Inspection on 05/11/07 for Shinewater Court

This inspection was carried out on 5th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shinewater Court 18/07/06

Shinewater Court 11/10/05

Shinewater Court 13/06/05

Shinewater Court 12/10/04

Shinewater Court 01/06/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 Shinewater Court Milfoil Drive North Langney Eastbourne East Sussex BN23 8ED Lead Inspector Jo Mohammed Key Unannounced Inspection 5th November & 14th November 2007 09:15 Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 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 Shinewater Court DS0000021212.V348604.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 Adults 18-65. 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. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shinewater Court Address Milfoil Drive North Langney Eastbourne East Sussex BN23 8ED 01323 769196 01323 460279 swc@disabilities-trust.org.uk www.disabilities-trust.org.uk Disabilities Trust 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) Miss Carol Wade Care Home 31 Category(ies) of Physical disability (31) registration, with number of places Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is Thirty-one (31). Service users are aged 18 - 65 years on admission. Only adults with a physical disability are to be accommodated. Date of last inspection 18th July 2006 Brief Description of the Service: Shinewater Court was opened in 1988 and is owned and managed by the Disabilities Trust. The home is set in a residential area close to the Langney shopping centre on the outskirts of Eastbourne town centre. It is registered to provide residential care for up to 31 people with a physical disability, aged from 18-65 years of age, on admission. The premises were purpose built, have overhead tracking hoists and wheelchair access. Accommodation comprises of twenty-three bed-sitting rooms and eight self-contained flats all with en-suite facilities over two floors. An alarm call system, television and telephone points are fitted as standard. Communal areas comprise of a large café style dining room/lounge and three smaller kitchens. Throughout the communal areas of the home are electric doors and a lift that provides access to the lower ground floor. Meals are prepared on the premises. Other facilities include an activities centre, a physiotherapy room, transport and large garden. Information about the service, including the Statement of Purpose, Service User’s Guide and inspection reports is made available to prospective service users or their relatives, on request, as part of the admission process. Copies of these are also given to service users living in the home. The range of weekly fees, as of 5th November 2007 is £597 - £1,078. There are additional charges for hairdressing, transport, newspapers and holidays. The home has just started to offer respite care again with the intention to offer this service more regularly. In addition to the accommodation described above are seven flats in the same premises where private tenants reside who arrange their own care. It was identified that care staff within the home only assist these people in an emergency situation as the lifeline system is linked to the main home and they can be the first on the scene. Apart from eating in the main restaurant of the home, it was said these people are independent. It is identified in the home’s Annual Quality Assurance Assessment that as these privately owned flats become vacant, they are being purchased back by the Disabilities Trust and refurbished with the intention to provide additional accommodation for more independent living. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects a key inspection based on the collation of information received since the last inspection, including the Annual Quality Assurance Assessment dated September 2007 and responses received from the Commission’s surveys that were sent to the home to distribute amongst service users’ and relatives regarding their views on the home. The findings of these surveys have been reflected in the text of the report. An unannounced site visit was conducted by a Regulatory Inspector on 5th November 2007 from 9.15am until 5.40pm. On the day of the inspection there were twenty-six service users living at the home. A separate visit to the home was made by a Pharmacist from the Commission on the 14th November 2007 due to some matters arising with medication procedures at the main inspection. The purpose of this visit was to assess compliance with the requirements of the previous inspection in July 2006 and to inspect the key standards. It found that nearly all of the key National Minimum Standards assessed had been met. The inspection involved a tour of the premises, examination of the home’s records, discussion with the deputy Manager who was in charge of the service, whilst the Registered Manager was on leave. Three staff were interviewed as part of the process and two service users as well as chatting with other service users whilst touring the premises. What the service does well: Shinewater Court is committed to maintaining and raising standards of care and achieving the aims, objectives and stated purpose of the home. From the information recorded in the home’s Annual Quality Assurance Assessment there is recognition of the home being pro-active and striving to achieve more. The home is an established and well-managed service that provides care and accommodation to people with a physical disability. Service users are involved in the planning and delivery of their care. Attention is given to staff receiving regular training and staff spoken to were knowledgeable about their roles and responsibilities. Good systems are in place for the admission and ongoing care of service users. Independence is promoted and a range of activities are available. Service users are well informed about the services available to them in the home. Some service users are involved in the recruitment of new staff and regular meetings with the Manager are held. Good food is provided. Contact with health care professionals is regularly maintained in monitoring individuals’ health care. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 & 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The admission procedure ensures that service users are admitted only on the basis of a full assessment. Prospective service users are provided with sufficient information to decide and inform them whether the home is able to meet their specific needs with copies of the Statement of Purpose and Service User Guide given to them as well as service users that currently live in the home. EVIDENCE: Information about the service is made available to all current and prospective service users. A generic information pack, including a current Statement of Purpose and Service User Guide is in place. Every service user living in the home also has a file in their bed-sit or flat with the same information as well as a signed copy of their contract. It was identified that the Statement of Purpose and Service User Guide may need to be updated further to reflect the introduction and provision of respite care, the purchasing and refurbishment of private flats as they become vacant with the intention of how these are to be used in the future. Also identified was to outline and include the number of privately owned flats within the premises confirming that these operate separately from the main running of the home. A revised copy of the home’s Statement Of Purpose should be forwarded to the Commission following any revisions made. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 9 The admission process for a service user admitted to the home earlier this year was tracked. A separate file is kept containing a detailed assessment that was completed prior to the service user moving into the home and subsequent information relating to date of admission and how this person’s care needs had been re-evaluated in a formal review setting. This review showed how new goals had been set, an overview of care requirements and it also demonstrated the service user’s and other interested parties involvement in this process. At the last inspection, a recommendation was made that the completed needs assessment form be signed by or on behalf of the service user. It was confirmed that this is now being done. During the course of the site visit it was identified that a trial period is intended to be introduced for new service users and how prospective service users are invited to visit the home for a day or more according to preference prior to moving in. The home’s Annual Quality Assurance Assessment identifies future plans to have an assessment flat for prospective service users to enable them to stay at the home prior to moving in for longer periods. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users’ have individual assessed plans of care in place, however further consideration should be given to ensuring staff have the necessary written guidance detailing how they should support service users with their care needs and where necessary risks in areas of daily living are documented as appropriate for each service user. The introduction of a link worker will further enable service users to ensure their care and social needs are regularly discussed, documented and met. EVIDENCE: All service users have files in their rooms that contain a breakdown of assessed care and social needs that are clear to follow. For one person case tracked this was on the whole found to be complete apart from some sections such as education, employment, emotional, social, future goals and skills of daily living that were blank. It was noted that against the majority of care needs the type of support recorded showed ‘full input was needed’, it was not fully evident from this statement how the care needs of this person were to be met. It was explained that staff knew how to carry out care practices because they had gone through them during induction as well as service users saying how they wanted their care delivered. Within this file was one main manual handling risk Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 11 assessment detailing guidance in how to support this person, no other risk assessments relating to other activities were found. For another service user case tracked similar information detailing care practices was found with instructions stating, ‘needs help’. A manual handling and medication risk assessment was in place, although it was not clear whether this person fully or partially administered their medication. Regular reviews of both files were noted as being recorded on the front pages with evidence that the service user and a staff member had agreed and reviewed the content. Service users spoken with during the course of the day confirmed this practice of involvement. Separate daily records are kept in the office that are completed by staff on each shift primarily about how service users are supported with their personal care. A separate record of the frequency as to when service users attend activities is also maintained. At the last inspection a requirement and recommendation to ensure care plans were regularly reviewed and service users were directly involved in this process including signing individual care plans has been met. It was identified that with the introduction and development of a new staff link worker role this would ensure that service users individual plans of care were regularly reviewed with them. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Good community links enabling social inclusion is available to service users living in the home as well as a range of educational and social activities that are offered in-house and externally. Maintaining contact with family and friends is supported. Independence and choice is promoted and service users benefit from a well-run restaurant offering good meals. EVIDENCE: Independence is promoted within the home, although the level of service users independence varies. Service users are provided with opportunities to progress their social, communication and independent living skills. Many service users express their independence by directing staff in how their care is delivered. It was identified that the introduction of the link worker will further enable service users on an individual basis to make their choices, preferences of daily living activities known. A view was expressed that service users can within reason get up and go to bed when they want too and staff are generally very good and treat with dignity. It was observed that staff knock on service users bedroom doors prior to entering. Service users, who choose to are enabled and supported as appropriate by staff to participate in the local community, including visiting local shops, cafes, and places of worship. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 13 The home’s Annual Quality Assurance Assessment confirms that links with family and friends are developed and maintained according to individual preference through visits, telephone contact and correspondence. There is unrestricted visiting times to the home. One service user explained how they help out in a local school, that they independently went to the local shopping centre and used their computer. They also confirmed that choice and decision-making is not a problem and negotiated. Another service user described how they have chosen not to attend the activities centre and preferred to spend time chatting, reading newspapers and listening to the news, this person said they ‘were never bored’ and when they did go out, staff support was given. Other people spoken to gave examples of how they spent their time by going to the Gym, watching television and using their computer. Staff confirmed that several service users go on activity holidays and are usually supported in making these arrangements by the activity staff. The home has an activities centre run by full time staff and volunteers. This is equipped with computers and adaptations. Service users can participate in a range of activities such as information technology, art, college, craftwork, quizzes, pottery, bowls, music, cookery, drama, gardening and outings. The home’s Annual Quality Assurance Assessment indicates the activities co-ordinator is exploring alternatives to college courses. The home has a minibus and a donated vehicle that is used to transport service users to their destinations. There are also plans to fundraise for a smaller vehicle. It is indicated that there is difficulty in accessing public transport and so service users primarily rely on the home’s transport or adapted taxis. Two chefs run the kitchen and take it in turns to purchase food for the home. A daily menu is displayed in the dining area with two choices for the main meal at lunch. A seasonal and planned menu is also recorded in a daily diary that offers varied, balanced and nutritious meals. Special diets can be catered for. The home runs a restaurant type service that caters for service users, staff and people living in the private flats. Meals are served in the dining area and there is more than one sitting. It was identified that there are several alternatives for service users to choose from both at lunch and teatime, although not all are displayed on the menu board. There were some gaps in keeping full records of alternative meals and dating this information. Service users, spoken with said the food ‘was lovely’ and ‘I have a choice’. It was observed how staff supported service users during the lunchtime service in an appropriate manner. There is a chilled water filter and juice dispensers available at all times. Also available are three communal smaller kitchens that are used for cookery sessions by the activities staff and as private spaces for service users to meet guests. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported with their health and personal care needs in a professional and sensitive manner with good support received from health care professionals. Medication systems reviewed by a Pharmacy Inspector from the Commission were adequate, implementing additional measures so that service users are fully protected and safeguarded by the home’s policies and procedures are necessary. EVIDENCE: Service users seen spoke about the type of support they required from staff in meeting their personal care needs and comments such as ‘the standard of care is excellent’ and ‘most of the staff are generally good and treat with dignity’ were expressed. An issue that was raised was the length of time in waiting for staff to attend to personal care. Staff explained their roles and responsibilities well describing how a Team Leader co-ordinates each shift and how staff are allocated to service users who need help with personal care and how this organised according to service users daily activities and appointments. The role of the link worker that has