Inspection on 19/09/06 for Shelley Park & Shelley House

This inspection was carried out on 19th September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shelley Park & Shelley House 27/12/08

Shelley Park & Shelley House 16/01/06

Shelley Park & Shelley House 28/06/05

Shelley Park & Shelley House 13/01/05

Shelley Park & Shelley House 07/07/04

Shelley Park & Shelley House 29/03/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOME ADULTS 18-65 Shelley Park & Shelley House 32 Florence Road Boscombe Bournemouth Dorset BH5 1HQ Lead Inspector Carole Payne Key Unannounced Inspection 19th September 2006 08:45 DS0000020492.V312273.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 DS0000020492.V312273.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. DS0000020492.V312273.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shelley Park & Shelley House Address 32 Florence Road Boscombe Bournemouth Dorset BH5 1HQ 01202 396933 01202 396933 shelleypark@lineone.net. 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) Shelley Park Limited Mrs S Poultney Care Home 37 Category(ies) of Past or present alcohol dependence (1), Physical registration, with number disability (36), Physical disability over 65 years of places of age (36) DS0000020492.V312273.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named service user (as known to the CSCI) to be accommodated in the category YA (A). This service user requires personal care. The above service user’s care plan is to be reviewed monthly by the multi-disciplinary team, to include the placing Social Worker during the first six months of admission, to ensure the user’s needs are being met by this placement. (No review dates were set on Shelley Park & Shelley House Care Assessment/Plans). Staff must receive professional training in the management of the user’s Cognitive and emotional functioning abilities, behaviours and needs. The age range of service users permitted to be admitted to this establishment is 18 years and above. Service users with acquired brain injury may be cared for at this establishment if it is evident that the staff employed have the skills, knowledge and competencies to care for them and that their qualifications and training in this field of practice are current. ie. Within the previous three years. 16th January 2006 3. 4. 5. Date of last inspection Brief Description of the Service: The home provides care for up to thirty-seven younger adults who have some form of neurological dysfunction. It is situated in a residential area of Boscombe close to the shopping centre and within easy walking and wheelchair distance of the promenade and beaches. There are good transport links both locally and nationally, with several bus stops and coach and train stations situated nearby. The current fee range is £586.32 to £1439.16. Shelley Park and Shelley House are two buildings located in the same grounds and owned by Shelley Park Ltd. A pleasant garden with garden furniture separates the two buildings. There is off street parking at the front of the building for visitors or parking is available on the main road and side streets, directly outside the home. Shelley Park is the main residential unit and Shelley House ground floor is used for daily living activities, therapy sessions and rehabilitation. There is a small snoezelen (multi-sensory) room and adapted kitchen area. This building also provides office accommodation on the first floor for the owners and the administrator. DS0000020492.V312273.R01.S.doc Version 5.2 Page 5 Shelley Park provides accommodation over four floors and a lift is available to floors 1 - 3. The home has 21 single bedrooms 1 of which has an en-suite facility and 5 double bedrooms. Shelley Park provides care for young adults both male and female with neuro disability resulting from a wide range of conditions including severe brain injury or disease, multiple sclerosis, cerebral palsy, stroke and spinal injury. The home has its own transport and regularly organises social outings. Mrs Sally Poultney - one of the Directors - is also the Registered Manager and there is a home manager who oversees the day-to-day running of the home and a director of care. DS0000020492.V312273.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out on the 19th September 2006 and took a total of 11.5 hours, including time spent in planning the visit. The inspector, Carole Payne, was made to feel welcome in the home during the visit. The registered manager, Mrs Sally Poultney, was in the home throughout the inspection and was present to give support with the inspection when required. The home manager, who is responsible for the day-to-day management of the home, and the director of care were available throughout the visit, providing information as required. This was a statutory inspection and was carried out to ensure that the residents who are living at Shelley Park are safe and properly cared for. Requirements and recommendations made as a result of the last inspection visit were reviewed. The premises were inspected, records examined and the daily routine observed. Time was spent in discussion with five people living at the home, four visitors and four staff members on duty. Four resident survey forms, two General Practitioner (GP) comment cards, four comment cards from health and social care professionals in contact with the home and four comment cards from relatives / visitors to the home have been received by the Commission for Social Care Inspection. Friends or family members had completed some resident survey forms on behalf of residents. Throughout the visit both the registered manager, the home manager and the director of care demonstrated a commitment to address any issues raised. What the service does well: A comment from a relative returning a comment card was that ‘the polite and caring manner of reception and management and in particular the home manager is of a very high standard. I also find the nursing staff very knowledgeable, experienced and helpful towards the service users and me.’ A care manager / placement officer returning a comment card said that residents placed at the service ‘are very satisfied.’ All General Practitioners and health and social care professionals returning comment cards said that they were satisfied with the overall care provided. A thorough assessment of residents’ needs and wishes is carried out prior to residents moving into the home, enabling people to be assured that their needs and aspirations will be met by the service. From assessments carried out comprehensive care records are developed, which support staff to deliver care, which meets residents’ needs, wishes and personal goals. DS0000020492.V312273.R01.S.doc Version 5.2 Page 7 Residents and their representatives are provided with assistance to make decisions about their lives, which enable them to experience a varied quality of life. Information about residents is handled with respect, protecting the confidentiality of people living in the home. People living at Shelley Park are well supported to take part in activities, according to their age, religion and peer group, enabling them to enjoy preferred interests and an individual lifestyle. Residents enjoy good links with the local community, enabling them to feel at home in the locality in which they live. Family members and friends are made welcome at the service, supporting people living in the home to continue to experience relationships, which are meaningful to them. The home respects residents’ rights and good support networks are in place to enable people to experience as much responsibility for their daily lives as they are able. The home has supportive plans in place, which enables people to receive assistance with personal care in the way that they prefer and require. Residents, therefore, receive sensitive care, which is reflective of their needs, promoting their physical and emotional well being. Efficient complaints’ procedures support people living at Shelley Park to feel confident that staff members will listen to any issues they raise and act upon them. The home has policies, procedures and training in place, which raises awareness of abuse, and protects people living at the service from harm. Residents live in a hygienic environment, which provides them with a comfortable and safe place, in which to live. Well-trained staff members enable the service to fulfil the needs and preferences of people living at Shelly Park A well organised home and regular consultation with people living at the service supports the running of the home in the best interests of residents. Good practices and procedures protect the safety and welfare of residents. What has improved since the last inspection? DS0000020492.V312273.R01.S.doc Version 5.2 Page 8 The home manager has confirmed since the inspection that there is a continual process to upgrade service users rooms and replace flooring where needed Progress has been made in ensuring that the home’s recruitment practices fully protect people living at Shelley Park. The home now ensures that all documentation/information relating to residents is securely stored to maintain the confidentiality of residents. The home is well maintained and repairs are made in a timely fashion, protecting people living in the home and providing a safe working environment. The service has reviewed rooms, which are shared and ensured that the size and layout are suitable to safely meet residents’ current needs. This will be reviewed according to the changing needs of residents. Issues highlighted at the last inspection regarding the storage of dirty laundry trolleys and keeping sluice doors closed have been addressed. Oxygen cylinders are stored safely. The local fire service has been contacted and assessed any potential fire hazards with regard to this. The home has ensured that nurses’ stations and the ramp to level ‘B’ are safe areas for people to live and staff members to work. The safety of the ramp will need to be reassessed according to the changing needs of people living at the service. What they could do better: Work is currently in progress to improve the clarity of the core care plans, to ensure that they clearly inform the provision of care, meeting residents’ needs. The service is introducing a formal clinical nutritional risk assessment tool, to support the carrying out of detailed risk assessments in relation to the dietary and nutritional needs of residents and to support the input of the hospital dietician. . The registered person should ensure that the details of risk assessments carried out reflect current policies and procedures. The registered person must ensure that residents are fully protected by the generally good practices, which exist with regard to the home’s procedures for the safe handling of medicines. However, the Medication Administration DS0000020492.V312273.R01.S.doc Version 5.2 Page 9 Records must detail any sensitivity to medication, or none known, and the registered person should ensure that following any incident which compromises the safe administration of medicines, an action plan is produced to ensure future safety and good practice. The home manager is monitoring standards of cleaning in the home following the expression of concern, ensuring that it is carried out to the satisfaction of residents and their representatives and protects people from the risk of infection. On the day of the visit, which was unannounced, good