Inspection on 06/07/06 for Shire Oak House

This inspection was carried out on 6th July 2006.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Shire Oak House 05/10/05

Shire Oak House 26/04/05

Shire Oak House 08/01/05

Shire Oak House 01/09/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Shire Oak House 33 Lichfield Road Shire Oak Walsall West Midlands WS9 9DH Lead Inspector Maggie Bennett Key Unannounced Inspection 10:30 6th July 2006 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 Shire Oak House DS0000020828.V298763.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. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shire Oak House Address 33 Lichfield Road Shire Oak Walsall West Midlands WS9 9DH 01543 372331 01543 372331 petedavies38@hotmail.com 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) Quality Homes (UK) Limited Mrs Michelle Louise Ward Care Home 26 Category(ies) of Dementia (9), Old age, not falling within any registration, with number other category (26) of places Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 9 residents (max) Dementia Care age 55 years and above Adherence to the Action Plan submitted by the registered provider dated 16 March 2006. 5th October 2005 Date of last inspection Brief Description of the Service: Shire Oak House is a large detached residence in the Shire Oak area of Walsall. It is surrounded by open countryside. The home has been extended and provides accommodation for up to 26 people. All bedrooms are single and the majority have an en suite toilet and wash hand basin. There is a passenger lift to the first floor. The home has parking facilities to the front and extensive gardens to the rear. It is owned by Quality Homes (UK) Limited who have other homes in the Walsall and Wolverhampton area. The home is registered to accommodate residents who are over 65 years of age, up to 9 of whom may have dementia. Fees charged at the home range from £327.15 to £343.64. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 2 days and a total of 11 hours were spent in the home. Prior to the visit a Pre Inspection Questionnaire was completed by the Registered Manager of the Home and returned to the Commission. In addition 5 surveys were returned from service users. In some cases the surveys were completed by relatives, on behalf of individual service users. All of the Key Standards of the National Minimum Standards were assessed on this occasion. During the course of the visit discussion took place with several service users, some visiting relatives, staff members and the Manager and Deputy Manager of the home. The care plans and assessment information of a number of service users were seen in order to “case track” their care at Shire Oak. The systems and process of medication administration was assessed. Various documents were seen in order to verify the maintenance and servicing of equipment. A tour took place of the building. All the key standards of the National Minimum Standards were assessed on this occasion. At the last inspection of the home a total of 22 statutory requirements were made. It was found on this occasion that 16 of these requirements have been met or are in the process of being met. A further 9 statutory requirements were made on this occasion. The improvements noted at the last inspection have been maintained and further improvements have been made in several areas. The overall conclusion is that the home continues to make steady progress, with the management and staff having an improved understanding of their service users’ needs and of their own capabilities and knowledge. Steps need to be taken to bring the bedrooms and bathrooms in the older part of the building up to the standard of the remainder. What the service does well: There is a welcoming and cheerful atmosphere at Shire Oak. It is clear that visitors are welcome at any time and are greeted by staff and offered refreshments. Service users spoke highly of the staff at the home, making comments such as “they’re all very, very good” and “we have a lot of good staff.” Staff show a good understanding of the needs of the service users with dementia and have clearly benefited from their recent training. The home is proactive in getting prompt medical attention for its service users. Rights to privacy and autonomy are upheld, with service users confirming that they can choose what time they get up and go to bed and whether or not they wish to join in activities. A number of outside trips are organised. Meals at the home are much enjoyed and offer choice and variety. The importance of good staff training is recognised by the Company. Both the Registered Manager and Deputy Manager are clear of their roles and display good leadership skills. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: As stated above, the gathering of assessment information has improved, but the home’s own assessment tool does not yet contain all those areas listed in Standard 3.3 of the National Minimum Standards. Similarly care plans are improved, but the home needs to involve service users more in the development and reviews of their care plans. Care plans need more information on how particular needs or concerns are to be addressed and care needs to be taken that plans are up to date. A number of areas with regard to medication administration and storage need to be addressed (these are detailed in Standard 9 and in the Requirements section of the report). As stated above, the provision of outside activities has improved, but the home needs to further develop the specialist activities for those service users with dementia. Although there are 2 assisted baths in the home, plus a shower and an unassisted bath, the bathroom at the front of the property is unpopular with service users and the majority wish to take their baths in the other ground floor bathroom. The Responsible Person must take steps to ensure that there are sufficient assisted bathing facilities on the first floor. The standard of décor and furnishings in the older part of the building needs attention in order to bring it up to the standard in the rest of the home. Other environmental issues needing attention are listed in the Environmental and Requirements Sections. