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Inspection on 08/02/06 for Shenstone Hall Nursing Home

Also see our care home review for Shenstone Hall Nursing Home for more information

This inspection was carried out on 8th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Care staff were engaged in conversation regarding the management of dying residents and coping with death. It transpired that bereavement training is undertaken in line with the homes Ethos. One member of staff stated that `we are very respectful and offer the families hospitality during these sad occasions`. Another said ` someone always go to the funeral, as this is the last thing we can do for them`. A recent death was discussed and it was clear that the staff handled the whole event with professionalism and dignity.

What has improved since the last inspection?

Two new industrial washing machines have been purchased.

What the care home could do better:

Recruitment procedures were not inspected in full, as the inspectors were told that the care manager had the key to the to the personnel files but was not on duty during the visit. However, a newly employed member of the care staff was engaged in conversation during the inspection and she informed inspectors that the owner Dr Mahanta had interviewed her the previous Friday. She had provided the name of two referees but was employed to start work the following Monday, with no time to take up written references. The care worker also stated that she produced a Criminal Records check that had been undertaken some months ago at her previous employment. CRB checks are not transferable and all new staff should undergo a POVA first check, which is then followed up by a CRB disclosure. Written references must be obtained prior to commencing employment. Not all care staff had received formal supervision every two months. During a tour of the laundry it was evidenced that the home had been without the provision of red alginate bags for soiled/foul linen for some time. The appropriate equipment should be provided at all times. Each resident must have a photograph kept on care records. Some parts of the kitchen needed further cleaning and the staff required an update of HACCP requirements.