standards of cleanliness were apparent. The safety of shared rooms and a ramp is reviewed according to the changing needs of service users accommodated. A review of Registered nurse staffing levels at night should be carried out ensuring that the levels are adequate to meet the nursing needs of residents. Improvements in recruitment practice must be sustained, keeping residents’ safe. It is recommended that future annual quality assurance reports are issued on headed paper, including details of evidence used and be signed by the manager. This recommendation was made in the last inspection report issued to the home and could not be reviewed at this inspection as a new annual report is yet to be carried out. Although the home has a cohesive and very competent senior management team it is not evidenced from the rosters that the registered manager currently spends sufficient time at the service to carry out the registered manager’s role. From discussions with the registered manager she spends time outside the service in carrying out key senior management and liaison roles. It must therefore be ensured that she appears on the roster of the home when she is based at the service. Following this inspection the registered manager has made a firm commitment to formalise the current arrangements for the dayto-day management in terms of putting forward the home manager for consideration for registration as the registered manager of the service, thus formalising the current structure in place. 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. DS0000020492.V312273.R01.S.doc Version 5.2 Page 10 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 DS0000020492.V312273.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A thorough assessment of residents’ needs and wishes is carried out prior to residents moving into the home, enabling people to be assured that their needs and aspirations will be met by the service. EVIDENCE: The registered manager normally undertakes pre-admission assessments. Two pre-admission assessments were viewed for residents who had recently moved into the service. The registered manager had visited one prospective resident and the home manager and director of care had undertaken a further visit to meet with the resident and ensure that the service was able to meet the person’s needs. Due to the complex needs of residents moving in, a care plan is often drawn up prior to admission. Relatives are encouraged to play a part in the pre-admission process and to come and look around the service. One relative spoken with said that they had been very ‘impressed’ with the home, when they had come to look around and had felt reassured that the service could meet their family member’s needs. The pre-admission documents seen included detailed information regarding the person’s clinical needs and informed the admission process. Information had been collated from external healthcare professionals and the information provided had been used to ensure DS0000020492.V312273.R01.S.doc Version 5.2 Page 12 that the home was fully informed and prepared, when the resident moved in. A new pre-admission document has been devised and is currently being piloted alongside the existing record in use. Two residents responding in survey forms said that they had received enough information about the home prior to moving in, one person said that they had not, but were advised that it would be nice for them to move in and were told about the activities organised by the home. DS0000020492.V312273.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Comprehensive care records support staff to deliver care, which meets residents’ needs, wishes and personal goals; work is being done to improve the clarity of the core care plans. Residents are provided with assistance to make decisions about their lives, which enable them to experience a varied quality of life. A detailed process of assessing and identifying risks supports people to enjoy independence, where possible, in their daily lives. By ensuring that there are links with supporting policies and procedures this would support the home’s thorough standards of assessment. Information about residents is handled with respect, protecting the confidentiality of people living in the home. DS0000020492.V312273.R01.S.doc Version 5.2 Page 14 EVIDENCE: Three care plans were viewed for people living in the home. Care planning documentation is very detailed and there are a lot of assessment and care records to support the delivery of care for each individual. At the time of the inspection, the management team were reviewing care planning, as although key information is present within records, some important information is omitted from core care plans. For example, measures in place to support a person who wanders at night, smokes in their room and encouragement to carry out key activities, which can be accomplished independently. It is intended that key care and support required will be brought together into the core care plans, so that they provide easily accessed points of reference. Care records are signed to state that they have been discussed with the resident or, if applicable, their representative. Detailed daily records are completed and there is a monthly record of events, which brings together progress, incidents and important issues that have occurred that inform the continuing caring process. Health and social care professionals returning comment cards said that any specialist advice given is incorporated in the residents’ plans. Care records include information about people’s preferences, supporting them to play a central role in making decisions about their daily lives. One resident spoken with said that they make decisions