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 7 Staff training has improved considerably, but the home must ensure that all staff receive regular refresher training in first aid, food hygiene and fire safety. 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. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. Standard 6 is not applicable. All prospective service users receive an assessment prior to their admission to the home. The homes own assessment tool needs to be reviewed so that all the areas detailed in Standard 3.3 are covered and the service user can be assured that the home can meet their needs. The staff show a good understanding of the needs of service users with dementia. The training they have and are continuing to receive is clearly of benefit. The overall outcome for this group of Standards is judged to be Adequate. EVIDENCE: The case files of the three most recently admitted service users were seen during the inspection. Two service users were funded by the Local Authority and the third was privately funded. The files of those who were funded by Walsall Council contained an up to date assessment, either from the Council or Walsall NHS Trust. In all cases there was evidence that a representative from the home (usually the Registered Manager or Deputy Manager) had visited the person and carried out an assessment. The homes own assessment did not include all those areas detailed in Standard 3.3. Areas omitted were: mental state and cognition, personal safety and risk and carer and family involvement Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 10 and other social contacts/relationships. The information from the assessment had been used to develop a plan of care for daily living. Since the last inspection the home have increased the numbers of people they can admit who have dementia. One of the conditions of this increase was that all care staff undertake suitable training. This training is now ongoing. Staff seen spoke enthusiastically about the training and all those spoken to said that it had helped them better understand the needs of their service users with dementia. Staff were observed assisting a service user with dementia to the table for lunch. They explained afterwards that this particular person had difficulties with spatial awareness and needed assistance to find the chair and sit down. This person was assisted in a patient and kindly way. One member of staff said that since the training she had realised how much more personal attention those with dementia needed. A senior member of staff said that she felt that those who had had the training had really benefited and that it was apparent to her which staff had been trained, because their awareness was so much better. It remains a recommendation that training is sought in epilepsy care. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The home’s care planning systems have greatly improved and now provide a clear picture of service users’ needs. The home needs to improve this system still further by ensuring that, where possible, service users are involved in drawing up their care plans and reviewing them. Care must be taken to ensure that instructions with regard to healthcare needs are up to date. The improvement noted at the last inspection in medication administration has been maintained, although there are still some shortfalls, which need to be addressed before this standard can be fully met and service users protected. Service users confirm that they are treated with respect and that their right to privacy is upheld. The overall outcome for this group of Standards is judged to be Adequate. EVIDENCE: The care plans of 4 service users were seen. Since the last inspection the home have developed a new care planning system, which includes the following information: Front Sheet - with all relevant details,, including medication condition; Special Instruction Sheet, which gives staff guidance as to how to deal with particular situations, such as aggressive behaviour. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 12 Bath/weight; G.P. Report (gives information of what the G.P. said and prescribed after each visit); Personal Care; Communication; General Health; Continence; Sleep Pattern; District Nurse Visits; Mental Health Assessment; Pressure Sore Risk Assessment; Nutritional Guidance Plan; Community Psychiatric Nurse Visits; Individual Risk Assessment; Daily Records. There are also toileting charts (which do not appear to be being completed at present). Risk assessments had improved and each care plan seen contained an individual risk assessment. Not all care plans contained evidence of a monthly review. For example, one care plan dated 15th May 2006 had not been reviewed. Overall, however, these care plans are a great improvement on those previously used by the home and give a good indication of the needs of the service users. Several service users were asked about their care plans and none had any knowledge of them. There was no evidence from the files that service users are involved in their care planning or in the reviews of the plans. All service users now have a pressure care risk assessment on file. Any service users who are at risk of developing pressure sores are provided with pressure relieving mattreses and cushions. Professional advice with regard to continence promotion is available and continence charts are kept where appropriate. The Community Psychiatric Nurse visits some service users following referral from the G.P. The staff carry out light exercise sessions with the service users and this was confirmed by several service users. Nutritional