CARE HOMES FOR OLDER PEOPLE Shenstone Hall Nursing Home 13 Birmingham Road Shenstone Nr Lichfield Staffordshire WS14OJS Lead Inspector Mrs Sue Mullin and additional Inspector Mrs W Grainger Unannounced Inspection 8 February 2006 10:35 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 Hall Nursing Home DS0000022373.V280185.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 Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shenstone Hall Nursing Home Address 13 Birmingham Road Shenstone Nr Lichfield Staffordshire WS14OJS 01543 480222 01543 480222 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) Dr Dhiraj Mahanta Mrs Deborah Mahanta Claire Annette Broadway Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (3), Physical disability (42), Physical disability of places over 65 years of age (42), Terminally ill (4) Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. PD Minimum age 60 years TI - Minimum age 60 years. Date of last inspection 13th September 2005 Brief Description of the Service: Shenstone Hall is a Grade II (star) listed building originating in parts to the seventeenth century. The home was first registered in 1987. It has been sympathetically extended and currently provides nursing care for up to fortytwo elderly persons. Care is also provided on a respite basis to enable carers to have a break from time to time. The home is situated in a rural area of Staffordshire and enjoys extensive views over open countryside. Good road networks ensure easy access to local amenities provided in nearby Lichfield. Accommodation is provided on two floors. The home has 22 single bedrooms and 10 shared rooms. Eight of the thirty-two rooms have an en-suite facility consisting of toilet and wash hand basin; all other bedrooms have handwashing facilities. The home has four communal dining and lounge situated on two floors accessible by a passenger lift. There are suitably adapted bathing and toilet facilities throughout the home and a central kitchen and laundry. There is a car parking space and garden area for the residents to enjoy. Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors using the National Minimum Standards for Older People as a reference, made this statutory unannounced visit. The total time spent for the inspection, including pre and fieldwork, amounted to 9.5 hrs. A registered first level nurse Mrs Janet Hudson was in charge of the home accompanied by a full team of staff. The inspection included the following elements; a sample tour of the building, inspection of records relating to provision of care, discussions with residents and with the staff members on duty. Observation and sampling of other services provided such as catering and laundry, and an inspection of the staffing levels. It was evident that aspects of care had been addressed well, with residents able to choose the home following an assessment and invitation to visit the home. Service user plans had been well written, based on the community care plans completed by social workers. Health, personal and social care needs had been met and well documented. Privacy, dignity and choice aspects for residents were being upheld. The home was fit for purpose, well maintained, and provided a safe environment for the residents and staff. A homely atmosphere had been created, and the premises were very clean, warm and tidy. Adequate areas for residents were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities including catering and laundry were adequately provided. Staffing levels and skill mix had been adequate to meet the assessed needs of the existing residents. Staff training met the majority of mandatory requirements. Following receipt of the report the owner of the home, who arrived as the inspection was finishing has written to the CSCI informing them if the inspectors had have asked him for access to the personnel files he would have been able to oblige. This will be fully checked on the next inspection. The owner also reports that red linen bags have been purchased and are now available in the home. Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? 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 Hall Nursing Home DS0000022373.V280185.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 Hall Nursing Home DS0000022373.V280185.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): 1,3,4 Information had been available for prospective residents and they had been enabled to make an informed choice about residing in the home. Individual health, personal and social cares needs had been established prior to admission and met once a resident in the home. EVIDENCE: Several care plans were sampled and a pre admission assessment was in place. However they did not all contain evidence that written confirmation was provided that stated the home could meet all assessed needs. A variety of folders were in use and it was recommended that all information should be contained in a single folder for ease of case tracking. The documentation seen, and a discussion with residents evidenced that residents had been assessed, prior to admission and they had been enabled to make a choice about the home. Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 9 The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within the service user plans. Staff demonstrated their skills to deliver the appropriate care to residents. Shenstone Hall Nursing Home DS0000022373.V280185.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): 7,8,10,11 The personal plans were generated based on the needs of individuals. Records examined, practices observed, and the comments of residents and staff, confirm that health and personal care needs are being well met. All residents receive full NHS entitlements. EVIDENCE: A selection of care plans were examined at the time of the inspection and the care of the residents was tracked. It was identified that care plans had been developed adequately. Those seen contained clear reports and identified changes and intervention required. Records were cross-referenced with the care of one resident; all care was being given to this person. There was an initial assessment, which identified problems/needs and care plans had been developed in respect of these. Risk assessments were in place and the Waterlow risk and handling assessments reviewed monthly. Weights are recorded in the care plan. Through case tracking it was discovered that care was delivered as per care plan. Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 11 There was evidence of visits by GPs when required and residents were advised and treated by other professionals. There was written evidence of hospital visits having been maintained. The nurses confirmed that the home has good GP support and that the residents have visits from the optician and chiropodist. There is also access to a dentist should this be required. A resident who had been in the home since August 2004, did not have a photograph on the care plan. Each resident must have a photograph kept on care records. The medication procedure was not examined on this occasion. Residents spoken to were complimentary about the home and about the staff. They felt that they were treated with dignity and respect. Shenstone Hall Nursing Home DS0000022373.V280185.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): 13, 15 Residents informed the inspector that they were satisfied with the way the home encouraged their family and friends to visit. Menus were varied and offered a good choice and provision of good quality home cooked food. The catering staff required further training to ensure that all the procedures in respect of HACCP were fully met. EVIDENCE: Two residents engaged in conversation explained that their family members visited frequently and were always welcomed into the home and offered hospitality. The menus identified a varied menu; residents, catering staff and care staff explained to one inspector that any request for an alternative to the menu would be prepared. This was evidenced during the inspection when residents were asked their choice for lunch. The fridge and freezer temperatures were satisfactory. The fridge located next to the stairs to the cellar was in need of a clean where milk had been left to adhere to the slots in the shelf rails, and at the back of the fridge where excess water is channelled. Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 13 The inspector had concerns in respect of the awareness of HACCP by the main cook. Chickens were covered with a cloth after they had been removed from the oven; no check on the temperature had been taken. The food probe was found in a dirty cluttered drawer. The probe was in a poor hygienic condition, there were no records of probe calibration. It is important that the probe is calibrated on a regular basis and records maintained in line with the Environmental Health Agency regulations. It was recommended that the home purchase another food temperature probe. The medi-wipes used for cleaning the probe were eventually found at the back of a cupboard. The pack had been opened incorrectly making the wipes non sterile and not suitable for use. Shenstone Hall Nursing Home DS0000022373.V280185.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): 16,18 Residents and their representatives can be assured that the home act upon any complaints made and that they are protected from abuse. EVIDENCE: There was a comprehensive complaints procedure on display in the home and the Commission was dealing with one complaint at the present time, which has not yet been completed. No other complaints have been received. Four of the present staff had completed a day course for the Protection of Vulnerable Adults; four more staff were to attend the same course on the 24th February 2006. From the discussions with the staff the inspector was satisfied that they had been made aware of the Protection of Adults policy; and chain of procedures for reporting any suspected abuse. Shenstone Hall Nursing Home DS0000022373.V280185.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): 19,26 The establishment was clean and well maintained with good outdoor facilities. However, staff were not being provided with the appropriate equipment to protect them selves fully from cross infection. EVIDENCE: The home was very clean in all residents’ areas, warm, bright and comfortable. External areas and gardens were well kept. Some kitchen areas needed more cleaning input and this was discussed at the feedback. During a tour of the laundry it was evidenced that the home had been without the provision of red alginate bags for soiled/foul linen for some time. Staff were using yellow medical waste bags. The appropriate equipment should be provided at all times. Staff told the inspector that the red bags had been requested for a while but had not been provided. Shenstone Hall Nursing Home DS0000022373.V280185.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): 27,29,30 Staffing levels and skill mix were appropriate to the residents needs. Recruitment procedures did not ensure full protection to the residents. All staff with the exception of the catering staff had received mandatory training. EVIDENCE: This care home with nursing was previously registered under South Staffs Health Authority and the levels and skill mix of staff required at 31 March 2002 are maintained. At the present time there is between one and two qualified nurses on duty on the early shift. There are usually two trained nurses on duty on the early shift for 5 shifts a week. For the rest of the 24 hours a day there is one qualified nurse on duty and additionally, on the: • • • Early shift (7.30 – 2.00) there are 7/8 care staff. (Some care staff start and finish at different times to ease the daily workload and this seems to be working well.) Late shift (2.00 – 9.30) there are 5 care staff Night shift (9.30 – 7.30) there are two care staff Two domestics a day but no separate Laundry staff. Handymen/gardeners where needed. One cook per day with sufficient kitchen assistants. Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 17 The home does not have an in house administrator. There were 34 residents residing in the home all requiring nursing care. On the day of the inspection it was determined that there were appropriate staffing levels and skill mix on duty. Recruitment procedures were not inspected in full, as the inspectors were informed that the care manager had the key to the personnel files but she was not on duty that day. Dr Mahanta the owner arrived as the inspection was finishing and has subsequently informed the CSCI that he could have accessed the files if he had been asked. These will be thoroughly checked on the next inspection. However, a newly employed member of the care staff was engaged in conversation during the inspection and she informed inspectors that the owner Dr Mahanta had interviewed her the previous Friday. She had provided the name of two referees but was employed to start work the following Monday, with no time to take up written references. The care worker also stated that she produced a Criminal Records check that had been undertaken some months ago at her previous employment. CRB checks are not transferable and all new staff should undergo a POVA first check, which is then followed up by a CRB disclosure. Written references must be obtained prior to commencing employment. Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 18 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): 36,37,38 Care staff require more frequent formal supervision. The home has appropriate policies and procedures in place and health and safety aspect were good. EVIDENCE: A number of staff were spoken to at the time of the inspection. All of them confirmed that they had received regular updates in mandatory training. This included moving and handling training, fire safety food hygiene as required and COSHH. Care staff had also attended sufficient fire drill training during the last twelve months. Not all care staff had received formal supervision every two months. All care staff must receive a minimum of six formal supervisions per year and it is good practice to record such sessions, for the supervisor and supervisee to sign them and a copy kept by both. Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 19 The issues which should be covered in supervision are listed in ‘Care Homes for Older People’, National Minimum Standard 36.3. The progress of this will be determined on the next inspection. Some of the Health and Safety records were checked and found to be in order. Hoists and passenger lift were serviced regularly. The fire safety records were examined and fire alarm and emergency lighting testing is undertaken at appropriate intervals. Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 20 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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 3 3 Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO 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 4 Regulation 14(1)(d) Requirement The home must provide written confirmation which states they can meet all assessed needs prior to residents being admitted. Each resident must have a photograph kept on care records. All equipment used in the kitchen must be maintained in good working order. All catering facilities must be kept clean. CRB checks are not transferable and all new staff should undergo a POVA first check, which is then followed up by a CRB disclosure. Written references must be obtained prior to commencing employment. The registered person must ensure that all catering staff receives HACCP training. Care staff must have formal supervision every two months. Timescale for action 08/02/06 2 3 7 15 Schedule 3 (2) 23 (2)(c) 23 (2)(d) 01/03/06 08/02/06 4 29 Schedule 2 (5)(7) 08/02/06 5 6 30 36 18 (1)(c) (i) 18(2) 25/03/06 08/03/06 Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 22 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 15 Good Practice Recommendations It was recommended that the home purchase another food temperature probe. Shenstone Hall Nursing Home DS0000022373.V280185.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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