about their routine. Potential restrictions on freedom and choices are clearly stated. On one file it was noted that where people other than the resident had made a decision, the reason was recorded and discussed with the person, their family member or representative. Information is provided regarding local advocacy services as necessary. Residents are supported to manage their own finances where possible. A relative said that the home had provided a safe unit in their relative’s room, for the secure storage of personal monies. When the home handles personal monies, efficient records were sampled of money held, with receipts and safe processes for signing money paid in and out. One resident said that they visit the local shops and enjoy undertaking errands; the home thereby supports the resident to take responsibility for handling money and making personal decisions. Daily records kept include reference to the personal decisions that people living in the home have made. Two residents responding in survey forms said that they are always able to make decisions about what they do each day, one said that this was usually the case and one person said never; it was evident from discussion with the relative completing this form on the resident’s behalf that DS0000020492.V312273.R01.S.doc Version 5.2 Page 15 this is due to the person’s complex needs, which restrict the personal capacity to make decisions. However, efforts were being made to enable the person to enjoy more interaction and control over their lives. All relatives / visitors returning comment cards said that if residents are unable to make decisions for themselves they are consulted about their care. Detailed risk assessments are carried out, both prior to, and on admission, from records seen. Risk assessments include the use of clinical tools. It was advised that the service should resource a clinical risk assessment tool for nutrition. The home manager has confirmed since the inspection that a risk assessment tool is now in place and ready to be trialled in the home. General risk assessments are carried out, including manual handling and pressure sore risk assessment and specific risk assessments inform the development of each care plan, which sets out how the presenting risk / hazard is to be minimised. One resident spoke of the personal freedom that they enjoy, which is clearly supported by a risk assessment process, which enables any potential risks to be minimised. One resident likes to smoke; there is a risk assessment on file. Currently the resident is left to smoke unsupervised in their room. The home manager confirmed that it would be ensured that personal outcomes reflect the current policy regarding smoking in the home, which stated that residents could not smoke unsupervised in their own rooms. During the tour of the environment it was noted that confidential information is securely stored. Issues highlighted in the last inspection report have been addressed. Information on notice boards and located at nurse’s stations, did not breach residents’ rights to confidentiality. The home has now become computer networked for all its care plans and report writing, which is password protected, ensuring that residents’ data is kept confidential. DS0000020492.V312273.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People living at Shelley Park are well supported to take part in activities, according to their age, religion and peer group, enabling them to enjoy preferred interests, and an individual lifestyle. Residents enjoy good links with the local community, enabling them to feel at home in the locality in which they live. Family members and friends are made welcome at the service, supporting people living in the home to continue to experience relationships, which are meaningful to them. The home respects residents’ rights and good support networks are in place to enable people to experience as much responsibility for their daily lives as they are able. Residents are offered a varied and healthy diet, which meets their individual needs, enabling people to enjoy meals and mealtimes. DS0000020492.V312273.R01.S.doc Version 5.2 Page 17 EVIDENCE: Information seen in pre-admission assessments, and assessments and care plans completed following moving into the home, included details about the activities that residents enjoy. Links have been made with local colleges. One resident said that they go to a local day centre. However, due to the complexity of people’s needs, much of the occupation which takes place in the home, takes place in the rehabilitation unit of Shelley House. The unit provides rehabilitation and therapeutic support to residents. Rehabilitation assistants help residents to follow programmes, for example to improve and maintain muscle tone and undertake daily living activities. An activity and therapy matrix is maintained upon each resident’s file. The home has a mini bus. Residents enjoy visits to local places of interest and people are supported to use facilities in the local community, including places of worship, library and the local cinema. One resident had been swimming on the day of the visit and another had been out to the local shops. The home manager said that some residents go out to church. Details regarding faith and religious needs were seen on one of the care plans viewed and arrangements had been made for a priest to visit the resident at the service. Four relatives responding in comment cards said that they are always made welcome in the home. Care records include detailed information about the meaningful relationships residents enjoy and a relative / next of kin liaison sheet is maintained, which, from those seen, included comprehensive details of contact with