screening is undertaken and service users are regularly weighed. It remains a strong recommendation that seated scales are purchased as several of the service users are unable to stand on the homes scales. Service users have access to other healthcare professionals such as chiropodist, dentist and optician. It was noted in daily records that a service user had spots of blood in their urine. There was no reference to this in the care plan and no way of cross checking how this had been dealt with and how the matter was being monitored. Another care plan gave out of date instructions with regard to a service users legs stating that they must be soaked twice a day. This was completely contrary to present instructions, which were that the legs must be kept dry. Staff on duty knew which was the correct procedure, but any new member of staff or agency staff coming on duty could be in danger of following the wrong instructions. All interventions noted on care plans must be up to date and regularly reviewed. Service users spoken to said that they did receive medical help when they needed it. One person said that when they had had chest trouble, the Doctor was called straight away. Of the relatives surveys returned, 2 said that they usually received medical help when needed and 3 said that they always received medical help when needed. The home are experiencing difficulties with ambulance transport when service users have Outpatient appointments. When the appointment is booked the home request to be able to take an escort, as several of the service users have dementia and others have sensory impairments. Recently the ambulance have refused to allow the homes escorts to travel in the ambulance to accompany Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 13 the service user and this has caused difficulties when the service user is seen alone in Hospital. The home does not yet have in place a formal protocol for assessing and monitoring service users who wish to self-medicate. None of the present service users wish to do this, but the home must be prepared and have a protocol in existence. The medication and accompanying records were inspected. A random sample of medication cassettes and Medication Administration Record charts were seen and there were some discrepancies, with gaps on the administration sheets where tablets had been given. The Registered Manager stated that either she or the Deputy Manager were now carrying out monthly monitoring checks on the medication administration system and records to verify this were seen. The Registered Manager explained that they had requested their Pharmacist to put actual times on the administration sheets, rather than morning, noon, tea, night as not all tablets were prescribed to be taken at these periods of the day. On inspection it was found that service users medication is now organised within the trolley into separate storage areas. The home now have a maximum/minimum thermometer and a separate fridge for medication and are recording the temperature on a daily basis. Records are kept of all medicines received, administered and leaving to home. The home needs to ensure that when controlled drugs are prescribed, these are stored in an appropriate metal cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973. The home does have a Controlled Drugs Register in place and this is being completed correctly. There was evidence that where G.P.s are making changes to medication dosages following a home visit, they are writing their instructions on the MAR chart. The medication trolley was found to be sticky and in need of cleaning. All the service users at Shire Oak have single rooms and personal care giving takes place in private. Service users spoken to confirmed that they were treated with respect and and that their right to privacy was upheld. One service user did say that she could not make a phone call because it was a long way to walk to the phone. It is recommended that the home purchase some portable phones so that service users can make and receive calls in private. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Service users spoken to felt that their individual wishes were listened to and accommodated. There are a number of opportunities for activities, both inside and out of the home. Some service users feel they would like even more and further consultation needs to take place. Specialist activities need to be provided for service users with dementia. Family members spoken to said that they were always made to feel welcome. Service users said that they enjoyed the meals at the home, which offer choice and variety. The overall outcome for this group of Standards is judged to be Good. EVIDENCE: Service users spoken to during the inspection said that they were able to exercise choices with regard to whether or not they joined in with activities and where they took their meals. One service user preferred to stay in her room and take her meals in her room. She spoke with the inspector and explained why she preferred to do so. Service users personal interests are noted when they are assessed. The home offers a range of in house activities and this includes a regular craft session where service users make floral displays, table mats, etc. which are used in the home. Activities are provided on 6 days a week. Outside activities include theatre trips - several service users recently went to Singing in the Rain and Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 15 there has also been a trip to the Safari Park. The Registered manager states that they are looking at improving still further the in house activities. Specific areas for improvement are specialist activities for those with dementia and more one to one sessions with staff. Despite the evidence that a range of activities are offered, some service users and relatives felt that they would like to see “a bit more going on”. It is therefore