recently been introduced was also discussed which was mentioned by both service users and staff in providing an overview of the duties undertaken in this role Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 15 such as checking medication, care plans, weights, cooking, shopping and assisting with cleaning rooms. Staff spoke about how they act as enablers and promote the independence of service users. It was identified that a Physiotherapist visits the home twice a week and an Occupational Therapist once a week. It was also identified that good support was received from Doctors and Dentists in a nearby health centre and from District Nurses as and when required. Where necessary there is specialised equipment in place to undertake manual handling tasks with overhead hoists in service users bedrooms. Staff record in daily care records that are located in the staff room primarily about each service users’ personal care. Some issues regarding medication were raised at this inspection and a Pharmacy Inspector from the Commission visited the home separately to assess medication practices and procedures. All residents had been assessed and enabled to retain responsibility for their medicines and self-administer with assistance from support workers. Each room had a drawer for storing medicines and residents confirmed that their room was always locked when they were out. However, this practice was not seen as always being followed on the day of the main inspection with some bedroom doors found open. Medication risk assessments were written for self–administration, although these were not entirely clear as to whether service users fully or partially administered their medication. The home purchase and store securely a small number of medicines to treat minor ailments. A General Practitioner visits once a fortnight, to carry out medication reviews. Regular prescriptions for an eight-week supply are dispensed into weekly compliance packs, to promote self-administration. Staff record the date of receipt of regular medicines every eight weeks, although the packs are supplied weekly. Not all receipts included a quantity and only those put in the daily notes were signed. Staff had missed recording the receipt of two courses of antibiotics, one of which had been prescribed in case symptoms did not improve and had not been given to the resident. Medication administration record charts were not used. There were no records of when residents received their dispensed medicines. Disposal records were detailed and signed. Controlled drugs were stored correctly and administration recorded in a register. The Manager said that staff received induction training and that additional training was being planned for seniors to carry out delegated healthcare tasks. Currently the district nurses have an overview of such tasks but this is not recorded. A community Pharmacist visits the home yearly. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are safeguarded from abuse through relevant staff training, policies and procedures. They are also aware and informed of how to raise concerns and complaints. EVIDENCE: The home has a complaints procedure in place and service users have been given copies of the complaint procedure that they keep in their bedrooms. Service users and members of staff spoken to during the inspection confirmed that, should they have a concern or complaint, they would know who to report it too. It is anticipated that with the introduction of a link worker this will further enable and assist service users to raise concerns as and when needed. It was noted that there have been four complaints recorded by the home since the last inspection. All had been responded to with one outcome still pending. Policies and procedures relating to abuse, including whistle blowing are in place. All staff attend yearly training in the Protection of Vulnerable Adults and staff demonstrated awareness in reporting adult protection matters. There have been no adult protection alerts since the last inspection. The latest and revised ‘Sussex Multi-Agency Policy and Procedure for Safeguarding Vulnerable Adults’ was not available. A copy of this should be obtained. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service is accessible to service users and was purpose built. Service users benefit from having freedom of movement around the home and good-sized accommodation in either a flat or bed-sit. Some attention and overview to the standards of cleanliness around the home and formalising any maintenance, renewal and decoration works is considered necessary so that the environment is kept well maintained. EVIDENCE: Accommodation at Shinewater Court is spread over two floors. Comprising of Bed-sits and flats, all with en-suites and overhead tracking hoists. CCTV cameras are in place covering external areas only. Doors at the main entrance and along the communal corridor are automatic, wide and allow ease of access. There is a treatment room for Physiotherapy and Occupational Therapy. There is also a room used to store and charge wheelchairs, a laundry room and activity centre. The main communal space is the restaurant/dining area that is linked to the lounge space with a television. Three separate and smaller kitchens are located around the home for service users to use. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 18 Service users rooms reflect individuals taste, choice in décor, furniture and are personalised. The home is currently purchasing private flats within the same complex that become vacant and refurbishing them with the intention to utilise them for more independent living. One of these was being done up at the time of this visit. A section of the main hallway was being decorated at the time of the inspection; other areas of the corridor did show signs of wear and tear with marks and scuffs on walls. The carpet around these areas was also showing signs of wear and tear. Some repairs were needed to service users bedroom furniture, loose tiles in an en-suite bathroom; some carpets stains, marks on walls and a very musty smell in one of the en-suite bathrooms. The general standard of cleanliness of en-suite bathrooms and those with a kitchenette including cleaning of extractor fans does need some attention. A rusty looking kettle holder in one service user’s room needed replacing. The area near where wheelchairs are stored was cold and lacked a comfortable appearance. It was identified that an ancillary member of staff works for four hours a day between Monday-Friday cleaning the main communal areas around the home and that a schedule is followed and tried to achieve by the end of the week. Care staff clean other areas around the home such as service users bedrooms, kitchenettes and en-suites, with support from some service users. It was explained that decoration of service users rooms is done when people go on holiday or when they become vacant. There is no formal or written planned maintenance and renewal programme for the fabric and decoration of the premises and this should be introduced. The laundry room is situated on the lower ground floor. This was operational and satisfactory, with sluice cycles on washing machines and hand washing facilities. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 19 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home ensures the safety and protection of service users by having good recruitment practices and procedures in place. Service users benefit from having caring and supervised staff on duty to support them in meeting their needs. EVIDENCE: Information taken from the home’s Annual Quality Assurance Assessment indicates that all staff have job descriptions, a full induction for new staff is provided and the common induction standards have been introduced. It also identifies there are currently seven staff that have completed National Vocational Qualification training at level 2 or above and four staff who are working towards this. The home maintains an overall staff training plan showing dates and types of training staff have attended as well as having a detailed training programme. It was identified that all staff have individual training, development files and annual personal development reviews. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 20 All staff spoken with during the course of the inspection confirmed details about the training they had received and the training programme. They all described their roles and responsibilities very well. Regular staff meetings take place. Good recruitment and selection procedures are in place. Staff files that were inspected were found to be well maintained and contained all necessary recruitment details, including satisfactory written references apart from one minor omission, Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. A service user confirmed that they were part of the interview panel when recruiting new staff. At the last inspection a recommendation was made for the staff supervision matrix to be updated, fully completed and the recording format for staff supervision sessions to be amended to include action points carried over from previous sessions. This has been met, as it was confirmed that a yearly plan and new supervision form including action points had been devised. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 21 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is run well with an experienced registered Manager and dedicated staff team. Some attention to obtaining up to date views of stakeholders and collation of these findings is necessary. Some health and safety practices, particularly fire matters also need attention so that a safe environment is maintained. EVIDENCE: The home has an experienced and qualified registered Manager in post who has worked in the home for many years. Information taken from the home’s Annual Quality Assurance indicates the Manager is open and willing to improve the service, with the aim to provide a well run home in a relaxed atmosphere. The atmosphere at Shinewater Court was relaxed and welcoming. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 22 Staff, spoken to during the inspection felt valued and supported by the Manager and senior staff team. They were complimentary about the way the home operates expressing views such as: ‘I love working here and have a good time’, ‘This is the service users home’. ‘The people who live here dictate the regime’ ‘The home is run well’. It was evident that various quality audits about different aspects of the home were regularly undertaken, however service users and other stakeholders’ questionnaires and views about the service were not evident for this year, it was confirmed this had not been done for some time. A blank questionnaire form dated July 2007, was found in service users files. There was documentary evidence to show that regular service user meetings take place and that a past service user forum was held in 2006. A senior Manager from the Trust continues to carry out monthly Regulation 26 visits to the home and the latest report in respect of this was available for examination. A summarised account of findings and comments received from service users and relatives who completed the Commissions surveys are as follows: Were you asked if you wanted to move to this home Yes X 