families. Family and social contact details, record when relatives plan to visit. One file stated that a calendar is maintained so that the resident knows when their family member will be at the home. Details also included a family tree, enabling staff members to understand the personal relationships, which are important to the resident. Two relatives spoke of their confidence in the home to meet the needs of their family member and the inclusion, which is encouraged by the staff team, for them to be a part of their relatives’ lives. On the day of the visit two relatives were visiting the home to attend a review of their relative’s care. One relative sometimes eats a meal with their family member. Care records seen reflected the individual routines that resident’s experience. Three people responding in resident survey forms said that they could do what they want to during the day. One said that this could be restricted due to lack of staff. Throughout the visit staff members respected residents’ rights to privacy. Staff members knocked on residents’ doors before entering. Residents’ preferred names are recorded on care records. During the tour of the environment people living in the home were spending time in different areas of the home; in their rooms, communal areas and in the reception area DS0000020492.V312273.R01.S.doc Version 5.2 Page 18 and two residents had been out that morning. One resident was enjoying sitting with their relative in the garden. There is a kitchen area in Shelley House where residents can undertake daily living tasks. The chef confirmed that a varied menu is provided to meet with residents’ specialists’ needs and preferences. There is a monthly general menu in place. Hot and cold alternatives are available for both main meals and one resident said that they particularly enjoy the cooked breakfast. The chef said that he attends some resident reviews so that the person’s dietary needs can be discussed and met. One diet is prepared in accordance with the person’s cultural needs and two vegetarian diets are provided. Specialist dietary needs such as those for people suffering from diabetes and pureed diets are also part of daily meal preparation. Packed lunches are also provided for residents attending local day centres. Themed meals also add variety to the regular menu, such as Chinese and Italian menus. Some residents also enjoy lunch club at Shelley House. The main meal on the day of the visit was well presented and appetising. Two visitors commented that pureed food is always served separately allowing the person to experience the different textures of the meal. The chef confirmed that residents are offered choices about what they would like to eat. From individual records seen, residents make choices about what they would like and the size of the portion. This was reflected in the meal served, as one resident was tucking into a second helping of dessert. Drinks were observed to be available throughout the day and regular recording of fluid intake was noted on one of the files seen. A summary record had been collated, detailing input and output, giving an overview of fluid balance, supporting monitoring and identification of healthcare needs. DS0000020492.V312273.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service and relates to two items highlighted in relation to the safe administration of medicines. Good practices exist in other areas of personal and healthcare support reviewed; which effectively support and protect the people living at Shelley Park, many of whom have very special needs in terms of the care support required. The home has supportive plans in place, which enables people to receive assistance with personal care in the way that they prefer and require. People living at Shelley Park receive sensitive care, which is reflective of their needs, promoting their physical and emotional well-being. The home has generally efficient procedures in place for the safe handling of medicines, which protect people living in the home; two issues, which have been raised are being responded to proactively by the service. DS0000020492.V312273.R01.S.doc Version 5.2 Page 20 EVIDENCE: Pre-admission assessments and assessment and care records completed on admission include details of people’s needs and wishes in respect of the help that they receive with personal care. Detailed pre-admission information was provided on one of the records seen in relation to the support required and equipment needed to enable the person to bathe safely. A daily personal hygiene chart is also completed, which tracks help provided and needed. Equipment is in place in the home to support residents to bathe safely. Detailed information was seen, which had been taken prior to moving into the home regarding people’s healthcare needs. This included, on one file seen, information regarding the person’s medical condition, statements from external healthcare professionals involved, including physiotherapist details regarding safely moving the prospective resident. Before admission thorough checklists are completed to ensure that vital equipment is in place. There were detailed records of the names and contact details of people involved in the person’s care for reference. Throughout the person’s stay in the home detailed contact sheets with the General Practitioner, specialist nurses and other external healthcare professionals are maintained, enabling the service to monitor input from healthcare professionals and clearly identify and meet presenting needs. On admission risk assessments are completed. Health monitoring and promotion undertaken includes the monitoring of weights, as appropriate, and fluid balance. Acute interventions are recorded in relation to