recommended that particular attention is given to obtaining the views of service users and their relatives about the provision of activities. Service users spoken to confirm that they are able to see their visitors whenever they wish. There are no restrictions on visiting, unless requested by a service user. Information on the homes policy on maintaining involvement with relatives and friends once service users have moved to Shire Oak is contained in the Service Users Guide. The local Vicar visits on a regular basis and at Festival times brings a Choir. Service users are able to look after their financial affairs for as long as they are able, although none choose to do so at present. The Registered Manager is recommended to obtain information on the local Age Concern Advocacy Service for any service users who do not have a representative. Service users spoken to said that they were happy with the food provided at Shire Oak. One said that they always had lovely puddings. 3 full meals a day are offered and there is a choice at all these meals. 3 of the returned surveys returned said that the service user always liked the meals, 2 said usually. Menus seen verified that there was a choice and a choice was offered during the inspection. The meal was much enjoyed. The kitchen was inspected and was found to be in good order. Fridge and freezer temperatures are taken daily. There were adequate supplies of food available, including fresh fruit and vegetables and full fat fresh milk. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. There is a Complaints Procedure in the home and all service users have a copy. The home needs to ensure that their service users and relatives can feel comfortable about expressing their concerns, comments and complaints. There is a clear Adult Protection Procedure in place and staff receive regular Adult Protection Training. This overall outcome for this group of Standards is judged to be Adequate. EVIDENCE: There is a copy of the Complaints Procedure on display in the home. All service users have a copy of the Service Users Guide in their rooms (these were seen during the inspection) and this contains a copy of the Complaints Procedure. From the surveys returned, there was an indication that a service user would “not want to make a fuss”. This may indicate that the complaints procedure does not have a high enough profile within the home and that further discussion should take place with service users, their relatives and staff to ensure that all feel comfortable with voicing their complaints, concerns or suggestions for improvement. One complaint and one concern were made to the Commission since the last inspection. Both were investigated by the Registered Manager. In both cases, some elements of the complaints were upheld and those issues have now been dealt with. The home have an Adult Protection Policy in place, which is in line with the Social Services Policy and the Department of Health document, “No Secrets”. The Manager was informed that the Walsall Social Services Policy and Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 17 Procedure has been revised and that the home should ensure that they obtain a copy of the new document. The majority of staff took part in Adult Protection training last summer. The new staff are now undertaking this training. The home now have a policy in place with regard to staff preclusion from involvement in the making of service users wills. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25 and 26. The communal areas of the home are well maintained and comfortable. The majority of service users do not wish to use the shower and this means that there is no assisted bath on the first floor. Bedrooms in the older part of the building are in need of redecoration and refurbishment in order to bring them up to the standard of the rest of the home. Standards of hygiene and cleanliness are generally good, although there is room for improvement in some areas. The overall outcome for this group of Standards is judged to be Adequate. EVIDENCE: Generally the home is well maintained, although some areas in the older part of the building (particularly individual rooms) are now in need of refurbishment. There is a maintenance and refurbishment programme for 2006/07 in place and this was seen at the inspection. There are pleasant gardens, which are safely accessible to the service users. There have been no recent inspections from either the Fire Officer or the Environmental Health Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 19 Officer. It is noted that in 2 cases, automatic door closures have been removed from bedroom doors because the 2 service users in these rooms were at risk of accidents when trying to negotiate their zimmer frames through the doors. These doors are fitted with intumescent strips and are not propped open at any time. The home has two lounges, one tends to be used more by those service users who have dementia and separate activities sometimes take place in here. There is a separate dining room. All bedrooms, apart from one, have an en suite toilet. There are 3 bathrooms and one shower room in the home. Only 2 of the bathrooms are assisted and the shower is rarely used. There must be 1 assisted bath to 8 service users (this can include the shower if it meets service users needs). The first floor bathroom must be adapted so that it can be used by service users with rooms on this floor who need an assisted bath. There are no shared rooms in the home. The following areas are in need of attention: The carpet on the back stairs and landing is fraying (this is due to be replaced). A number of individual bedrooms had pads stored in the en suite bathroom. There were so many in some rooms that they were creating a hazard. Storage must be found for the pads. A number of the en suite toilets did not have toilet rolls. Several bedrooms did not have a lockable facility. Room 23 - the tiles