Inspection on 01/09/05 for Shian

This inspection was carried out on 1st September 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

Shian 18/11/08

Shian 26/11/07

Shian 14/09/06

Shian 01/02/06

Shian 21/03/05

Shian 29/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Shian 1 The Paddock High Spen Rowlands Gill NE39 2BD Lead Inspector Nic Shaw Announced Thursday 1 September 2005 at 12pm st 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Shian Address 1 The Paddock High Spen Rowlands Gill NE39 2BD 01207 545 534 01207 545 534 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) Northgate & Prudhoe NHS Trust Mrs Claire Mars Care Home only 3 Category(ies) of LD Learning disability (3) registration, with number of places Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21st March 2005 Brief Description of the Service: Shian provides ordinary housing for people with learning disabilities, all of whom were formally resident in a long stay hospital. Shian can provide personal care for 3 people. The service cannot provide nursing care. The home is a large detached bungalow situated in a residential area. There is a dining room, lounge with conservatory, kitchen and four bedrooms, one of which is a sleep-in room/office. The home is surrounded by a well maintained garden which service users can access safely. There are seperate laundry and storage facilities. The home is situated close to the town centres of High Spen where a range of community facilities such as shops and public houses can be easily accessed. There are bus stops nearby which link with the main regional centres. The home also has its own transport. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours in September 2005 and was a scheduled announced inspection. The inspection process involved obtaining information from relatives on the quality of the service through questionnaires, observing interactions between the staff and the people who live in the home as well as talking to the manager, service users, staff and a visiting relative. A sample of records were examined including care plans, rotas, accident book and fire log book. A tour of the building took place which included all communal areas and a sample of service users bedrooms. The judgements made are based on the evidence available on the day of the inspection. What the service does well: There are lots of opportunities provided for the service users to take part in leisure activities. The home has its own transport, which is paid for by the organisation, so that the service users can enjoy trips further away. One service user has recently been on holiday to Paris and the staff are currently in the process of finding a suitable venue so that the other two service users can experience a holiday away from home. The staff are experienced and provided with a range of training by the organisation which helps them to carry out their role as care staff well. The staff spoken to said that they enjoyed their work and felt involved in the running of the home. The registered manager is friendly and approachable and the staff and visiting relative said that they would have no hesitation in speaking to her if they had any concerns. One relative spoke positively of how the staff are now supporting her daughter to visit her at home. The environment offers the service users with a homely, clean, comfortable place in which to live. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 6 The manager and staff make sure that service users enjoy good health by arranging regular health care checks. There are regular staff supervisions and staff said that this provides them with the opportunity of raising any concerns they may have. 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. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1&2 Information is available to inform service users that the service will be able to meet their needs. Service users needs are always assessed prior to admission in order to determine that their needs can be met in the home. EVIDENCE: There is a Statement of Purpose and a Service User Guide. An examination of these documents concluded that service users are provided with information on the services and facilities provided at Shian. Advice was offered as to how these documents could be developed. For example; reference is made to viewing “home working procedure 1” for information on the home’s admission procedure instead of this information being available with the Statement of Purpose. The manager was receptive to the advice offered. Records examined concluded that there are clear admissions procedures in place. This includes obtaining an up-to-date care management assessment so that future prospective service users are assured that the service will be able to meet their needs. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6&7 The standard of information recorded in the care plans has improved. These reflect the service users health and personal care needs, therefore in practice their care needs can be met effectively. The staff and manager continue to develop appropriate and effective ways of communicating with the service users so that they are provided with opportunities for making decisions for themselves. EVIDENCE: Since the last inspection it was evident that work has continued in relation to developing the care plans. The sample of care plans viewed were comprehensive covering all aspects of the individual’s personal, social and healthcare needs. Clear step by step guidelines are provided for staff to follow in relation to individual needs. However, as discussed with the manager and staff, some of the positive interventions carried in practice had not always been recorded in the care plan and the manager agreed that this is an area for future development. Discussion with the manager and staff concluded that they continue to look for ways of communicating with the service users. This is of particular