the person’s medical condition and it was noted on one file that when there are changes in the person’s condition, action is taken to meet changing needs. Rehabilitative elements are also recorded. During the tour of the environment one resident was undertaking controlled exercise with the support of two rehabilitation assistants. Contact with physiotherapists, audiologists and occupational therapists were seen on files and discussed with one resident’s family member, which promotes the quality of life experienced by the resident. From daily records seen specialist resources are accessed according to the needs of the individual, for example contacting the Macmillan services in relation to meeting the needs of a terminally ill resident. Two General Practitioners returning comment cards said that they are satisfied with the overall care provided by the service. A health and social care professional in contact with the home said that the ‘senior manager always implements all care needs’ liaising with the nurse specialist when necessary. Records seen demonstrated that efficient recording is carried out for the receipt, administration and disposal of medicines. Medication Administration record (MAR) charts do not currently state any sensitivity to medicines or none DS0000020492.V312273.R01.S.doc Version 5.2 Page 21 known. Although this was recorded elsewhere in care records, it is important that this information is available when carrying out the administration of medicines. A medication error has occurred since the last inspection visit to the home, when medicine was given to the incorrect resident, who had a similar name to the person for whom the medicine was prescribed. The service appropriately informed the Commission for Social Care Inspection of the immediate action that was taken at the time to ensure that the resident experienced no adverse effect. However, the service should ensure that any such incident includes reflection on practice, enabling highlighting of any future alterations to practice or training needs. The home has measures in place for the safe storage of medicines; the medicines trolley is secured and medicines requiring refrigeration are stored at an appropriate temperature, which is monitored and recorded. Records for the safe administration of controlled drugs showed that two people sign to indicate that balances are checked, when each dose is given. The amount of a controlled drug held corresponded with the amount recorded in the Controlled Drugs register. MAR charts seen showed that medicines are signed for at the point of administration. At the time of the visit no residents were taking responsibility for the administration of their own medication. Oxygen was safely stored and hazard warning notices in place on the door of a room containing oxygen. Dorset Fire and Rescue have written since the last inspection and indicated that they have no adverse comment to make regarding the procedures the home has in place for the safe storage of oxygen. DS0000020492.V312273.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Efficient complaints’ procedures support people living at Shelley Park to feel confident that staff members will listen to any issues they raise and act upon them. The home has policies, procedures and training in place, which raises awareness of abuse, and protect people living at the service from harm. EVIDENCE: The home has a clear complaints procedure in place, which is displayed in the home. The pre-inspection questionnaire submitted by the service details no complaints received since the last inspection. However an issue has been raised with the provider since the visit, which is being responded to appropriately. Three people returning survey forms said that they knew who to speak to if they were not happy and were aware of how to make a complaint. The home has an efficient tracking process for recording complaints received. There was a risk assessment in each care plan seen regarding the person’s vulnerability to abuse, for example in relation to unaccompanied outings made outside the home. Staff members receive training in adult protection as part of updating in practice, on a yearly basis. A training matrix is maintained to identify and track training requirements. Staff members complete questionnaires to ensure that they understand learning completed. The home has a copy of the local No Secrets adult protection guidelines. DS0000020492.V312273.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a clean and hygienic environment, which provides them with a comfortable and safe place, in which to live; this must be supported by regular consultation and review to ensure that cleaning is carried out to a satisfactory standards, meeting with the requirements of residents. EVIDENCE: The environment at Shelley Park provides homely and well-equipped surroundings to meet people’s needs. There is limited communal space at Shelley Park. However, Shelley House, which has level access, provides additional space where residents can experience activities of daily living and rehabilitation. Shared rooms offer restricted space where there are two wheel chair users sharing; however, from observation of the environment, efforts are made to both maximise the use of space available and ensure that residents can be cared for safely. There are three rooms on one level, which are accessed by a stair lift and a ramp. It was evident at the time of the visit that DS0000020492.V312273.R01.S.doc Version 5.2 Page 24 residents accommodated on this level had been assessed to ensure that they are able to manage the environment safely. All areas of the home seen were well maintained. Individual rooms seen were personalised with possessions and furnishings. In the service’s pre-inspection questionnaire no changes are recorded to the environment since the last inspection. The home manager has confirmed since the inspection that there is a continual process to upgrade service users rooms and replace flooring where needed All areas of the home seen were clean and hygienic. Four residents responding in a survey form said that the home is usually fresh and clean. One resident felt that their room was not cleaned to an ‘acceptable standard.’ They said that it depended upon the cleaning staff members that are on duty. One relative returning a comment card said that the cleaning of the room their relative is in is sometimes ‘not as clean as it could be.’ The home manager was contacted following the inspection regarding this feedback. She had already had a meeting with the cleaning staff following issues she had highlighted and is monitoring the standard of cleaning to ensure that it is carried out to a satisfactory standard. Staff members observed good infection control practices; wearing gloves and aprons, as appropriate and washing their hands when they had carried out tasks. A requirement made in the last inspection report had been complied with regarding storing laundry trolleys appropriately and keeping sluice doors closed. DS0000020492.V312273.R01.S.doc Version 5.2 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Well-trained staff members enable the service to fulfil the needs and preferences of people living at Shelly Park Progress has been made in ensuring that the home’s recruitment practices fully protect people living at Shelley Park; this must be sustained, keeping residents’ safe. EVIDENCE: During the visit staff members demonstrated sensitivity to the needs of residents in their care; communicating with then and ensuring that the care provided met with their wishes. A trained member of staff spoke of how much she enjoys working at the home. All four residents who responded to a survey form said that staff members always treat them well; two residents said that staff always listen and act upon what they say, one resident said that staff usually listen. The home manager takes responsibility for organising training in the home. She has devised an induction record, which supports staff members through the induction process to the home and she has completed this in line with DS0000020492.V312273.R01.S.doc Version 5.2 Page 26 Skills for Care standards, the recognised standards for induction training in care homes. The home has a training room, in which organised courses can take place. A health and social care professional returning a comment card said that teaching ‘is carried out at the home if necessary and when requested.’ The manager is also looking at the knowledge sets which are available on the Skills for Care website, for future use. The Skills for Care website can be accessed at: http:/www.skillsforcare.org.uk/ This includes information regarding induction standards and there are downloadable knowledge sets and learning logs for areas of practice including: Dementia Infection Control Medication Workers not involved in direct care These knowledge sets are the first 4 of approximately 30 that are currently planned. They are designed to improve consistency in underpinning knowledge for the adult social care work force in England. They identify learning outcomes and are designed for use alongside the Common Induction Standards, which are also available from this web site. They also count as underpinning knowledge towards NVQs and link to the Health & Social Care National Occupational Standards. The home maintains a matrix of training completed to identify training requirements and copies of certificates of attendance are individually stored. Training provided includes specialist training to meet the individual needs of residents. At the time of the visit there were forty-four care staff. Fourteen staff members possessed a National Vocational Qualification (NVQ) in Care at level 3; two staff members had an NVQ 2. Minutes were seen of a recent trained staff meeting, expressing concern from Registered nurses regarding the adequacy of the allocation of only one Registered nurse at night. The service accommodates a considerable number of residents with complex nursing needs. The registered provider had decided to undertake a review of the Registered nurse staffing levels at night, in terms of duties undertaken. This is recommended within this report. Four recruitment files were viewed; two for staff members who had recently started work in the home and two for staff who were in the process of DS0000020492.V312273.R01.S.doc Version 5.2 Page 27 application. Two members of staff had started work prior to the receipt of a Criminal Records Bureau check. One application form did not contain a full employment history or copies of proof of identity. One staff member had started work before references were received. However, there was evidence that the application form had been reviewed to ensure that full employment histories are now obtained and the home had waited for the return of the Criminal Records Bureau check for the two most current applicants and was awaiting a reference for one person. Improvements in recruitment practice must be sustained. No member of staff must start work without a POVAFirst (a check of the Protection of Vulnerable Adult’s Register, which details people who are deemed unsuitable to work with vulnerable adults), from which they may work under supervision, or a Criminal Records Bureau check being received. Two written references must have been received and there must be copies of proof of identity, including a recent photograph on file. A summary list is maintained, and