Inspection on 09/01/06 for Shenleybury House

This inspection was carried out on 9th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Shenleybury House 02/08/06

Shenleybury House 25/10/05

Shenleybury House 22/02/05

Shenleybury House 11/10/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Shenleybury House Black Lion Hill Shenley Hertfordshire WD7 9DE Lead Inspector Mrs Alison Butler Unannounced Inspection 9th January 2006 01:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 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.V277068.R01.S.doc Version 5.1 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.V277068.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: Shenleybury House is a residential care home offering accommodation to fifteen older people. It is a pleasant 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 present the home as a pleasant community atmosphere. Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted during the afternoon. The inspection focused on the requirements and recommendations and the core standards that had not been inspected at the previous inspection. Time was spent talking to the residents and staff. Care records were also examined. Where standards remain the same the information has been carried forward. What the service does well: What has improved since the last inspection? What they could do better: Replacement carpet is required in the lounge and main corridor area as these have become worn and an area in the lounge could be a trip hazard as it had a tear. Hand washing facilities must be available in all bathroom and toilets; this should include liquid soap and soft disposal hand towels to prevent the spread of infection. A replacement monitor for the computer would be a great asset for the manager to effectively manage the administration tasks of her role. Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 6 A audit trail needs to be set up for monies and valuables which may have to be placed in the safe for safe keeping. The proprietor must ensure that regulation 26 reports are completed every month and a copy is forwarded to the Commission For Social Care Inspection. A redecoration needs to be in place detailing timescales for action. 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.V277068.R01.S.doc Version 5.1 Page 7 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.V277068.R01.S.doc Version 5.1 Page 8 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 Information is available to prospective residents to ensure they are able to make an informed choice. EVIDENCE: The Statement of Purpose has been updated and the Commission For Social Care Inspection has received a copy. Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 9 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, 9 & 10 Full assessments have been carried out to ensure the home are able to meet the needs of the residents. Care plans need to be reviewed to reflect their changing needs and current goals for health and personal care. EVIDENCE: All residents plans examined had been generated from the pre admission assessment and provides the basis of care to be offered to the resident. The manager has plans to change the format of the care plans and to look at the monthly reviewing process to ensure each area is reviewed and not just general information written in the review, as is what happens at the moment. The plans are drawn up with the involvement of the resident and/or family as appropriate. Residents were well kempt and spoke highly of the care the staff provide. They stated that the staff treated them with respect. Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 10 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, 13, 14 & 15 Autonomy is promoted within the home. Visitors are welcomed and contact is maintained with the local community. Residents receive a well balanced diet. EVIDENCE: Weekly activities are available these are carried out by the care staff. A music man comes to the home on a monthly basis, a church service is held on a monthly basis in the home. The role of senior staff is being looked at to have one responsible for ensuring a plan of activities. The plan is to be put into a pictorial format to make it easier for the residents to see what is going on and when. Residents meetings have commenced although the minutes are not yet available to them this has been hindered as the monitor for the computer is unable to be used. Residents are able to discuss the menu and the cook also discusses this with them on a 1-1 basis. A four weekly menu is available with 1 main meal and alternatives are offered if required. Residents spoken to were complimentary about the meals provided at Shenleybury. Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 11 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 & 18 A complaints procedure is in place, which ensures the rights of all residents are maintained. Training in adult protection has been booked to ensure the residents are protected. EVIDENCE: No complaints have been received since the last inspection. A good system is in place for the recording of all complaints. Details of the Commission For Social Care Inspection have been included in the procedure to ensure everyone knows they are able to refer their complaint to the commission. The open door policy of the manager encourages and empowers residents and staff to make their complaints and concerns known and that they will be dealt with effectively. Residents and staff felt confident their complaint or concern would be dealt with effectively. Adult protection training has been arranged and all staff should have attended by the end of January 2006. Staff spoken to during the inspection understood the whistle blowing procedure Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 12 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 & 26 The home does not provide a comfortable and homely atmosphere in all areas. It was clean and tidy to a reasonable standard on the day of the inspection EVIDENCE: New chairs have been purchased since the last inspection which the residents have stated they are very happy with and they were very comfortable. The manager must put together a full plan on the redecoration, renewal and replacement of the home putting in reasonable timescales of when the work is to be completed. The carpets in the lounge and corridors are showing signs of wear and are threadbare in areas. The carpet in the lounge has a torn area, which could be a trip hazard. The carpets must be replaced. Discussion took place with the manager and they may want to provide alternative flooring in different areas. The carpets in place at the moment are extremely highly patterned, which can Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 13 make it difficult for the residents who have mobility and some sight impairment to distinguish if there is a variation in levels. A number of toilets and bathrooms had no liquid soap and/or soft disposable hand towels in place. This must be rectified to prevent the spread of infection. Residents personal toiletry items should be labelled and/or removed from communal bathroom after use to ensure they are used only for the intended recipient, again this is to prevent the spread of infection. The manager stated that a water safety audit had been carried out although the certificate had arrived. The inspector was able to see that an invoice had been received for the work that had been carried out. The manager will forward a copy of the certificate to the Commission For Social Care Inspection. Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 14 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, 29 & 30 The numbers of staff and their deployment is sufficient to meet the personal care needs of the residents. Training has been carried out and further sessions arranged to ensure staff are competent to do their jobs. Recruitment practises are adequate to protect the needs of the residents. EVIDENCE: At the last inspection residents expressed concerns that they had to wait for their breakfast, as care staff were busy assisting other residents with their personal care needs. The domestic staff on the morning shift are now serving breakfast to those residents who require it. Care staff require training in Food Hygiene as they prepare the evening meal and must be aware of the food hygiene regulations to protect the residents at all times. Staff files showed that the required information was available for inspection with the exception of 1 reference although a telephone reference had been received the manager must ensure she records details of the discussion, with whom she spoke and when it happened. Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 15 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, 33, 36 & 38 Care staff are supervised in their day to day work and through formal supervision. The home appears well managed and the staff are committed to providing a good service to the residents. The manager is committed to ensuring the welfare, health and safety of the residents. Ensuring policies and procedures in place has been hindered by having no computer monitor in place. EVIDENCE: The manager has made good progress in putting in new process and procedures to benefit the residents. This has become difficult to continue as the computer monitor didn’t pass the electrical testing and is therefore not in use. The proprietors should provide a monitor to ensure the manager is able to carry out her requirements as a manager and her time would be used more efficiently. The manager has commenced NVQ 4 and is aiming to complete it during this year. Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 16 A quality assurance audit must be put in place and this should seek the views of residents, families and other professionals who access the service. A report must be written on the findings and include an action plan and how to improve the service provided. This must be kept under review and be made available to all interested parties and a copy forwarded to the Commission For Social Care Inspection. The proprietor must ensure that a monthly regulation 26 visit and a copy of the report sent to the Commission For Social Care Inspection. Failure to comply may result in legal action being taken. The manager does not hold regular monies for the residents, although at the time of the inspection a residents had recently passed away and her purse and contents were being held. This was handed back to the family who had come to carry out a check on what belongings there were in the room. The manager must put an audit trial in place to protect all parties and ensure signatures are obtained when returning them. Supervision of staff has commenced and it is recommended that a matrix is put in place to assist in ensuring that it happens at least six times a year. Accident and incident records were well kept and the manager carries out a monthly audit to look at patterns and any follows ups are required such as a medication review, which had recently happened for one individual. Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 2 X 2 Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 18 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 OP7 Regulation 15 (2)(b) & (c) Requirement Care plans, guidelines and risk assessments must be reviewed. Timescale for action 31/03/06 This has been brought forward from the previous inspection report and a new timescale set 2. OP18 18 (1)(a) 13 (6) All staff must receive Protection of Vulnerable Adults training. 28/02/05 This has been brought forward from the previous inspection report as the timescale has yet to expire 3. OP19 23 (2)(d) The manager must complete a detailed redecoration and renewal of works plan. Works must be prioritised and works commence. This has been brought forward from the previous inspection report and a new timescale set 31/01/06 4 5 OP19 OP26 23 (2)(d) 13(3) 6 OP30 18(1)(a) The proprietor must replace the carpets in the lounge, dining and main corridor. The manager must ensure appropriate hand washing facilities are available in all bathrooms and toilets to prevent the spread of infection The manager must ensure all staff that are involved in the preparation of meals have been trained in Food Hygiene DS0000019523.V277068.R01.S.doc 30/04/06 31/01/06 31/03/06 Shenleybury House Version 5.1 Page 19 8. OP38 13 (4)(a) & (c) Legionella testing certificate must be obtained. (See also Regulation 23 (2) (c). This has 31/01/06 been brought forward from the previous inspection report as the timescale has yet to expire. 14. OP33 24 Quality assurance service user 15/01/06 questionnaires must be produced and circulated. The proprietor must ensure that monthly visits are carried out and a report forwarded to the Commission For Social Care Inspection. 31/01/06 15 OP33 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations 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. The manager should make the minutes of the meetings available to the residents in an appropriate format The manager should ensure that personal toiletries are labelled and returned to the individual’s bedrooms after use. The manager should ensure details of a telephone reference are recorded including details of the information given and date and with whom spoken. The proprietor should ensure that a new computer monitor is purchased to enable the manager to carry out her fully responsibilities more effectively The should ensure an audit trial is in place for any valuable items that are held by the home for safe keeping. 2 3 4 5 6 OP14 OP26 OP29 OP31 OP35 Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 20 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 © 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 Shenleybury House DS0000019523.V277068.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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