8, No X 0 Did you receive enough information about the home before you decided it was the right place for you Yes X 8, No X 0 Can you do what you want to do during the day Yes X 9, No X 0 Do you know who to speak to if you are not happy Yes X 8, No X 1 Do you know how to make a complaint Yes X 9, No X 1 Do you make decisions about what you do each day Always X 7, Usually X 2, Sometimes X 0, Never X 0 Is the home fresh and clean Always X 3, Usually X 4, Sometimes X 2, Never X 0 Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 23 Do the staff treat you well Always X 5, Usually X 2, Sometimes X 2, Never X 0 Do the carers listen and act on what you say Always X 0, Usually X 7, Sometimes X 2, Never X 0 Other general comments expressed were: ‘I would like to see more staff so I can spend more time talking to people’ ‘The care is very good’. ‘Often short staffed, wish we had more’ ‘The food is good and nicely presented’. ‘Could be more evening activities, not a lot going on’ ‘The bar can only be used for special functions’. ‘Shinewater Court on the whole is run very efficiently’. ‘Not a lot to do for visually impaired people’. ‘The home encourages independence’. ‘Due to lack of staff they can’t always do as requested’. ‘It does not go anywhere if I am not happy’. ‘Bathroom cleaning should not be done by staff and needs regular inspection’. ‘I have not needed to raise any concerns’. ‘Shinewater Court is a very good home with friendly and caring staff.’ It was identified that the health, safety, welfare of service users and staff is maintained with appropriate, regular training for staff. Generic risk assessments are in place. The home’s Annual Quality Assurance Assessment indicates that health and safety records and the maintenance of equipment are in order. Fire records examined showed a number of past gaps in the weekly testing of fire alarm call bells and no evidence of emergency lights being tested. Although, it was identified that fire alarm bells go off regularly there was no evidence of fire drills being logged and following discussions with some staff it was confirmed they had not been involved in fire drills. The home’s fire risk assessment was found to be in need of updating with the last review recorded in October 2006. Controls Of Substances Hazardous to Health ‘COSHH’ were found to be stored safely and securely. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 25 No 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 YA6 Regulation 15 [1] Requirement The Registered Person must consider in consultation with service users how to provide and document in more detail, written guidance for staff in how they should undertake the care and support needs of service users. The Registered Person must consider if there are any other individual risk assessments that may need to be included in service users care records according to daily living activities. -The Registered Person must ensure a complete account of medicines is kept, including receipt, administration or supply for self-administration as well as disposal and that medication is stored securely and safely at all times. -The Registered Person must ensure care staff who help service users with their medicines receive appropriate training and are competent. A healthcare worker must train care workers to carry out any Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 26 Timescale for action 31/12/07 2 YA9 13 [4] 31/12/07 3 YA20 13 [2] [4] 01/12/07 delegated healthcare tasks, such as giving medicines by invasive techniques. -The Registered Person must ensure medication risk assessments consider risks to all people; not only the service user and clearly state whether service users fully or partially administer medicines. 4 YA24 23 [2] [b] [c] & [d] -The Registered Person must 31/12/07 carry out a review of cleaning practices and ensure there is sufficient time and resources to undertake this work. This should not detract from care staff carrying out their primary role of care and social duties with service users. -The Registered Person must arrange for service users furniture to be repaired and compile a planned maintenance and renewal programme for the fabric and decoration of the premises. 5 YA39 24 The Registered Person must ensure that quality assurance questionnaires are issued to all service users, relatives, professionals with feedback collated, findings acted upon and made available within the home. -The Registered Person must ensure the content of the home’s fire risk assessment is updated and reviewed. -The Registered Person must ensure that regular fire drills involving all staff are conducted with records kept of the time, duration and staff names in Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 27 31/12/07 6 YA42 23 [4] [c] [e] 31/12/07 attendance. -The Registered Person must ensure that weekly testing of the fire alarm call bells and regularly testing of emergency lights is maintained. 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 YA17 YA20 YA23 Good Practice Recommendations The Registered Person should ensure a full record of alternative meals choices is maintained including dating these records. The Registered Person should ensure there is a policy on medicines purchased to treat minor ailments, with a detailed protocol for staff to refer to. The Registered Person should obtain a copy of the ‘Sussex Multi-Agency Policy and Procedure for Safeguarding Vulnerable Adults’. Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Shinewater Court DS0000021212.V348604.R01.S.doc Version 5.2 Page 29 - 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. 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