routine updating carried out, of Registered nurses professional identification numbers with the Nursing and Midwifery Council, ensuring that there current registration is valid allowing them to practice as Registered nurses. DS0000020492.V312273.R01.S.doc Version 5.2 Page 28 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A well organised home and regular consultation with people living at the service supports the running of the home in the best interests of residents. The time spent in the home by the registered manager, must reflect the responsibility of the role. Good practices and procedures protect the safety and welfare of residents. EVIDENCE: The registered manager was in the home during the inspection. However, the home manager, acted as the home’s representative during the inspection. One of the relative’s spoken with commented that she had not seen the registered manager for a long time. The registered manager is not on the home’s working roster. The registered manager said that although she is away from the home for periods of time, mostly in connection with the running of the home, she has DS0000020492.V312273.R01.S.doc Version 5.2 Page 29 continuing contact, both with the home manager, and the director of care. It was evident from the overall standards that the management of the home has positive outcomes for people living at the service. The job descriptions of the registered manager and the home manager are similar in terms of day-to-day management responsibility. The registered manager is accountable for the day-to-day running of the home. Hours spent by the registered manager in the home, therefore, must be included in rosters, so that the time spent in the day-to-day management of the service is clear and transparent. Throughout the visit the management team, which included the registered manager, the home manager and the director of care, worked cohesively to ensure that the needs of residents were safely met, including attendance at reviews and the meeting of clinical and administrative needs. The home has procedures in place for seeking the views of people living in the home regarding the service that they receive, including the use of questionnaires. The home manager monitors standards according to the National Minimum Standards for Adults (18 – 65). From this audit outcomes are recorded and any action required documented and undertaken. An annual development plan is produced each year. The home has complied with requirements issued in the last inspection report regarding consulting with appropriate authorities regarding the safe storage of oxygen cylinders and ensuring the safety of a ramp to level B. (This will need to be risk assessed on a continuing basis according to the needs of residents.) Nurses’ stations are strategically pointed so that they meet the needs of people living at the service. Records show that staff members receive regular training in areas of safe working practice, including fire and drill. The pre-inspection questionnaire completed by the home manager, details current up to date maintenance of facilities and services in the home. DS0000020492.V312273.R01.S.doc Version 5.2 Page 30 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 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X DS0000020492.V312273.R01.S.doc Version 5.2 Page 31 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 YA20 Regulation 13 Requirement The registered person must ensure that residents are protected by the home’s procedures for the safe handling of medicines. The Medication Administration Records must detail any sensitivity to medication or none known. 2. YA34 19 All new staff must only commence employment after 2 satisfactory references have been received by the home. (Previous timescale 31/01/06 not fully met.) The registered person must ensure that full and thorough recruitment practices are carried out, protecting people living in the home. A POVAFirst must be returned before a staff member is able to work under supervision, or a Criminal Records Bureau check must be received. 15/10/06 Timescale for action 15/10/06 DS0000020492.V312273.R01.S.doc Version 5.2 Page 32 3. YA37 10 and 17 Schedule 4 (7) The registered manager must ensure that she appears on the roster of the home, demonstrating that she spends sufficient time at the service to undertake the day-to-day operation and responsibilities for the home, managing the care and welfare of people living in the home. In accordance with this requirement rosters must be submitted to the Commission for Social Care Inspection to demonstrate compliance with this requirement. 15/10/07 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. 2. Refer to Standard YA9 YA20 Good Practice Recommendations The registered person should ensure that the details of risk assessments carried out reflect current policies and procedures. The registered person should ensure that following any incident which compromises the safe administration of medicines, an action plan is produced to ensure future safety and good practice. The registered person should undertake a review of Registered nurse staffing levels at night, ensuring that the levels are adequate to meet the nursing needs of residents. It is recommended that future annual quality assurance reports are issued on headed paper, include details of evidence used and be signed by the manager. This recommendation could not be reviewed at this inspection as a new annual report is yet to be carried out. 3. YA33 4. YA39 DS0000020492.V312273.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000020492.V312273.R01.S.doc Version 5.2 Page 34 - 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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