Inspection on 09/02/06 for Shenstone

This inspection was carried out on 9th February 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 but made no statutory requirements on the home.

Other inspections for this house

Shenstone 24/07/07

Shenstone 19/02/07

Shenstone 23/03/05

Shenstone 14/12/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Shenstone Kent Road Halesowen West Midlands B62 8PQ Lead Inspector Linda Brown Unannounced Inspection 9th February 2006 11:00 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 Shenstone DS0000036811.V282201.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. Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shenstone Address Kent Road Halesowen West Midlands B62 8PQ 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) 01384 813470 01384 813471 N/K Dudley Metropolitan Borough Council Mrs Trisha Ghaley Care Home 41 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (27) of places Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. All requirements contained within the registration report of 10 and 11 February 2003 are met within the timescales contained within the action plan. Agreed between Dudley Metropolitan Borough Council and the National Care Standards Commission. Day care provision must not encroach on the facilities, staffing and services provided to residential service users. That the category of one OPx1 to change to one MDEx1 reverting back to original category once the named service user ceases to live at the home. One service user identified in the variation report dated 11 May 2005 who is in the category PD may access the home`s respite services. One service user (male) identified in the variation report dated 12 August 2005 may be accommodated at the home in the category DE(E) who is aged 57 years and over. This will remain until such time that the service users placement is terminated at which time the registration will revert back to DE(E). 31/05/05 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Shenstone is a purpose built building of three - storey construction originally built in the 1960’s. It was refurbished in 1998 and is owned by Dudley MBC .It currently accommodates up to 41 service users. The building has 5 separate but interlinked units within the building of which one unit has 5 short stay beds for respite purposes, the remaining units having 9 beds . Each unit has its’ own kitchenette/ dining room lounge. Shenstone aims to provide 24 –hour care in a residential environment. The premises are light and airy and the décor and furnishings maintained to a good standard .All the windows are double-glazed. The home is situated on the main Kent Road close to nearby Blackheath and Halesowen Town centres. Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a four-hour period. Two inspectors were present. Inspectors toured the building and spoke with staff and residents. Time was spent looking at service users files, examining records for the standards to be inspected and reviewing the requirements made at the last inspection. 22 Comment cards received from service users and five from family and friends. What the service does well: What has improved since the last inspection? 14 requirements were made at the last inspection and twelve have been met. Files examined at inspection confirm the manager has worked hard to ensure care plans now contain all relevant information as required at the last inspection. Risk assessments are reviewed regularly and health appointments documented All requirements regarding medication have been addressed. There is a comprehensive complaints, adult protection and residents money procedure produced by Dudley MBC in place. Unfortunately the member of staff was unable to find them when the home was last inspected. However it is now available electronically and access is available for all care staff. All staff have completed the basic adult protection training. Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 6 Requirements made with regard to the laundry area have been addressed and risk assessments put in place. New systems have been implemented with regard to the safe keeping of service users money. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shenstone DS0000036811.V282201.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 Shenstone DS0000036811.V282201.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): 1,3,5,6 Prospective Service users their relatives and friends have the information they need to make an informed choice about where they live. And have the opportunity to visit and assess the quality, facilities and suitability of the home No service user moves into the home without having his/her needs assessed and been assured that these will be met. Shenstone does not provide facilities for intermediate care. EVIDENCE: The home provides a very detailed statement of purpose, which covers all relevant information there is a brief history of the local area as well as the information about the home. The statement of purpose supplements the service user guide which gives details about how to apply for a place, trial periods, where the home is situated, facilities available, how care is provided, how quality is assured and how to comment or make a complaint including the address of the Commission which needs updating with the Commissions new name. Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 9 Prior to admission a detailed needs assessment is completed at the unit or in family home . The service user is then invited to come for lunch or stay for day. The manager is committed to involve the service user and does not want the decision to move to Shenstone made solely by the relatives. Relatives are welcomed during the information sharing and communication so they can assist the service user in making a choice. They are then given a service user guide, daily routine mealtimes etc and statement of purpose. Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 10 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): 10,11 Service users feel they are treated with respect and their right to privacy is upheld. The death of service users is handled with dignity and propriety and care is taken to ensure that their needs and wishes are known and respected. EVIDENCE: 22 Comment card were received by the inspector all 22 responses stated that service users are treated well and their privacy was respected. Service users met during the inspection confirmed they were well looked after and welltreated. One resident told the inspectors “ the staff could not be kinder”. Inspectors observed staff knocking on doors and asking service users views before entering their rooms. 5 visitors /relative comment cards received confirmed family /friends can visit at any time and in private if they choose to do so. Service users were well presented and wearing their own clothes. A separate folder is maintained and this contains individual sheets with details of the person to contact for each resident in case of emergency or death. The specific preferences of individuals are recorded and there is detailed guidance Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 11 for staff where residents have particular religious or cultural needs. An example was found of a resident whose religious needs were recorded, together with a brief explanation for staff. Where there is no next of kin, a social worker’s telephone number is supplied. This folder is available to staff. Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 12 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 The majority of service users find that their lifestyles and expectations in the home matches their interests and needs, but the manager must develop individual activity plans to ensure that all service users needs are met in this respect 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. EVIDENCE: Service users seen by inspectors confirmed they were able to move around the different units where appropriate and join in with what activities were going on. Residents were seen playing cards with staff. Day trips have been arranged and outings to garden centres however staff informed inspectors residents are not keen to go out especially at this time of year. Staff raise funds to provide extra outings and activities. The manager has implemented a programme to promote activities by arranging for members of staff to attend craft making classes in order to bring the skills back to the unit. Many activities are available in house including candle making, card and coaster making, vases, and bingo. However several Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 13 comment cards received from service users answered “no” to the question Does the home provide suitable activities? The manager needs to review the activity programme in consultation with service users to ensure that individual preferences and needs are met. This should be demonstrated through individual activity plans. There is an open door policy and family and friends are welcome to visit at any time however if possible they are asked to be mindful of mealtimes. All comment cards received from families and friends confirmed they can visit in private at any time and are kept informed of important matters. Service users views are sought prior to admission, they are consulted regarding their daily care and where possible are involved in reviews of care plans. Independence is promoted and service user are able to personalise their room with belongings, which they have brought with them. Information is available for families and friends to enable them to access external agents such as advocates Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 14 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): These standard were not inspected at this inspection however requirements were made at the previous inspection. EVIDENCE: The manager has a detailed complaints procedure which is made available to service users, families and friends. Information given to service user at the admission stage explains the complaints procedure. One comment card from families and friends stated they had no knowledge of how to make a complaint or access an inspection report. The admission process now in place ensures service user and families are given appropriate information with regard to complaints however the manager must ensure that all existing families have assess to the information. Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 15 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): Not inspected at this inspection however all key standards were covered at last inspection EVIDENCE: Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 16 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 Service users needs are met by the numbers and skills mix of staff in three of the four units however the manager needs to review the staffing in the dementia care unit. EVIDENCE: Rotas were examined during the inspection. Cover is adequate and reaches the recommended requirement. Cover is maintained during periods of sickness with the use of regular agency staff. However in discussion with staff it was felt that staffing on units where service users are more able and self-sufficient staffing is adequate but the dementia care unit needs increased staffing in order for staff to provide individual care to service user. Out of the five comment cards received from families /visitors one raised concerns regarding staffing levels. The manager should review the needs of the service users in the dementia care unit and increase the staff accordingly. Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 17 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): 33,38 The home is run in the best interests of service users The registered manager ensures the health, safety and welfare of service users. EVIDENCE: Dudley MBC has a implemented a quality assurance monitoring system, which is accessible electronically. The manager spent time with the inspector explaining the system and evidencing the monitoring of the service. Residents, staff and service user views are obtained in order to improve the service. There are suitable policies and procedures in relation to health and safety within the home. Staff receive training in manual handling, basic first aid and food hygiene. There are systems for the recording and reporting of accidents Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 18 and incidents. A COSHH folder is maintained and updated when new products are used. There are suitable arrangements for ensuring infection control and staff were seen to have easy access to gloves and aprons. Risk assessments are carried out in relation to the premises and the service users. There are regular checks on services to and equipment in the home. There are regular fire drills and all fire fighting and detection equipment is checked on a regular basis. The manager informed the inspectors that the five-year electrical wiring certificate was still outstanding however the department was aware of this and the manager is assured Shenstone is on the maintenance list for the work to be completed. In discussion with inspectors the manager explained the need for staff to decant cleaning materials into smaller containers as many items are delivered in 5-gallon containers. The manager must provide staff with a risk assessment and clear guidelines on the labelling and storing of any chemicals that are decanted. Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 19 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 3 Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 20 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 4 (5) (f) Requirement The manager must update the Statement of Purpose to include the Commission for Social Care Inspection . The manager must ensure that leisure activities cater for the individual needs of service users and develop individual activities plans. The manager must review the staffing ratio in the dementia care unit to ensure the individual needs of service users are met The home must develop a policy for sexuality and relationships. (This is a previous requirement) Timescale for action 01/04/06 2 OP12 16 (2) (m) 01/05/06 3 OP27 18 (1) (a) 01/04/06 4 OP33 13(4) 17 01/06/06 5 OP38 23(2) (b 13(4) The home must produce a policy for the values of privacy, dignity, choice, fulfilment, rights and independence (This is a previous requirement) The home must hold a current 10/05/06 five-year electrical wiring certificate in its records. (Outstanding from last inspection previous date 30/06/05) The manager must supply staff Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 21 with written guidelines and risk assessments ,regarding the decanting, labelling and storing of chemicals into smaller containers 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 10 16 26 Good Practice Recommendations To give thought to installing a pay phone on the second floor for the service users accommodated there. The manager should ensure that all existing families/friends are aware of the complaints procedure. The manager should develop a programme of redecoration To maintain the upkeep of the building as the staff smoking room is in need of decoration. Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Shenstone DS0000036811.V282201.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!