importance in relation to empowering people to make decisions and choices for Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 10 themselves. A picture menu has been developed to help the service users choose what they want for their meals. The manager gave an example of how the staff noticed one service users develop a particular interest in a member of staff’s necklace. In response to this communication the staff supported this service user to buy a necklace for herself, which the manager said she has continued to wear ever since. In order to involve service users in day to day decisions in relation to the home, for example the re-decoration process, samples of fabrics for curtains and colour schemes are brought into the home for the service users to look at. Review meetings are regularly held and discussion with relatives confirmed that the home always consults with them particularly in relation to finances, on behalf of their relative. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13&15 Service users are assisted to lead active and fulfilling lifestyles by having a regular community presence, regular contact with their families and by accessing a range of leisure and social facilities. This will assist in them leading a full and enjoyable life. EVIDENCE: During the inspection service users were observed visiting the bank. Discussion with a visiting relative concluded that the service users are always out and about in the community. She said that her relative had recently been supported by the staff to go on holiday to Paris and that this was the first time she had been abroad. She went on to say that the staff had videoed this occasion so that she and her husband could share in this new experience. It was also positive to note that the staff took time to contact the relatives to let them know that their family member had arrived safely at their holiday destination. Discussion with the staff confirmed that they were enthusiastic about finding new activities for the service users, including bike rides, experiencing a train Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 12 ride and the possibility of one service user, who loves music, going to an open air concert. The home has access to its own transport and “enabling” staff, who are employed by the organisation to specifically support service users with leisure activities, visit the service users 3 days each week. Relatives spoken to said that they could visit their family member at any time and that the staff also support service users to visit them at home. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19&20 Service users receive the support they need from staff to ensure that their personal, physical and emotional health needs are met. Although good systems for storing and administering service users medication are in place, which ensures that service users get the treatment they have been prescribed, some aspects of record keeping need to improve. EVIDENCE: Care plans examined confirmed that the service users have regular access to their GP and other medical professionals such as the District Nurse. Discussion with the manager concluded that she has contacted the physiotherapist in order to assist the staff with reviewing and up-dating the moving and handling plans. Monthly house meetings are held in which any changes in the service users health care needs are discussed and closely monitored. Observations made confirmed that staff provide service users with support in relation to their intimate personal care in a sensitive discreet manner, carrying out care tasks in the privacy of the person’s bedroom. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 14 Continuity of care is provided through a keyworker system and the visiting relative spoken to said that she knew who her family member’s keyworker was. A sample of medication records were examined. In all but one instance the medication records confirmed that medication had been administered appropriately. In this instance, where the medication had not been signed for, the manager confirmed that this had been administered, as the tablet was not in the monitored dosage system supplied to the home by the pharmacist. The manager agreed it would be beneficial to develop the home’s self-auditing procedures to include a check that all medication administered had been signed for. It was advised that items such as prescribed creams should have clear instructions on the label in order to inform staff of administration procedures. “As directed” should be avoided. It was also suggested that a list of those staff authorised to administer the medication should be maintained together with a list of specimen signatures. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Appropriate policies and procedures are in place, supported by staff training, which ensure that service users are protected from abuse and neglect. EVIDENCE: The home has its own policy and procedure documents relating to abuse which are available to staff to guide them if they have any concerns in this area. Staff spoken to confirmed that they knew what to do should they witness or suspect abuse and that they had recently received training in relation to this which they said was very interesting and beneficial to them. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 The building was clean, warm and generally well maintained offering the service users a comfortable, homely place in which to live. EVIDENCE: The home was found to be clean, warm and homely. All of the bedrooms are single occupancy and those viewed were filled with the individual’s personal effects reflecting their likes and interests. One service user’s bedroom is soon to be re-decorated and equipped with new bedroom furniture. Discussion with the manager and the visiting relative confirmed that the service user is to be fully involved in this process. There is a separate bathroom/ toilet facility which is equipped with a specialist bathing facility. There is a separate shower. The shower seat is starting to show signs of rusting and should be addressed. Communal space consists of a lounge, dining room and conservatory area. New blinds have been fitted throughout the home and discreet coverings have been fitted to the corners in corridors to protect these areas from damage. The conservatory has been enhanced with multi sensory equipment such as fibre optic lights and aromatic items. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 17 Outstanding issues from the last inspection include the lighting throughout the home, which needs to be improved and the communal furniture in the lounge the material of which is worn and thin in places. These issues were discussed with the manager who stated that she has requested additional funding from the organisation to address these issues and is awaiting confirmation of this. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,34,35&36 The service users welfare is promoted and protected by a well trained, supervised staff team who are clear of their roles and responsibilities as care staff. However, some of the staff need NVQ training in care. Staff records are not held within the home and as such it was not possible to confirm that the service users are supported and protected by the home’s recruitment practices. EVIDENCE: Staff spoken to confirmed that they have received a range of training provided by the Trust. This has included risk management, person centred planning, the Disability Discrimination Act and more recently “conflict and resolution”. Of the 13 staff, 4 staff are currently completing the NVQ level 2 qualification in care. This falls short of the national minimum standard of 50 , which must be achieved by 2005. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 19 Discussion with the staff confirmed that they were clear of their roles and responsibilities as care staff and that they had all been given a copy of the General Social Care Council code of practise. They also confirmed that they received regular supervisions, once every eight weeks, which provides them with the opportunity of raising any concerns they may have as well as discussing training needs. There are no staff recruitment records available to inspect in the home as required by the Care Home Regulations but these are available within the organisation’s personnel department. As such it was not possible to fully assess the staff recruitment procedures in order to ensure that they are robust and as such protect the service users. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39&42 The health and safety of the service users is promoted by a well managed staff team. Systems for obtaining the views of the relative’s, as advocates of the service users, are in place and their views listened to and used to improve the service. EVIDENCE: The registered manager is currently completing the NVQ level 4 qualification in management and care. Staff spoken said that her management style was open and inclusive and that they very much felt listened to. They also said that they would have no hesitation in approaching her if they had any concerns. One relative spoken to also said that they “liked the new manager’s ideas”. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 21 Records examined confirmed that there is a quality assurance system in place. This involves the staff team deciding upon a particular element of service delivery they wish to monitor to ensure that the specified standard is met. At present maintenance checks and fire safety checks are being monitored to ensure that these are being carried out appropriately. Due to the communication needs of the service users it would not be possible to obtain their views on the service provided through questionnaires, however, discussion with the manager confirmed that questionnaires are to be sent to the relatives, as part of the annual review process, the results of which will be used to improve the service. Appropriate records are held in relation to accidents. The fire log book examined confirmed that fire alarms are tested regularly and fire equipment and emergency lighting checks are carried out as recommended by the fire authority. Staff spoken to confirmed that they received annual health and safety training including fire fighting, food hygiene and emergency first aid. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x x Standard No 31 32 33 34 35 36 Score x 2 x 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shian Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 3 x B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 23 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. Standard 6 Regulation 15(1) Requirement Care plans must continue to be developed to reflect the interventions carried out by staff. There must be no unexplained gaps on the Mediaction Administration Record. Prescribed items must have clear instruction on the label advising staff of when and where these are to be administered. A specimen sample of signatures should be maintained for all staff authorisd to administer medication. The maintanance issues identified in the report must be addressed. 50 of care staff must have an NVQ level 2 qualification in care. Records of staff recruitment must be avialble for inspection.(Timescale not met 30/08/05). Timescale for action 31/12/05 2. 20 13(2) 31/10/05 3. 4. 5. 24 32 34 23(2)(b) 18( c )(i) 17(2) 31/12/05 31/12/05 31/12/05 6. Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 24 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 Good Practice Recommendations Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Baltic House Port of Tyne, Tyne Dock South Shields NE34 9PT 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 Shian B52 B02 S7387 Shian V220879 1 Sep 2005 Stage 4.doc Version 1.40 Page 26 - 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!