Inspection on 22/10/07 for Shiels Court

This inspection was carried out on 22nd October 2007.

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.

Other inspections for this house

Shiels Court 28/08/09

Shiels Court 03/01/07

Shiels Court 19/12/05

Shiels Court 24/08/05

Shiels Court 18/05/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Shiels Court Braydeston Avenue Brundall Norwich Norfolk NR13 5JX Lead Inspector Maggie Prettyman Unannounced Inspection 22nd October 2007 09:30 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 Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 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. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shiels Court Address Braydeston Avenue Brundall Norwich Norfolk NR13 5JX 01603 712029 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) shiels@broadgate-healthcare.co.uk shiels@broadgate-healthcare.co.uk Mr M Afsar Mrs Susan Jane Brooksby Care Home 40 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (40), Old age, not falling within any other of places category (3) Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One (1) Service User under the age of 65 may be accommodated. Three older people whose names are held on the Commission’s records, who do not have dementia, may be accommodated. Once these service users have left the home the registration will revert to 40 older people with dementia. 3rd January 2007 Date of last inspection Brief Description of the Service: Shiels Court is a large Victorian house situated in the village of Brundall. The original house has been altered and extended over the years and now provides care and accommodation for up to 40 older people with dementia. The bedroom accommodation for residents is on three floors and consists of 26 single and 7 shared bedrooms (all with en suite WC). The communal space consists of one very large lounge with a partition across separating the dining room, a separate smaller lounge and at the rear of the building a further small lounge, which is often used by staff for training purposes, and by visitors as an area to meet residents in private. The home also has extensive gardens currently being altered to meet the needs of the residents. The home informed CSCI of its charges in October 2007 and charges from £430 to £434 per week. Residents are expected to pay extra for hairdressing, chiropody newspapers, magazines, manicures and hand massage. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the provider, some residents and their relatives as well as other who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and current judgements for each outcome group. This inspection took place over 8.5 hours and included a tour of the building, observation of residents, discussion with staff, managers and visitors as well as examination of files `and safety records. Prior to the inspection the manager completed an extensive Annual Quality Assurance Assessment, and 11 questionnaires were returned from people living at the home. What the service does well: What has improved since the last inspection? The home has significantly improved its practice and facilities since the last inspection. These improvements include; • • • • • • • A rewritten Service User Guide Life history work Improved individual records and care planning Nutritional assessment and screening Additional meals A new medication administration system Improved computerised care records DS0000063180.V353430.R01.S.doc Version 5.2 Page 6 Shiels Court • • • • • • • • • • • Activities workers Increased outings Development of the garden to better meet peoples needs Extended visiting times Improved car parking Redecoration of 21 bedrooms Use of appropriate colour ways in halls to assist peoples orientation A new fire alarm system Bathrooms tastefully refurbished A new boiler and radiator covers Improved levels of management and housekeeping staff What they could do better: This inspection demonstrated that the home continues to improve its service and that the manager, proprietors and staff are fully committed to this process. During the inspection some areas of improvement were identified and six requirements and three recommendations have been made as a result. Requirements • • • • • • Peoples individual toiletries should be marked as such and kept separately in shared rooms Menus should be planned in advance Fresh fruit and vegetables should be available for use at all times Details of peoples individual dietary likes, dislikes `and needs should be displayed prominently in the kitchen Footrests should be in place and used on all wheelchairs Output water temperatures should be checked and recorded Recommendations • • • A smoking shelter area should be provided that is not close to people’s bedrooms An audit of accidents and incidents should be undertaken Shampoos and other toiletries should be securely stored in bathrooms 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. The summary of this inspection report can be made available in other formats on request. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 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 Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The information available to people before using the service is being improved. An assessment is undertaken before anyone moves in to the home to ensure that his or her needs can be met. EVIDENCE: The manager showed the inspector a new service user guide that is in the process of being finalised. This document is detailed and informative and will greatly benefit people thinking of moving to the home and their families. A selection of contracts inspected demonstrated that the home forms a written agreement with people or their families detailing the services offered by the home. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 9 Inspection of peoples individual records demonstrated that a good needs assessment is undertaken prior to people moving to the home. The manager of the home or her deputy undertakes this assessment. The assessment form and supplemental sheets cover a wide variety of issues. The form itself could be improved by expanding the space available for written notes. The home does not provide intermediate care Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 10 and 11 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care support that people receive is based on their individual needs. People are treated with dignity and respect. EVIDENCE: The home has worked hard since the last inspection to put detailed plans of care for everyone living at the home. Files inspected carried information about individual care with evidence of regular review and update. Files of people recently admitted were of an even higher standard. The home is to be commended for the hard work that it has undertaken in this area. Records are held in both hard copy and computer format. Life histories are being taken, and this information is being used to help make the service reflect people’s likes and needs. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 11 Evidence from individual files, observation of care given during the day and discussion with a visiting health care professional demonstrated that the home meets the health care needs of its residents. Nutritional and weight screening is being introduced and evidence of people accessing a range of health service services was seen. The home has introduced an extra meal to promote nutrition and encourage people to eat regularly. A new system of medication has been introduced that incorporates a “Blister Pack” dispensing system. The senior worker administering drugs on the day of inspection was interviewed and records and drug stocks were randomly audited. The system was found to be safe and well managed. Evidence of medication fridge temperatures being checked was also seen. Staff were observed treating people with dignity and respect during the inspection. Regular visitors to the home confirmed that this is the case at all times and that people’s individual clothing is carefully looked after. Evidence of name of choice being used was seen. Screening was in place in all shared rooms. During the inspection it was noted that toiletries are not always named and that in shared rooms these items, including toothbrushes and soap, are often kept on the same shelf. In addition some roll on deodorants and a used razor were found in communal bathrooms. This is not good practice and separate areas and labelling must be provided to ensure that personal items are not shared between residents. A requirement has been made in this respect. Pre inspection information demonstrated that people usually remain at the home to end their days. The visiting health care professional confirmed that the home provides good end of life care. The manager confirmed that relatives are involved in this process and that facilities for people to stay overnight are offered if needed. Staff have been given supportive training to help them to deal with bereavement and loss. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is working to make peoples lives more stimulating and enjoyable. Work must be undertaken to ensure that meals reflect the individual needs and tastes pf people living at the home. EVIDENCE: The manager has introduced a daily range of activities that are given by a team of staff that have been appropriately trained. A group activity was observed, and both residents and staff were fully engaged and enjoyed the event. Minibus outings are taking place as well as 1:1 sessions and group activities. The garden has been developed to have more plants of a sensory nature, and the manager hopes to continue this project next spring. Most people living at the home find it difficult to express choice, so the work on life histories is being used to inform and develop practice where possible. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 13 People confirmed that when they visit the home they are warmly welcomed and supported by kind and friendly staff. Visitors can now come to the home at any time. Most people living at the home find it difficult to express choice and to exercise control in their lives. People bring personal possessions to the home with them, and the manager is working to help people to identify their own rooms by giving the door a “front door” appearance with beading and numbers. It was a disappointment to find that, despite having developed a menu plan that had been researched both in terms of peoples likes and dislikes as well as in terms of nutritional balance, the home is failing to keep to planned menus. The cook prepares what she wishes daily, and people are not consulted about what is provided for the main course. Orders for fresh fruit and vegetables were examined, as all vegetables provided on the day of inspection were frozen and the main meal was individual frozen pies. Extremely limited supplies of fresh fruit were available. It is difficult to understand how the kitchen can make best use of ordering fresh products when meals are not planned. Hand written notes about dietary needs were seen, but a comprehensive list of dietary needs and preferences is not maintained. These issues are most unsatisfactory and requirements have been made as a result. On a more positive note, the kitchen was found to be clean, and staff were working conscientiously. Fresh cakes had been baked which were of a high standard and a wide selection of finger foods were prepared for afternoon tea and supper. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A good complaints procedure is in place and staff are trained in the protection of people who use the service. EVIDENCE: The home has reported some concerns to the Commission, which had been appropriately addressed and resolved. The complaints procedure is displayed in each person’s room. Visitors interviewed confirmed that any minor grumbles are quickly resolved. Evidence of staff training in adult protection was seen. Staff are aware of whistle blowing principles and procedures. The manager stated that she covers issues of adult protection at interview, and that this is fully covered during induction and further reinforced during regular training updates. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home continues to work towards improving its environment, but much work remains to be done. EVIDENCE: The building is large and old, and as a result maintenance and upkeep is an ongoing and difficult task. Considerable investment in redecoration and recarpeting has been undertaken throughout the home. A new fire alarm system is being installed and the main fire escape is due to be replaced. Following this a new call system is planned. Work has been done to improve the car park and gardens. Unfortunately, despite all this work, the environmental standards of the home still do not reflect the standards of care and support that it offers. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 16 The homes staff work hard to keep it clean, but some areas could be tidier and better organised. The kitchen and servery areas are examples of this. The home has worked to eliminate odours, with new flooring being put in problem areas. During the inspection one ground floor resident’s room was found to smell quite strongly of cigarette smoke. An outside smoking area is located nearby, but has no shelter and would appear to be unusable in bad weather. A recommendation has been made in this respect. Examination of the laundry demonstrated that clothes and linens are appropriately sorted and washed. A staff member was observed working carefully to ensure a garment was properly ironed, and a system of baskets helps to ensure that items of clothing are returned to their owners. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is staffed by appropriate numbers of people who are vetted by the manager before they commence employment. A good level of staff training is in place, but the home is yet to achieve its NVQ targets. EVIDENCE: Rotas were examined and staff activity on the day of inspection observed. The level of cover provided appeared to meet the needs of people living at the home. Staffing levels in management and housekeeping posts have been improved and activities workers are now employed in addition to care and domestic staff. The home has not yet achieved 50 NVQ qualification and needs to continue working towards this. Staff files were examined and found to meet the requirements of the standards. The manager is aware of her responsibilities in this area, and is careful to vet people thoroughly. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 18 Three training courses were taking place on the day of inspection. An external trainer was using a dedicated training area to deliver courses that staff enjoyed and benefited from. The trainer had her certificates of competence with her and was professional and enthusiastic. The home is committed to ongoing training for staff and evidence showed that it works hard to provide suitable and effective courses from both internal and external resources. Evidence of structured induction training for new staff was also seen. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The homes manager is a concerned, committed and caring person who has made many significant positive changes since she was appointed. The management of the home has been further strengthened with the introduction of two new senior posts. EVIDENCE: During the inspection the manager displayed a consistently concerned and caring attitude. Senior members of staff were found likewise to be committed Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 20 and caring in their roles. The management structure has been recently expanded to provide further quality control and staff supervision. A quality assurance questionnaire has been given to relatives, but the home has yet to report on its findings. Evidence was seen of a number of quality audits that are routinely undertaken as part of the homes day-to-day operation. Small amounts of cash are held on behalf of some residents. A random sample were checked and found to be accurately recorded. Requirements relating to health and safety made at the last inspection have been met. Evidence of mandatory training in Health and Safety was seen. Chemicals were found to be securely stored. Fire safety records were found to be in place. Accidents and incidents are recorded, but not audited. A recommendation has been made in this respect During the inspection it was noted that some wheelchairs had footrests missing which is a potential hazard for users. A requirement has been made in this respect Output water temperatures are not routinely checked to ensure that people are safe from scalding. A requirement has been made in this respect Shampoo and other toiletries were found in bathrooms not securely stored. Although bathrooms were found to be locked, this could still present a potential hazard to residents. A recommendation has been made in this respect Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 21 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 22 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 OP10 Regulation 13.3 Requirement Separate shelves should be provided for toiletries in shared rooms, and all personal toiletries must be individually labelled A menu must be followed that is nutritionally balanced and has been developed following consultation with people living at the home. The home must plan menus to ensure that sufficient quantities of fresh fruit and vegetables are used and available. A comprehensive list of dietary likes, dislikes and nutritional needs must be compiled and used in the preparation of people’s individual meals. All wheelchair footrests must be in place and properly used Output water temperatures must be checked and recorded in bathrooms and hand basins Timescale for action 30/11/07 2 OP15 16 I 12.3 30/11/07 3 OP15 16.i 30/11/07 4 OP15 16.i 12.3 30/11/07 5 6 OP38 OP38 13.4 13.8 30/11/07 30/11/07 Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP26 OP38 OP38 Good Practice Recommendations The home should consider providing a smoking shelter which is not close to resident’s individual rooms. The home should consider auditing accidents and incidents to identify and eliminate any underlying patterns and trends Shampoos etc should be securely stored in bathrooms. Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Shiels Court DS0000063180.V353430.R01.S.doc Version 5.2 Page 25 - 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. 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