CARE HOMES FOR OLDER PEOPLE
Shenleybury House Black Lion Hill Shenley Hertfordshire WD7 9DE Lead Inspector
Louise Bushell Unannounced Inspection 25th October 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Shenleybury House Address Black Lion Hill Shenley Hertfordshire WD7 9DE 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) 01923 859 238 01923 859 238 Shenleybury House Limited Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 22nd February 2005 Brief Description of the Service: Shenleybury House is a residential care home offering accommodation to fifteen older people. It is a beauty period building, in a rural setting within attractive grounds. The home is situated on the edge of Shenley village and neighbours the Roman Catholic church. The house is spacious, bright and holds many of its original features. Most of the service users are local people which presents the home as a pleasant community atmosphere. Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of the inspection year. Many positive aspects were present throughout the inspection. The inspection took place late morning through to late afternoon. Time was spent with the newly appointed manager of the home and the service users actively seeking their views and opinions regarding the home. Where information has remained the same following the last inspection, this has been carried forward to this report. What the service does well:
Many positive aspects were presented at this unannounced inspection. The environment presents as a period home, retaining many of its original features. The communal parts to the home are tastefully decorated with appropriate furnishings. They present as being light, airy and encourage integration with others through its layout and design. All bedrooms are ensuite and are personalised to each service users individual taste. A new manager is in post and although she is not registered yet she has relevant experience and knowledge to support in the smooth running of the service. The new manager is also a member of the Care Homes Provider Association. An effective system is in place for the recording of all complaints, which breaks down clearly the actions and issues that arise from the complaint and the remedial actions that have occurred. Many positive comments were received from a number of service users regarding the staff and the quality of food. Service users stated that “staff are very caring”, “staff always give me the time of day and help me”, “staff are wonderful and kind”. A menu board is in place, which is updated daily displaying the meal choices available. All service users have detailed contracts in place, which work in conjunction with the assessments and the funding paper work from social services. All of which were available for inspection. The manager discussed the homes referral and assessment process in full. Polices and procedures are in place to support this process and offer guidance to both staff and service users. The process ensures that all service users are offered a trial period and intermittent reviews occur to ensure that the service user is happy and the home is able to maintain and meet needs. Medication risk assessments are in place for service users, these are detailed, well structured and contain all relevant information and clear guidelines for staff to follow. Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 6 The manager informed the inspector that the staff, service users, relatives and friends are going to be invited to attend a talk from the Alzheimer’s Society, this is to raise awareness and provide some basic training for staff in providing appropriate support to an ageing service user group. All staff have received the General Social Care Council Code of Conduct. The manager has more on order to have on display in the foyer area of the home. Following the tracking of care records it is clear that there is a sound working relationship with specialist service and other professionals within the home. What has improved since the last inspection?
Following the last inspection and the appointment of the new manager many positive changes have occurred and commenced. New information for in house training is being compiled; topics created so far include the five steps to risk assessment, legionella information, bullying and medication. These are going to be used as part of refresher and in house training sessions. The new manager has commenced service user and relative / friends / supporter meetings. Feedback so far from service users has been extremely positive. In general the manager of the home is in the process of reorganising and revamping all internal filing systems. Training has been arranged for all staff to attend, this will focus on basic literacy and numeracy skills, thus supporting the team in effective recording and monitoring systems, working in the best interests of the service users. A requirement was made at the last inspection for staff to receive structured training in the safe administration of medicines. This has commenced and all staff able to administer are completing this distant learning linked with a local college. For effective management of health and safety, staff now have disposable aprons available when supporting service users with personal hygiene tasks and the serving of foods. The aprons are different colours for different tasks. Following the appointment of the new manager, the home has had a new industrial washing machine, industrial dryer; quotes are being received for a new oven and dishwasher as well as new seating in the lounge. Service users are viewing the chairs over the next few weeks and their opinions and choices will be listened to as past of the process of buying a number of chairs to replace the tired and worn ones. Following the last inspection risk assessments have been completed for the safe use of radiators with out covers, medication and hot water. Daily fridge and freezer temperatures are now being recorded.
Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 7 A low impact exercise class is soon to commence in house for the service users. Information was passed to the manager regarding resources available to support in this programme. The manager stated that this would become a structured event once a week. Following the last inspection care plans were being devised and implemented. Progress is being made and an overhaul is currently being completed on all service user files and recording systems. Once fully complete the system in place is satisfactory in ensuring service users needs are being met. What they could do better:
Due to the manager being newly appointed there is now a need for supervisions to commence. A requirement was made at the last inspection; hence this will be brought forward. The manager stated that this is currently being planned. There is a need for the training systems in the home to be devised and all information reorganised so an over all assessment can be made regarding the skills of the team and the needs of the team. This must be linked to supervision. Individual training records must be available and show a clear record of training received and planned. The manager stated that training is an area that specific focus is being placed and there is a need for most staff to attend core mandatory training again. Specific training needs that must be prioritised are adult protection, manual handling, health and safety, first aid and food hygiene. The manager stated that there are currently a number of vacancies for staff currently. It was clear that active recruitment is occurring, however due to the deputy managers position being currently vacant, there is a need for consideration to be given should this post remain vacant for a period of time. Active recruitment must continue for the continuity of care for the service users and the morale of the staff team. Feedback from service users also determined that having two staff on in the morning is not adequate as they often have to wait for their breakfast, as support is required. The manager stated that she would be looking into this and increasing the ratio of staffing at peak times. This will also be further resolved with the employment of a deputy. The application form is still to be updated following a recommendation made at the last inspection. The manager stated that an overhaul of all polices, procedures, master copy documents is going to occur and changes made to update and revamp the current systems in place. Following the appointment of the manager a complete renewal and redecoration plan was competed and highlighted the works that were required in the home, including new equipment and redecoration to ensure that the home is well maintained. This is being forwarded to the Commission. The manager must prioritise the redecoration works required and commence these.
Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 8 The manager stated that the Statement of Purpose is being updated to reflect her new details and experience. Upon inspection further amendments were required to the complaints section of the document. Care plans are currently being completed and an overhaul of each service users file and recording systems is occurring. There is a need to ensure that both short term and long term care plans are in place to meet specific needs of the service user. Each care plan, guideline line or assessment must be reviewed to ensure changing needs are being met. The manager stated that an activity plan is being introduced; this displaying structured weekly activities that are going to be available. Feedback gained from service users determined that they like the activities that are made available however would benefit from a few more being introduced. A effective quality assurance service user questionnaire is still required to be implemented. 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. Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5 All service users are provided with accurate and adequate information, visits and discussions prior to admission to the home, ensuring that they are empowered and encouraged to make informed choices about where to live. EVIDENCE: A detailed and comprehensive Statement of Purpose is in place, providing sufficient information for all prospective service users, friends and relative and supporters. All service users are provided with the documents prior to admission to the home and following review. These are also on display. A recommendation has been carried forward from the last report regarding the Statement of Purpose being condensed into a “quick view, large print” copy, as the original format is in small format and is lengthy. There is a need for the Statement of Purpose to be updated to reflect the appointment of the new manager and the complaints section must be reviewed to detail that the Commission for Social Care Inspection can be contacted at any time concerning a complaint.
Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 11 The service user or representative and Registered Manager signs the document on agreement and admission to the home. Care records of service users were inspected and there was evidence of pre admission assessment of needs being carried out in each case. The home receives a copy of the pre admission assessment of needs of prospective service users for those who are funded by the Social Services and discharge letters from hospital, where applicable. The manager or a senior member of staff would carry out the home’s own pre admission assessment of needs of any referred service user. The home has a comprehensive and holistic pre admission assessment of needs. This information is used to formulate an initial care plan on admission. Prospective service users are invited to look around the home. Relatives invariably visit the home prior to admission of their next of kin to the home. The initial admission would be on a trial period for a mutually agreed length of time, which can be extended if need be. This allows the home staff ample opportunity to further assess the service user’s needs and to formulate a detailed care plan. A review would then occur at the end of the trial period to ensure that the service user was happy at the home and to assess if the home could continue to meet and maintain the needs of the service user. Contracts are in place for each service user and determine their individual right as a resident at Shenleybury House. Staff members were observed to be interacting well with service users, demonstrating good skills and knowledge to meet the specific care needs of the respective clients’ group. A number of service users were able to comment that the documents are available in the foyer to the house, as well as other information leaflets. Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 10 Service users have full assessments completed on their individual files, ensuring that an individual plan of care can be set out meeting individual needs. Short-term care plans are in need of completing to ensure a consistent level and approach of care is offered to individuals meeting individual health care needs. Care plans are required to be reviewed and updated to reflect changing needs and current objectives for health and personal care. EVIDENCE: All service users care plans were generated from the pre admission assessment and provides the basis of care to be offered to the individual. All care plans detail specific actions to be taken by the staff to ensure all aspects of the service users health, personal and social care needs are met. All care plans are currently being implemented within the home. Currently a general review occurs of the care plans however there is a need to ensure that each specific area of the care plans is reviewed once a month to reflect the changing needs and current objectives for health and personal care. Short-term care
Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 13 plans must be introduced to meet specific need, for example the management and safe working practices for pressure sore care. The plan is drawn up with the involvement of the service user as much as possible. Care plans examined had been signed by service users and or their representatives. All service users spoken with appeared well cared for clean. Self-care is promoted within the home where ever possible. Appropriate risk assessments and monitoring charts are in place to ensure an appropriate level of support is offered. The ethos of good practice within the home ensures that preventive and restorative care is provided. Specialist medical support and advice is offered within the home to any service users who may require it. All necessary equipment is provided within the home to meet service users needs. Following discussions with service users is was confirmed that the staff are very caring and supportive, encouraging them to make decisions about their lives with appropriate assistance provided. Service users commented that they felt respected at all times. Privacy and dignity was observed being upheld within the home. The manager and the staff of Shenleybury House have good, open relationships with the service users, their relatives and friends. Positive working relationships are also evident with the local GP, district nurses and other professional services that provide support. Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 12 & 14 Support is provided for all service users to maintain family, representative and community links as they wish, thus empowering and encouraging service users to maintain, respect, dignity and personal autonomy over choices in their lives. Activity plans are being introduced thus encouraging integration and further stimulation for the service users. EVIDENCE: The manager is currently devising a weekly activities programme to be commenced. An exercise programme is to be provided internally for all service users wishing to participate. Information was passed to the manager with regards to seeking further resources and information from Age Concern. Service users commented that they liked the activities available, especially the Bingo, however they would welcome some more. A Roman Catholic service is held on a weekly basis and a Church of England service held once a month. The manager discussed appointing a coordinators role to a member of staff who would then be responsible for completing the time table of activities and booking and organising entertainments. Involvement in other local community events is encouraged; emphasis is give to autonomy and choice for the service users. Residents meetings have
Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 15 commenced in the home and service users gave positive feedback regarding these. The manager is also introducing a relatives / friends / supporters meeting providing further information and consultation opportunities to encourage the open management approach of the home. Service users views and opinions are expressed freely within the home and efforts are clearly made to ensure that service users maintain vital links, personal autonomy and choices. If further support and or advice is required in order to ensure freedom of choice for the service users the home is able to link with specialist advocacy services in the best interest of the service user. . Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 A comprehensive complaints procedure is in place, which ensures that the rights of all service users are maintained. Polices and procedures are in place regarding abuse, to ensure all service users are protected. Training in adult protection must occur to ensure service users are further protected. EVIDENCE: A comprehensive complaints procedure, with a good system for the recording of all complaints is in place. This has clear actions that have been taken to resolve a complaint. There is a need for the complaints procedure to be reviewed to ensure that it reflects that at any stage a complainant may refer their complaint to the Commission for Social Care Inspection. The ethos of good practice within the home promotes that all complaints are taken seriously ad acted upon. The open management of the home encourages and empowers staff and service users to make complaints with effective resolution. Service users spoken with stated that they were aware of the complaints procedure and would not hesitate in making their complaints known to the management of the home. They stated that they felt confident that their complaint would be dealt with effectively. The organisation has its own Whistle Blowing procedure, which is displayed in various locations in the home and has adopted the Hertfordshire County Council Adult Protection Procedure. Information regarding the policy has been cascaded to all staff at team meetings, however there is a need for al staff to attend the county training.
Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 23, 24, 25 & 26 The home is reasonably well maintained, equipped and furnished. All areas are safe, comfortable and homely. This ensures that service users are able to maximise their independence and live in a warm, suitable, caring environment. EVIDENCE: The home is well maintained, clean and tidy. A maintenance person is employed to work in the home. Following the appointment of the new manager, a planned renewal and redecoration plan in place, with all emergency minor works being completed promptly. The manager must prioritise the works required and these must commence to ensure that the home remains comfortable, bright airy and fresh. The home is bright and airy, promoting an accessible safe space for all service users. Service users spoken to confirm that they like the decoration of the home and feel that it is a homely, calm environment to be in. There are many of the original features remaining in the house. There is ample communal space for the service users
Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 18 to rest, with a main lounge and quiet lounge and a large foyer to the front of the house. Communal indoor space provides lighting of a domestic style and a friendly homely atmosphere suitable for the needs of the service users. Bathrooms and toilet facilities are in abundance throughout the home, ensuring that they all suitably located for all service use, staff and visitors. Service users spoken to state that there are ample toilet facilities available at all times. Suitable grab rails and other aids are available throughout the home. A call point system is available throughout the home and call bells are suitably located for all service users. The home has a passenger lift to enable service users to have access to the 1st and 2nd floor or ground floor. All rooms are single and provide adequate and suitable en-suite facilities. Rooms are personalised and well decorated. All service users are encouraged to personalise their rooms to individual tastes. Laundry facilities are sited so that solid articles are not carried through where food is prepared. Hand washing facilities are provided throughout the building and staff are actively encouraged to maintain good hygiene practices. Policies and procedures are in place for the control of infection through out the home. There is a need for a certificate of water safety to be obtained with reference to Legionella disease to ensure the safety of all within the home. Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30 The home is suitably staffed in numbers to ensure that individual service users needs are met at all times. Staff are not adequately trained to ensure service users are in safe hands at all times. EVIDENCE: Staff were observed to be working in such numbers appropriate to meet all service users needs. Service users commented that there is a need for more staff to be on duty, especially in the morning, as they often have to wait for their breakfast, as support is required. The manager stated that following her appointment she intends to look at the staffing distribution ensuring that more staff are on duty at peak times of the day. This issue would also be resolved with the employment of a deputy who would be able to cover some of the peak times. Ancillary staff are employed, ensuring that the building remains well maintained and functions as a clean environment. It is recommended that the maintenance person and the domestic person also complete the adult protection training. NVQ’s are promoted at Shenleybury, a total of 5 staff have their NVQ level II and 1 having completed the NVQ III. The manager discussed training in detail and the plans that she has in place with regards to the implementation of the training records and the matrix system to show what staff have received training and the needs of the staff team. The ideas that were discussed would be good once in practice. The manager stated that training is a focus area as she is aware that a significant amount of work is
Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 20 required. Requirements have been made for all staff to have a detailed training record, all core and mandatory training and for the home to hold a matrix of all training received and required. The manager is also to commence her NVQ level IV registered Managers Award as soon as possible Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 & 38 The newly appointment manager appears to show effective leadership ensuring that the home is well managed in the service users best interests. Quality assurance questionnaires need implementing to ensure that the views of the service users are actively sought. Staff are currently not appropriately supervised, so the internal monitoring and management of staff is not occurring at a desired level. EVIDENCE: The manager of the home is newly appointed and had been in post three weeks at the time of the inspection. The manager has the experience and back ground to successfully manage the home. It was clear that throughout the inspection her management experience, style and leadership skill s would be advantageous to the smooth running of home. There is a need for her to commence the NQV level IV Registered Managers Award and to apply for
Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 22 registration. At the time of the inspection the application was complete and was ready to send. Since being appointed many of the internal management and monitoring systems have been further developed and changes made for the benefit of the service users. Service users and relatives / friends / supporters meeting have commenced and it appears that the manager has the right attitude in enabling and empowering service users to express their individual rights and wishes. The manager shows clear direction in what she wants to achieve and has a sound knowledge and understanding of the National Minimum Standards. The manager is aware of the works that are required to be completed in the home and shows the drive and determination to take it forward. There is a need for quality assurance questionnaires to be implemented, seeking the views of the service users. The findings from this must then be displayed an a clear action plan made for improvements following the feedback. Since being in post the manager has not yet commenced the supervision of the staff as it was felt that there needed to be a period of time that both the staff and the manager were able to build an effective working relationship with one another. These must now commence. The manager discussed the plans she had in place to structure the supervisions. All records are held securely, however there is a need for the manager to ensure that all records pertaining to the service users are up to date, reviewed and well maintained. The new care-planning system has been introduced and work is still required to ensure this is fully complete. Short term care plans must be introduced for those service users with specific needs that are supported by the out reach nursing team, to ensure that clear records of the condition and treatment are maintained. For health and safety purposes there is a need to ensure that a certificate of water safety is obtained for legionella testing and that all manual handling risk assessments and guidelines are reviewed. Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 2 X 3 3 3 3 2 3 STAFFING Standard No Score 27 2 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X X 2 2 2 Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 6 (a) Requirement The manager must review and update the Statement of Purpose to reflect the new manager. The complaints section in the Statement of Purpose is required to be updated to reflect that complaints can be made directly to the Commission. (This requirement has been carried forward for the last report, failure to comply may result in enforcement action being taken) Care plans, guidelines and risk assessments must be reviewed. Short term care plans must be in place for the management of service users specific health care needs. (See Regulation 17 (1) & (3)) The complaints procedure must be updated and reviewed to reflect that complaints can be made direct to the Commission. All staff must receive Protection of Vulnerable Adults training. The manager must complete a detailed redecoration and renewal of works plan. Works
DS0000019523.V263034.R01.S.doc Timescale for action 01/12/05 2 3 OP7 OP37OP8 15 (2)(b) & (c) 17 Sch 3 (3)(k) 01/12/05 15/12/05 4 OP16 22 01/12/05 5 6 OP18 OP19 18 (1)(a) 13 (6) 23 (2)(d) 28/02/05 01/12/05 Shenleybury House Version 5.0 Page 25 7 8 OP38OP25 OP30OP28 OP27 13 (4)(a) & (c) 18 (1)(a) 9 OP31 CSA para 11 (1) 24 18 (2) 10 11 OP33 OP36 12 OP38 13 (5) must be prioritised and works commence. Legionella testing certificate must be obtained. (See also Regulation 23 (2) (c)) The manager must commence a recognised management qualification. Qualified staff must on duty at all times. Training must occur for all staff covering core needs. Training records must be completed and held for all staff. The manager must apply for registration. The manager must commence the NVQ level IV Registered Managers Award. Quality assurance service user questionnaires must be produced and circulated. Staff supervisions must occur. Staff must have a minimum of six formal one to one supervision per year. Manual handling guidelines must be reviewed to ensure effective management of risks. 01/01/06 15/01/06 01/12/05 15/01/06 15/12/05 15/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 OP2 OP38OP28 OP27 Good Practice Recommendations The manager should make the Statement of Purpose is more accessible for the service users. The manager should implement an activities plan. The manager should allocate a coordinators role to a member of staff to facilitate the provisions of activities. It is recommended that ancillary staff receive Protection of Vulnerable Adults training. Shenleybury House DS0000019523.V263034.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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