Inspection on 15/07/08 for Shipley House

This inspection was carried out on 15th July 2008.

CSCI found this care home to be providing an Good service.

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

Shipley House 04/07/06

Shipley House 14/02/06

Shipley House 04/10/05

Shipley House 16/01/05

Shipley House 08/09/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Shipley House 10 Station Road Ilminster Somerset TA19 9BD Lead Inspector Kathy McCluskey Unannounced Key Inspection 15th July 2008 10:30 Shipley House DS0000016219.V365266.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 Shipley House DS0000016219.V365266.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. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shipley House Address 10 Station Road Ilminster Somerset TA19 9BD 01460 55628 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) Mrs Leah Manders Mr Matthew Manders Miss Amanda Jane Barthorpe Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2006 Brief Description of the Service: Shipley House is registered with the Commission for Social Care Inspection to provide personal care for up to 4 people with a learning disability who are aged 18 & 65yrs. The home is not registered to provide nursing care or care to people with a physical disability. It is one of two small homes owned by Mr and Mrs Manders and is situated in the town of Ilminster. The registered manager is Miss Amanda Barthorpe. The home is conveniently situated close to all local amenities. The main aim of Shipley House is to support more independent people to develop the full extent of their abilities and have full and happy lives. The staff team work across both houses, which means that there are regular occasions when people are left at home without a staff member for brief periods. We were informed that current fee levels are between £330 & £480 per week. People living at the home are responsible for purchasing personal items, toiletries etc. Each person contributes £12 per week from their mobility allowance which goes towards the running of the home’s mini-bus. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service for each outcome group under four general headings. These are; - excellent, good, adequate and poor. This unannounced key inspection was conducted over one day (4.5hrs) by CSCI regulation inspector Kathy McCluskey. Mrs Manders, one of the registered providers was available throughout this inspection. At the time of this inspection 4 people were living at the home and there were no vacancies. We were able to meet with all people living at the home during this inspection and they were keen to show us around their home. We also met with one member of staff. As part of this key inspection, the registered person was required to complete an Annual Quality Assurance Assessment (AQAA) for the Commission. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Details have been included throughout this report as appropriate. We also sent comment cards to people using the service, staff and healthcare professionals. We received completed comment cards from 3 people living at the home and 2 members of staff. Comments have been incorporated within this report. We would like to thank all involved for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: Shipley House provides people with a very homely and well-maintained environment. It was evident that the people living at the home were very much in control of the running of the home. The home have not had any vacancies for over 6 years. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 6 People benefit from a small and stable staff team. Staff turnover is very low. Staff like working at the home and feel well supported. Staff told us that they received the training needed to enable them to meet the needs of the people living there. The home promotes NVQ training for staff. Currently 83 of the staff team have obtained a minimum of an NVQ Level 2 in care which exceeds the recommended 50 of the National Minimum Standards. People living at the home told us that the staff were ‘wonderful’. Staffing levels are low but this appears adequate given the high level of independent living skills of people currently at the home. People told us that staff were ‘Always’ available when they needed them. The registered person and staff told us that staffing levels were increased to meet the needs and social needs of the people living there. The home supports people to live the life they choose and people are given opportunities and supported to access a wide range of leisure pursuits, educational facilities and work placements. People are very much part of the local community and are able to access local facilities independently. The home has a mini bus available for people. People are fully involved in the running of the home, menu planning, shopping, cooking etc. Each person has a plan of care and they are fully involved in the care planning and review process. People are supported to live an independent lifestyle through the risk assessment process. People told us that they felt confident in raising concerns should they have any. No concerns were raised with us during this inspection and no concerns have been raised with the Commission since the last inspection. The home have not received any concerns within the last 12 months. The home follows robust staff recruitment procedures, which reduce the risk of harm or abuse to the people living there. The home is effectively managed and procedures are in place to ensure the health and safety of persons at the home. Staff who completed comment cards for the Commission made the following comments under the heading, ‘What does the home do well?’; ‘Communication, listening and putting into practise for the needs of service users’ ‘It helps people live just like you or me, they have choices, friends, holidays, trips & college and the list goes on’ ‘They are happy, safe and have a good life and they choose these things, they are not told what they have to do’. What has improved since the last inspection? Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 7 No requirements were raised at the last inspection. The AQAA identified some environmental improvements that had taken place in the last 12 months, which included a new kitchen. 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. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 8 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 Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 9 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): 2, 3, 4 & 5 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. People are provided with the information they need to enable them to make an informed decision about moving to the home. The home has procedures in place to ensure that placements are only offered to people whose needs and aspirations can be fully met by the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide /Brochure which provides information about the home and services offered. We were informed that there had been no changes to these documents since the last inspection. These documents were not examined at this inspection. Three people completed comment cards for the Commission and all confirmed that they had received sufficient information about the home before deciding to live there. All four people currently living at the home have been there many years. The last admission to the home was six years ago. All confirmed that they had received a contract. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 10 We discussed the home’s admission & assessment procedures with one of the registered providers and we also received information about this in the home’s completed Annual Quality Assurance Assessment (AQAA). The AQAA told us that the home provides, ‘a stable, secure living and vocational environment’ and ‘we do not provide short term care or accept emergency admissions’ ‘Prospective service users have the opportunity to make sure they want to live with us by looking around, meeting everyone, being made aware of the Statement of Purpose, Service User Guide and Brochure’. The AQAA also stated that, ‘An assessment is carried out to ascertain the person’s needs and abilities’ ‘Risk assessments are also carried out’ ‘Placements are offered on a three month trial period and a further three months is offered if either party are unsure’ ‘Staff, service users, family, social workers and the proprietors are all involved in this process’. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 11 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. Peoples’ individual needs, aspirations and preferences are clearly set out in their plan of care and this enables staff to deliver a person centred approach to care. People are supported to take informed risks and to live an independent lifestyle in line with their agreed plan of care. EVIDENCE: Each person has a plan of care which details their assessed needs and aspirations. We examined one care plan at this inspection and this was found to be well maintained and up to date. The plan of care clearly identified the person’s needs and abilities. Preferences of the individual had also been recorded thus allowing staff to provide more person centred care. People living at the home do not currently require staff assistance to meet their personal care needs. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 12 People are supported to live their life to its’ fullest and each person is able to access the local community independently. Risk assessments are in place as appropriate. We were able to see that care plans were regularly reviewed with each person. In the home’s completed AQAA it stated that, ‘Care plans are drawn up with the service user at the six monthly internal reviews and the care plan is agreed with the placing authority’ ‘Risk assessments are also reviewed at this time and are amended as things change’ ‘External reviews are held annually which gives families the opportunity to attend if the service user wants them to be there’ In comment cards completed by people living at the home, all responded ‘Always’ to the question, ‘Do you receive the care and support you need’ and all responded ‘Yes’ to the question, ‘Do staff listen and act on what you say’. We received 2 completed comment cards from staff and in response to the question, ‘Are you given up to date information about the needs of the people you support or care for (for example, in the care plan)?’ both responded ‘Always’ ‘The care plans are redone regularly and always read by members of staff’ We were informed that people living at the home are able to manage their own finances. The home does assist one person to manage small amounts of ‘spending money’, which is kept securely in the office. Records of transactions are maintained and we have recommended that the individual and the staff member sign to confirm each transaction. We have also recommended that the registered person conducts monthly audits to check transactions and balances. During this inspection we were informed that the registered provider Mr Manders was currently financial appointee for all persons living at the home. It has been strongly recommended that where a person requires an appointee or other agent, that this person is independent from the service. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 13 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, 14, 15, 16 & 17 Quality in this outcome area is Excellent This judgement has been made using available evidence including a visit to this service. People are supported and provided with opportunities to live very full and meaningful lives whilst developing and learning new skills. EVIDENCE: The home’s completed AQAA stated; ‘Service users are assisted to live as independently as possible in our setting and to improve or maintain their daily living skills’ ‘Service users wishing to find a work placement are supported in this subject to assessment and availability and if possible, a placement close by is sought to enable the person to get there independently’ ‘Access to college and community education is encouraged and supported and we provide transport and in some cases, support staff’ During the afternoon of this inspection we were able to meet with all people living at the home and they were keen to tell us about the very full lives that they led. One person currently has a work placement in the local town which Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 14 they ‘really enjoy’. People told us that they attended various courses at the college in Yeovil and the Adult Learning and Leisure Centre in Chard is also accessed. On the morning of this inspection, people had been swimming’ All said that they had really enjoyed this. Swimming takes place every week. They also told us that they really looked forward and enjoyed the weekly visits to the local pub. People currently living at the home are very independent and are able to access the local community without staff support. They told us that they have a key to the front door and to their bedrooms. It was very evident that the people living at Shipley House are fully involved in the running of the house. When people returned from swimming they cooked and enjoyed their lunch-time meal independently. They said that each week they draw up a rota for ‘household chores and that ‘this works very well’. It was evident that people took pride in their home and they were very keen to show us around. People living at the home do all menu planning, weekly shopping and cooking. Transport and staff support is provided by the home. People told us that they ‘loved living at Shipley’, ‘It is my home, I am very happy’. The home arranges annual holidays for people and people are supported to maintain contact with their families and friends as appropriate. This was confirmed by the people living at the home. We were told that staffing levels are increased as necessary to ensure that people’s social needs are met. In completed questionnaires, people living at the home responded ‘Always’ to the question, ‘Are the staff available when you need them?’ The following comments were made by staff in comment cards for the Commission, ‘the home helps people live just like you or me, they have choices, friends, holidays, trips & college and the list goes on’ ‘They are happy, safe and have a good life and they choose these things, they are not told what they have to do’. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 15 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. People do not currently require staff assistance to meet their personal care needs. The home ensure that peoples’ healthcare needs are met and support is offered to access appointments as required. The home follows the correct procedures for the management and administration of peoples’ medication. EVIDENCE: We were informed that people living at the home do not currently require staff assistance to meet their personal care needs. Some people require prompts from staff and any needs are clearly documented in the individual’s plan of care. In the AQAA completed by the home it stated, ‘Service users have access to relevant healthcare services and all are registered with local GP’s where they Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 16 have annual health checks, medication reviews’ ‘Any information is recorded in their files and all staff are made aware to ensure correct care is delivered’ ‘Access to the dentist, chiropodist, hearing aid clinics and hospital appointments are also supported’ We were able to see evidence of the above in the care plan examined. Clear and detailed records had been maintained for any contact with a healthcare professional. In comment cards completed by people living at the home, all responded ‘Always’ to the question, ‘Do you receive the medical support you need?’ We examined the home’s procedures for the management and administration of people’s medication. We were informed that nobody at the home currently manages their own medicines. The home uses the Boots monitored dosage system (MDS) with pre-printed medication administration records (MAR). We examined all available MAR charts and found these to be fully and appropriately completed. The use of medication was low and medicines were seen to be securely stored. All staff have received training in the management of medicines from Boots the chemist. Care plans contained evidence that peoples’ medication had been reviewed annually by their G.P’s. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 17 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. People feel confident that any concerns would be listened to and acted upon. Procedures are in place to ensure that people are not placed at risk of harm or abuse. EVIDENCE: People told us that they did not have any concerns and they stated that they would not hesitate in raising concerns if they had any. In comment cards completed by people living at the home, all confirmed that they knew how to make a complaint. The home have not received any complaints since the last inspection conducted in 2006 and no concerns have been raised directly with the Commission. The home has a complaints procedure but this is not currently displayed in the home. A recommendation has been raised. The home has policies and procedures in place to reduce the risk of harm or abuse to the people living there. These include for staff; Acceptance of gifts policy, which also precludes staff from drawing up a will or benefiting from a will. The home’s ‘whistle blowing’ policy should be updated to include the contact details of the Commission and other appropriate external agents. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 18 The home has policies and procedures in place relating to abuse. To ensure that robust procedures are in place, the home should obtain a copy of Somerset’s Safeguarding Adults procedure May 2008. This was discussed with the registered provider during the inspection and contact details were given. Policies are also in place relating to the management of aggression/restraint. We were informed that nobody currently living at the home exhibited challenging behaviour. The home follows robust staff recruitment procedures. Enhanced criminal record checks (CRB) and Protection of Vulnerable Adult checks (POVA) are obtained before a person commences employment. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 19 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, 25, 26, 27, 28 & 29 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable and well-maintained environment. Each person has their own bedroom which they can personalise. The standard of cleanliness is good. EVIDENCE: Shipley House is a large red brick semi-detached house which appears well maintained and comfortably furnished. On the ground floor is an entrance hall, good sized lounge, large kitchen/dining area and laundry area. In the home’s completed AQAA it told us that, ‘We provide a safe and secure happy home environment’ ‘The home has a year planner with a list of jobs that may need doing’ ‘Service users are encouraged to participate in decisions about decoration and furnishing and they are able to personalise their own Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 20 rooms’ In the last 12 months, ‘A new kitchen has been fitted and the room decorated. The layout and fittings make it easier to use and a little more roomy’ All bedrooms are for single occupancy. One bedroom is located on the ground floor and this room is fitted with en-suite toilet facilities. Three further bedrooms are located on the first floor, which is accessed via stairs. Three of the four people living at the home were very keen to show us around the home and show us their bedrooms. Bedrooms were noted to be spacious and very comfortably furnished. It was also evident that people are able to personalise their rooms. People told us that they ‘loved’ their rooms. People told us that they had a key to their bedroom and to the front door. They told us that staff respected their privacy. The home has one toilet on the ground floor and one toilet on the first floor. As previously mentioned, one bedroom has en-suite toilet facilities. The bathroom is situated on the first floor. No concerns were identified regarding the current facilities. The office and staff sleep-in room are situated on the second floor. En-suite toilet and bathing facilities are available in the staff sleep-in room. The home is not registered for people with a physical disability and as such, the home is not fitted with any aids, adaptations or specialist equipment. On the day of this inspection the home was very clean. People living at the home appeared very proud of this and told us that they made sure that the home was clean and tidy. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35 & 36 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. People living at the home benefit from a small and stable staff team who have been appropriately trained. People are protected by the home’s staff recruitment procedures. EVIDENCE: At the time of this inspection four people were residing at the home. We were informed by the registered provider present that currently one member of staff is on duty throughout the day with one carer sleeping in at night. The registered provider stated that both she and Mr Manders, registered provider, were on call throughout the day and night. The registered provider informed us that staffing levels are increased as required to meet people’s social needs and to offer support to attend appointments. We were also informed that there were occasions where people were left in the house when the staff member goes to the sister home a short walk away. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 22 We spoke to the people living at the home about the current staffing arrangements and no concerns were expressed. As previously mentioned, people living at the home are very independent. We also spoke to the staff member on duty and again, no concerns were expressed. Two staff completed comment cards for the Commission and in response to the question, ‘Are there enough staff to meet the individual needs of all the people who use the service? Both responded ‘Always’ and the following comment was made, ‘if extra support is needed then a manager will support the service user eg; travelling, drs, appointments, personal shopping etc’. Three people living at the home completed comment cards for the Commission and in response to the question, ‘Are the staff available when you need them?’, all responded ‘Always’. We were able to meet with everybody living at the home and when asked, all commented on the kindness of staff. ‘They are wonderful’, ‘The staff are just amazing’, ‘The best’. The home’s completed AQAA, confirmed the independence of the people currently living at the home. The home’s AQAA also confirmed a low turnover of staff, ‘Low staff turnover and a small supportive staff team’. The AQAA also identified that the home has not used agency staff and that there have been no staff changes in the last 12 months. The home currently employs six staff five of which have obtained an NVQ Level 2 in care with one person currently working towards this award. This equates to 83 which exceeds the recommended 50 of the National Minimum Standards. The home’s AQAA confirms that the home has; ‘High level of NVQ Training, up to date mandatory training and additional training needs are identified and actioned’ ‘Training needs are agreed and targeted during staff supervision when a timescale for completion is set’ In completed comment cards staff told us that they ‘Always’ received the training they needed to meet the needs of people at the home; ‘Our training is kept up to date and anything that is deemed relevant is booked for each member of staff and we can also choose to do training that we would like’. We were able to see evidence that staff received formal supervision every three months. Records of supervision sessions had been signed by staff and these clearly identified any training needs/requests. In completed comment cards staff confirmed that their manager met with them ‘Regularly’ to give support and to discuss the way they were working. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 23 Staff meetings are held every two weeks and records are maintained. As previously mentioned, staff turnover has been low. We examined two staff recruitment files for the most recent staff employed, which was 2006. Files were well maintained and contained all required information. There was evidence that staff had not commenced employment until receipt of two satisfactory references, an enhanced Criminal Record check (CRB) and Protection of Vulnerable Adults check (POVA). We have recommended that the home updates its’ application for employment so that it requests at least 10 years employment history. As recommended at the last inspection, we were able to see that the home maintain records relating to interviews held for prospective employees. Recruitment files contained evidence that staff follow an appropriate induction programme on commencement of employment. The induction programme used by the home follows the Skills for Care Common Induction Programme. Two staff completed comment cards for the Commission and in response to the question, ‘Did your induction cover everything you needed to know to do the job when you started? Both responded, ‘Very well’, ‘I had a very good induction and shadowed the person I was replacing’ Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 24 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, 41 & 42 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. People live in a home which has effective management systems in place. The home provides people with opportunities to express their views. The home follows procedures to ensure the health and safety of persons at the home. EVIDENCE: The registered manager is Amanda Barthorpe. Miss Barthorpe was not available for this inspection. She has obtained the Registered Managers Award and an NVQ Level 4 in Care. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 25 The home has quality assurance procedures in place, which seek the views of people living at the home and their relatives/representatives annually. A selection of completed surveys from 2007 were viewed and comments/responses were noted to be positive. The home should also consider seeking feedback from care managers and other healthcare professionals on a formal basis. People living at the home told us that they had regular house meetings and that they could discuss things with staff ‘at any time’, ‘they are always ready to listen’. The registered providers base themselves at the home and are therefore available most days. People living at the home told us that the registered providers were ‘Wonderful’. We noted people to be very relaxed in the presence of the registered provider who was available during this inspection. At the time of this inspection, all records pertaining to people living at the home were noted to be securely stored. During this inspection we toured the premises and viewed a selection of records relating to Health & Safety and the findings were as follows; FIRE SAFETY – The home has completed a fire risk assessment and the registered provider confirmed that this had been viewed by the Fire Safety Officer. We did not examine the assessment at this inspection. We were able to see that the home had procedures in place to check all fire detection and emergency lighting systems. This is conducted on a weekly basis with records maintained. ELECTRICAL SAFETY – We were able to see that annual testing on portable electrical appliances was up to date. This was last carried out on 12/06/08. The home also has an up to date electrical hardwiring certificate dated 09/2007 and valid for 5 years. GAS SAFETY – The home showed us an up to date annual Landlords Gas Safety Certificate dated 02/2008. HOT WATER – We were informed that the bath hot water outlet had been fitted with a thermostatic control to ensure that the temperature is set within safe limits. As these devises are not failsafe, it has been recommended that the home conducts monthly checks on the hot water outlet to ensure temperatures do not exceed the safe upper limits set by the Health & Safety Executive of 44c. The shower should be set at 42c. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 26 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 x 2 3 3 3 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 3 25 3 26 3 27 3 28 3 29 3 30 x STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x x 3 3 x 3 3 x Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 27 N/A 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. Standard Regulation Requirement Timescale for action 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 YA7 Good Practice Recommendations Where the home assists people to manage small amounts of money, the registered person should ensure that each transaction is signed by the staff member and the individual. Systems should also be in place to ensure that transactions and balances are regularly audited. It is strongly recommended that that the registered person does not act as financial appointee for any person living at the home. The registered person should ensure that the complaints procedure is displayed in the home To ensure robust procedures are followed, the home should obtain a copy of the Somerset Policy on Safeguarding Adults, which was updated in May 2007. The application for employment form should be updated so that it requests at least a 10 year employment history. The home should conduct monthly checks on the bath hot water outlet to ensure temperatures do not exceed the DS0000016219.V365266.R01.S.doc Version 5.2 Page 28 2. 3. 4 5. 6. YA7 YA22 YA23 YA34 YA42 Shipley House safe upper limits set by the Health & Safety Executive of 44c. The shower should be set at 42c. Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Shipley House DS0000016219.V365266.R01.S.doc Version 5.2 Page 30 - 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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