Inspection on 14/06/05 for Shevington Court Nursing Home

This inspection was carried out on 14th June 2005.

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

Shevington Court Nursing Home 17/11/06

Shevington Court Nursing Home 10/03/06

Shevington Court Nursing Home 02/02/05

Shevington Court Nursing Home 14/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Shevington Court Nursing Home Holt Lane Rainhill Merseyside L35 8NB Lead Inspector Claire Lee Unannounced 14th June 2005 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 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. Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Shevington Court Nursing Home Address Holt Lane Rainhill Merseyside L35 8NB 0151 493 1345 0151 430 8431 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Highfield Care Ltd Mrs Brigid Alexander Care Home 46 Category(ies) of OP Old age registration, with number of places Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 46 (OP) Old age, up to 46 PD (E) Physical disability and up to 46 PD Physical disability aged 55 years. 2. Service users to include up to 5 under the age of 55 out of the total number of 46. 3. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the CSCI. Date of last inspection 2nd February 2005 Brief Description of the Service: Shevington Court is a residential care home, which is able to provide care for older people who require 24 hour nursing care. The home is registered for forty-six service users and is owned by St. Andrews Homes with the managing agent being Highfield Care. The Commission has however been notified of a recent change in ownership to Southern Cross and this application is being processed. Mrs Bridget Alexander has been the registered home manager for the past six years and has over 30 years experience of nursing care provision. Shevington Court is located within a suburb of St. Helens and is close to local amenities. The home is situated off the Prescot to St. Helens Road and provides ground floor accommodation to include 46 single bedrooms,1 smoking and 3 non smoking lounges, 2 dining rooms, a hair dressing room, 10 toilets, 4 bathrooms with adapted baths and 2 shower rooms. The home is surrounded by a pleasant garden and patio area suitable for the use of a wheelchair. Car parking space is available at the front of the premises. Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted by 2 inspectors and it took place over 7.5 hours. It was an unannounced visit and was carried out as part of the regulatory requirement for care homes to be inspected at least twice a year. There has been no cause for any visits to the home since the last routine inspection in February 2005. A partial tour of he home was conducted. Care records and other nursing home records were inspected. The manager, a registered nurse, 2 care staff, 6 residents and 1 relative were spoken with and their views obtained of the service provided by the home. What the service does well: The manager conducts the initial assessment with the resident and family member. The assessment process is very detailed to ensure residents are correctly placed at the home and that the staff can meet all their needs. Residents were very pleased with the care they receive and comments included, “I am settled here and the staff take great care of me and my family.” Residents interviewed stated that the staff were always helpful, attentive and pleasant. A relative whose family member had just arrived at the home said, “everyone has been so kind to us.” Residents have an individual plan of care, which includes nursing needs for example, mobility, washing and dressing, nutrition and skin condition. Risk management is also implemented where there is a risk of a fall and supporting documentation contains dependency assessments for moving a resident and assessing skin care. Interviews with staff confirmed that they are prompt to report any problems that may arise and they were knowledgeable regarding the assessment process and plan of care. The home has good contacts with community-based services and hospital staff and rehabilitation programmes are organised where appropriate. This also includes visits from an occupational therapist. Residents can see their GP (General Practioner) at any time and all visits conducted by external health professionals are documented. Each resident had a social profile with details of their family, friends and social Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 6 interests. Visitors were seen popping in at various times of the day and chatting with the staff. The home had a very pleasant relaxed atmosphere and residents were spending time together in the lounge and enjoying lunch in the dining room. Staff discussed the routine in the home and confirmed that it is always based on “what the resident likes”. This was confirmed by a resident who said, “I am able to please myself how I spend my day but the staff are always at hand to help.” Meals are served in the 2 dining rooms or in resident rooms if preferred. Residents were complimentary regarding the variety of hot and cold meals prepared. The menu board is changed daily and a printed weekly menu is available. The cooks meet with the residents to discuss their preferences and any special diet they may have. A resident said, “the cook is very good and looks after my diabetic needs.” The home is purpose built on one level and is pleasantly decorated. Bedrooms have personal possessions such as ornaments and pictures and residents can bring in pieces of furniture if they wish. This helps them to feel ‘at home’ in their new surroundings. Viewing a number of individual rooms, bathrooms/toilets and the recreational areas confirmed the home was clean tidy and hygienic. The lounges and dining areas are spacious and lead out to a patio area. Bathrooms have a good standard of equipment and staff have access to different types of manual handling equipment to assist with transferring residents. The upkeep of the home is very good and all areas are subject to a major 3year refurbishment plan. A resident said, “everyone works hard to keep the home nice and everyone takes a pride in the home.” The home is well managed. Staff were seen working as an effective team and also having time to sit and chat with the residents. Residents were complimentary regarding the standard of care they receive from enthusiastic, cheerful staff. What has improved since the last inspection? Staff adhere to the home’s policy for return and disposal of medicines. Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 7 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. Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 3 There was a good standard of assessments enabling the home to be sure of meeting residents’ care needs. EVIDENCE: The manager completes a very detailed assessment on every resident prior to admission. This is carried out with the resident and their family member if needed. Assessment details from other health professionals, for example, social workers, community and hospital based staff were also available and this information also assists when writing the plan of care. The assessment covers a full range of nursing needs including, skin care, mobility, nutrition, help with washing and dressing. Family, friends and social background was also documented. Admissions to the home are generally planned and routine. There may however be an occasion when an emergency admission would be accepted. A relative whose family member had been admitted recently said, “I am so Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 10 pleased with everything in the home, I could not ask for more, I know there are booklets on the home for me to look at.” Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 7,8,9,10 Residents health, personal and social care needs are addressed in care plans however this information is not always subject to regular review to ensure information recorded is accurate and up to date. Some omissions for medicines administered were also noted and these shortfalls have the potential to place residents at risk. EVIDENCE: The home cares for residents with complex nursing needs and general physical disabilities. Each resident had an individual plan of care that identified relevant aspects of health, social and personal care. Staff interviewed demonstrated a good understanding of these needs and how they were being met by the home. The care plans viewed were detailed and easy to read however not all had been subject to a recent review to ensure the information recorded was accurate and up to date. This was discussed in relation to general health needs and medical conditions that require intervention by a GP. Formal reviews with the residents and relatives are conducted and the care files evidenced agreement and signature by the resident and/or relative to their plan of care. Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 12 Residents with medical conditions, for example, diabetes were receiving specialist input from the diabetic community service and care needs were identified in their care files. Staff monitor this condition to ensure it is well controlled. The home has good links with community based services and this was discussed in relation to rehabilitation programmes for residents who require assistance with their mobility and also visits by an occupational therapist for wheelchair assessments. Dietary provision was also recorded and residents were weighed monthly. All visits by external health professionals were recorded in detail and a resident confirmed that he could see his GP at any time. A chiropodist visits the home regularly and staff arrange optical, dental and hearing appointments when needed. Care files included information regarding assistance with walking/transferring and assessing any areas of the skin that may be at risk. If a resident is at risk of having a fall then a risk assessment highlights the extra support and supervision the resident will need from staff. The home has a very good supply of equipment to assist those who are less able, including mattresses, cushions and manual handling hoists and stand aids. Where the use of equipment is required this was clearly stated in the plan of care. A resident stated, “the staff are very good at judging whether I need assistance when I get out of bed and they are very good at using the hoist.” Pressure sore management is implemented and a care file seen gave a detailed record of the current management and the progress of current treatment. A resident receiving this specialist care said, “the staff are very capable and ensure my dressings are done daily.” The registered nurses are responsible for completing a daily evaluation sheet twice a day and care staff take on the role as a ‘named’ carer for each resident. The carers are responsible for completion of a weekly written report however the carer’s records was not up to date and consideration should be given to discussing this further with the staff. The home has a locked clinical room for the safe storage of 2 medicine trolleys. Staff have access to information sheets on medicines used the home’s policy documents on medicine administration. Not all resident medicine charts evidenced a staff signature following administration of a medicine, details of residents’ date of birth or details of any known allergies. Quantity of medicines received in the building must also be recorded with the date and staff signature of the person responsible for receiving them. Medicine charts must record the amount of medication given, for example, one or two tablets when administering a variable dose. If not adhered to these issues might adversely affect the health and well being of the residents. The home’s pharmacist was visiting during the inspection and she confirmed that she visits the home on a regular basis to provide staff with support. Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 13 Staff were observed assisting residents with their meals and other personal care in a pleasant and sensitive manner. Staff knock on bedroom doors before entering and also allow sufficient time to assist residents with walking. A resident said, “I am not rushed and can take my time getting up in the morning.” Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 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 standard(s) 12,13 and 15 There was a very sociable atmosphere in the home and the routine was informal, relaxed and arranged around the individual needs of the residents. The lunchtime meal was provided in comfort. EVIDENCE: The home has 2 dining rooms with sufficient space to accommodate wheelchairs. Meals are served in these rooms of if a resident would prefer to stay in their room this wish is respected. The dining tables were laid for lunch and residents stated that, “this was a good time when everyone gets together.” The menu board displayed the meals for the day and this offered a good choice of hot and cold foods. A resident said, “the meals are always good and there is plenty of fresh food to eat.” The home has printed menus and although a choice is offered daily this is not always identified. Consideration should be given to including this information. Staff were observing assisting residents with their meals and this was carried out in an unhurried and discreet way. Both cooks have certificates in food hygiene. Residents’ preferred interests are well documented in their care files and the home offers a good range of activities and hobbies. The activities organiser has Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 15 been off for 6 weeks however is returning soon. Residents interviewed stated that they had missed the organised activities but the staff were, “doing a good job and doing what they could.” PAT (Pets as Therapy) dog and visitor were present during the afternoon and a resident said how much she enjoyed this contact. Films are shown and musical entertainment is arranged. Relatives and friends were seen popping in and out and being offered morning coffee and afternoon tea. A relative commented on the fact that she is always offered refreshments by the staff. A resident said, “my family can visit me whenever.” Discussion with a number of residents confirmed that they were happy with the routine in the home and having the smokers’ lounge was perfect. A resident said, “I often stay up late and the staff never mind what time I go to bed.” Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 The home has a complaint procedure and complaints received had been handled promptly and efficiently. Residents were confident that their concerns would be listened to and acted upon. EVIDENCE: The home has a complaint file and no complaints have been received since the last inspection. Previous complaints had been dealt with appropriately and in accordance with the home’s policy. The home’s complaint procedure has the address and telephone number of the local Commission office however it is recommended that this also be added to Southern Cross complaint policy. Staff interviewed were aware of the complaint procedure and what action to take should a concern or complaint arise. The Service User Guide is on display in the foyer and this has a copy of the complaint procedure. A resident interviewed stated, “I have had a few grumbles and the home has always dealt with them, Brigid (manager) is very good indeed and fair.” Abuse awareness is discussed during the induction process for all new staff and training is also provided by the home. The home has abuse policies and procedures, local guideline and a whistle blowing policy. Staff interviewed were familiar with these documents. Last year the home referred an agency member of staff to the POVA (Protection of Vulnerable Adult) list and went through the correct channels of advising the Commission, social services and the agency when carrying out the investigation. Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 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 standard(s) 19,20,21,22,23,24,25 and 26 The home is purpose built and the layout and location of the home is suitable for the people resident. The surroundings are well maintained, homely, pleasant and hygienic. There are sufficient suitable lavatories/ washing facilities and residents’ rooms are comfortable and clean. EVIDENCE: Whilst looking round the home it was apparent that there was a good programme of maintenance and decoration. There is a 3-year major refurbishment programme and residents have been involved with choosing new colours schemes and carpets. Recreational areas and a number of bedrooms viewed were decorated to a good standard and were clean and odour free. Bathrooms are fitted with bath aids to assist those who are less independent and there are also 2 walk in shower rooms. The home was bright and warm and the lounges had comfortable armchairs and coffee tables. Handrails were in place in the main corridors and bathrooms. Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 18 Bedrooms seen were comfortable and maintained satisfactorily. They were very homely in that they showed strong evidence of resident’s personalities, including personal items such as ornaments and pictures. A resident said, “my room is comfortable and I have everything I need.” A relative said, “the home is always kept nice and clean.” The home has appropriate disability equipment and being purpose built the corridors are wide and provide easy access for wheelchairs. A security system is in place at the main front door. Plans are in place to move an administration office to the ground floor to welcome people when they arrive at the home. Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Sufficient numbers of staff were deployed to meet the needs of the residents and recruitment procedures were robust. Staff files however lacked a record of induction and training to offer protection to people living in the home. EVIDENCE: The manager is on duty Monday to Friday and on occasions may work the weekend if cover is required. Two registered nurses are always on duty with 7 care staff from 8-2pm, 5 care staff from 2-8pm and 3 care staff for the night shift, 8pm-8am. The staffing rota was seen for this week and the number of staff on duty confirmed the figures for the day shift. A resident commented on the fact that the home is occasionally short staffed however everything is “just fine now.” Another resident said, “I think the staff are wonderful, they are first class and really care.” All residents spoken with commented on the hard working and very kind attitude of the staff. Sufficient housekeeping staff are employed for domestic and laundry duties and there are 2 cooks, a part time handyman and full time administrator. Residents interviewed were pleased with the laundry service and stated that their clothes were returned promptly each day. Agency staff are not used any existing shifts are covered by the home’s permanent or bank staff. The manager is available to bring in extra staff when required to meet the varying needs of the residents and to assist with trips out. Student nurses undertake a placement at the home when caring for the elderly and comments from the student included, “fantastic home, the manager is just Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 20 brilliant, excellent standard of care, good supervision, care staff very knowledgeable and understanding of the residents’ needs.” The personnel files of 7 staff employed indicated that the home had undertaken all the necessary recruitment checks to ensure protection of residents. Protection of Vulnerable Adults [POVA] checks and Criminal Records Bureau checks at enhanced level were available. Written references had been sought and this included information from the most recent employer. With regards to training there was little evidence of a formal induction given to new care staff. A registered nurse confirmed that she had gone through a checklist with the manager and had been shown round the home. There was however no formal induction on file. Discussion with the manager confirmed that a new accredited induction booklet was being introduced later this year. All records viewed did not evidence training for safe working practice areas, for example manual handling, first aid, food hygiene, fire prevention and infection control. This training is required and must be evidenced to ensure staff are competent and suitably trained to meet the needs of the residents. The home has a training matrix however this was incomplete and consideration should be given to updating this and also keeping certificates of courses attended in individual staff files. It was noted that food hygiene and health and safety were recorded together, a separate record must be maintained to ensure records are accurate. Staff are offered other courses relevant to the care of the elderly including basic nursing skills, care of the dying and basic life support. Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,31 Mrs Alexander’s managing approach is positive, enthusiastic and provides clear direction to staff. Monthly reviews of the home are conducted by head office to ensure residents receive a quality service in comfortable surroundings. EVIDENCE: Mrs Alexander is the manager of the home and has been in post since 1998. Mrs Alexander has over 30 years experience working in the care setting and held a position as an NVQ (National Vocational Qualification) trainer for NVQ studies. Mrs Alexander is a registered nurse with a current registration and has qualifications in management. Staff interviewed were complimentary regarding the manager’s expertise at running the home and the following comment was made, “I am really enjoying working here, the manager is so organised and professional.” A resident said, “the matron is very good.” Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 22 A monthly audit is conducted by a member of staff from head office and the report is sent to the local Commission office in line with the Care Standards Regulation. The report acts as part of the home’s systems for monitoring and ensuring standards. When Mrs Alexander is on leave, a peripatetic manger is allocated to the home and the area manager provides an on call system. It was evident that the home is organised and the care delivery is of a good standard. Mrs Alexander provides good leadership to the team of staff. Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x 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 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x x x x Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 24 yes Are there any outstanding requirements from the last inspection? 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. 2. Standard 7 9 Regulation 15 13 Requirement Timescale for action 1.8.05 3. 30 18/19 The manager must ensure care plans are subject to regular revew to reflect changing needs Medicine charts are to be signed 1.8.05 following administration of any prescribed medicine (timescale of 20.3.05 not met). Medicine charts must record the amount of medication given, for example, one or two tablets when administering a variable dose. Medicine charts must include the residents date of birth and any known allergies Staff must receive an induction 1.9.05 and have training in safe working practices (see main report for course details). Inductin records and training records must be kept 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 7 Good Practice Recommendations Consideration should be given to a review of the named F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 25 Shevington Court Nursing Home 2. 3. 4. 15 16 30 carer weekly record sheet To include the choice of meals on the printed menu The Southern Cross policy to include the address and telephone number of the local Commission office To update the training matrix for staff and keep certificates of training courses attended on file Shevington Court Nursing Home F53 F03 S5427 Shevington V226468 150605 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Burlington House South Wing, 2nd Floor Crosby Road North, Waterloo Liverpool L22 0LG 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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