register. Medication Administration Record sheets must also be signed or coded when medication is given. The Registered Provider must make sure that all complaints are recorded and available for inspection. To safeguard the service users the Registered Provider must make sure that all staff receive adult protection training. Bedrooms and shower room –
DS0000019895.V323748.R01.S.doc Timescale for action 01/04/07 2. YA20 13 01/04/07 3. YA22 22 01/04/07 4. YA23 13 30/06/07 5. YA24 23 30/04/07
Page 28 Sheldon Ridge Nursing Home Version 5.2 6. YA26 23 7. YA29 23 8. YA34 17 9. YA35 18 10. YA37 8 11. YA39 24 The Registered Provider must provide the Commission with a schedule of refurbishment work. To make sure the service users are not able to accidentally lock themselves in their rooms all bedroom door locks must be reviewed and a system put in place so that staff are able to gain entry at all times. The Registered Provider must install an effective nurse call alarm system. The system must be fitted with sounders that can be heard in different parts of the building or staff provided with bleeps so that they can respond quickly. The Registered Provider must ensure staff records are held in the home. The records must provide evidence that all the required recruitment checks have been completed. Previous timescales 30/04/06, 01/10/06 and 01/03/07 not met. The Registered Provider must make sure that all staff receive up dated mandatory training as detailed in the training audit provided by the manager. A Registered Manager must be appointed. Previous timescales 01/08/06 and 01/03/07 not met The Registered Provider must make sure that the quality assurance monitoring systems are developed further. 30/06/07 30/06/07 30/06/07 30/06/07 30/06/07 30/06/07 Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sheldon Ridge Nursing Home DS0000019895.V323748.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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
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