above the wash hand basin need replacing. There is no bedside light in this room. Several of the air extractors in en suite bathrooms did not appear to be working. Room 28 - the carpet needs cleaning. Room 12 - this room has a flourescent light strip, which should be replaced with domestic style lighting. The furniture in this room is tired and needs replacement, the easy chair is fraying on the arms. Room 8 - there is an unused telephone point falling off the wall. Room 7 - there is no thermostatic adjuster for the radiator. Room 6 - the wardrobe door does not close properly, there is mould on the wall of the en suite toilet due to condensation, the air extractor does not work. The air extractor in the separate toilet on the first floor was full of dust. Ground floor bathroom by front door - bath needs re-grouting and the whole room needs redecoration. Room 1 - the bed base is dirty. The en suite needs a new toilet seat. Room 2 - the chest of drawers is broken. Room 3 - there is a strong odour in this room and the floor covering must be replaced. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 20 Room 4 - the bed base is dirty, there is no air extractor in the en suite toilet and no toilet roll holder. The room needs redecoration and a new easy chair is needed. Room 5 - the en suite toilet needs decorating. A number of mattress covers were thin and of poor quality. Some were torn and crinkled and could cause pressure areas. These must be replaced with good quality mattress covers. Generally the rooms in the extension are well furnished and attractive. Some of the rooms in the older part of the building are badly in need of redecoration and refurbishment to bring them up to the standard of the newer rooms. The home is now registered to care for 9 people who may have dementia. It is strongly recommended that as carpets, curtains and bed linen are replaced consideration is given to purchasing items which are plain and matching, rather than bold patterns, which can be confusing. Water temperatures at outlets accessible to service users have been checked on a regular basis. The home must ensure that these are properly recorded and that if temperatures do exceed 43 degrees corrective action must be taken. The home must ensure that it has sufficient fans and air conditioning units during periods of hot weather. There is a separate laundry. The home uses Dissolvo bags for foul laundry and the washing machine has a sluicing facility. It was noted that the air extractor in the laundry was very dusty. Mops must be inverted and dried. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. There are sufficient staff on duty to meet the needs of the current group of service users. The importance of good staff training is recognised by the home, but some staff need updated training in mandatory health and safety areas (see Standard 38). There are sound recruitment procedures in place to protect service users. The overall outcome for this group of Standards is judged to be Adequate. EVIDENCE: At the time of the inspection there were 5 vacancies in the home, making a total of 21 service users. Staff rotas showed that there were usually 4 care staff on the morning shifts and 3 on the afternoon/evening shifts. On some occasions the care staff were responsible for preparing the tea-time meal. The Registered Manager stated that the home were advertising for a weekend cleaner and weekend tea-time cook. 3 staff have left since the last inspection and 2 are due to leave. New staff have already commenced their NVQ training. Night staff have yet to complete NVQ 2 and it is now urgent that they do so. There are no people under the age of 18 employed at the home. A number of staff files were seen in order to check recruitment procedures. These included the files of 2 new starters. In both cases the following were seen: application form containing a full employment history, 2 written Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 22 references and copies of statements of terms and conditions. It is the Companys policy to retain the original Criminal Records Bureau and POVA checks at their Headquarters and to give the Registered Manager written confirmation of a satisfactory check, quoting the CRB reference number. The home now has in place a satisfactory induction training programme. All new members of staff undergo this training within 6 weeks of appointment to their posts. On the day of the inspection 2 new members of staff were being shown around the home as part of their induction process. There is evidence that staff take part in regular training in the majority of the mandatory health and safety areas, although there are some gaps (see Standard 38) as well as training in other practice areas, such as Dementia Care, Adult Protection and The Safe Handling of Medicines. The homes training plan for the Year 2006/07 needs to be updated and a copy forwarded to the Commission. A copy of the individual training and development assessment and profile for each member of staff must be available in their files. Service users spoken to were, without exception, happy with the quality of care they received from the staff. The following are some of their comments: Shes a very good Manager. In the hot weather they kept bringing us squash. Theyre all very, very good. A lot of very good staff. Surveys received from relatives included some of the following comments: The present manager and staff members are excellent and offer a good standard of care to our mother. The staff are always helpful, courteous and friendly. If senior staff are not available, care staff will endeavour to respond/leave messages, etc. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The Registered Manager displays good leadership skills and is popular with service users and staff. The appointment of a Deputy Manager has further enhanced the development and improvement of the home. The home has commenced a process of obtaining the views of its service users and their representatives. Service users’ monies are kept securely and there are appropriate records in place. The health and safety of service users and staff are promoted, but the home must ensure that all statutory health and safety training is carried out at the required intervals. The overall outcome for this group of Standards is judged to be Adequate. EVIDENCE: The Registered Manager is in the process of completing the Registered Managers’ Award and care components of NVQ4. She has successfully completed the Aset Level 2 Dementia Care training and has taken part in other Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 24 relevant training, including Adult Protection. Although there are clear lines of responsibility within the organisation, the Registered Manager is not at present able to see the Criminal Records Bureau and Protection of Vulnerable Adults checks of prospective members of staff. The present process must be changed as it is the managers responsibility to ensure that only staff who have satisfactory checks are appointed by the Company (see Standard 29 above). Since the last inspection a Deputy Manager has been appointed and this additional post is proving to be of great benefit to the home. Staff now have a person they can go to for guidance in the absence of the Manager. The Deputy Manager has many years experience of working in the care profession and was employed at Shire Oak some years ago. Staff spoken to during the inspection felt that they were well supported by the Manager and Deputy Manager. A new member of staff felt that she worked in a well managed team which provided good care. She said: “If I didn’t think it was good, I wouldn’t work here.” Referring to all the staff and the Registered Manager, a comment on a relative’s returned survey stated: “…the present Manager and staff members are excellent and offer a good standard of care to…” Questionnaires have been sent to service users’ relatives in order to obtain their views of the home. In addition service users meetings are held on a monthly basis. The home obtains information from the returned surveys and meetings on various aspects of the home, including the following: Catering, Housekeeping, Care, and Administration. Staff meetings are also held and the Registered Manager states that these will be held on a monthy basis in the future. Comments from some of the surveys illustrate some dissatisfaction with the laundry (i.e. the wrong clothes going back to rooms). The home is regularly visited by the Companys General Manager, who supplies monthly reports to the Commission. The home takes charge of some monies on behalf of service users. A sample of the monies and accompanying records were seen at the inspection and all were in order. All monies are now kept in securely in individual containers. Staff files were checked for evidence of regular supervision sessions. It was noted that several staff had had supervision, but not at the required intervals (every 2 months). A random sample of staff files were seen to check training in the mandatory health and safety areas of first aid, fire safety, moving and handling, food hygiene and infection control. The files showed that the home had arranged recent training in moving and handling. The Registered Manager stated that training had also taken place in infection control, but certificates had not yet been received at the home. Training in first aid is outstanding for a number of staff members. The home must forward its Training Plan to the Commission detailing when training is to take place in: Fire Safety, First Aid and Food Hygiene. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 25 All hazardous substances are stored securely and analyses of products used are kept in the home. The gas and central heating system was maintained on 28th September 2005. The 2 bathroom hoists were serviced in November 2005 (certificates seen). The lift was serviced on 15th June 2006. The Registered Manager is to forward verification that the water has been checked for legionella. Water temperatures at outlets accessible to service users have been taken, but not recorded satisfactorily. There is a Fire Safety Risk Assessment in place, which is regularly reviewed. The fire alarm system is checked each week, emergency lights each month and Fire Drills have taken place on 20th January 2006 and 14th May 2006. From stickers on the fire extinguishers, it does not appear that the fire fighting equipment has been serviced since 2004. The Registered manager is sure that this was done last year and is to forward a certificate verifying this. Risk assessments have been carried out for all safe working practice topics. Accidents, injuries and incidents of illness or communicable disease are recorded and the Commission is notified. Induction training now meets Skills for Care specifications on safe working practice topics. Shire Oak House DS0000020828.V298763.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 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 X X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14(1) Requirement The home must ensure that when they assess a privately funded service user, all those elements of Standard 3.3 are covered. Where possible, the service user must be involved in drawing up their care plan. Care plans must be reviewed at least once a month. Service users must be consulted when their care plans are reviewed and their views must be noted. Care Plans must indicate how particular concerns (such as healthcare needs) noted in daily records are to be addressed. Care plans must have up to date information on interventions to be used. A formal protocol for assessing and monitoring service users wishing to self-administer medication must be developed. (Previous timescales of 30/09/05 and 30/11/05 not met). Correct records must be kept of DS0000020828.V298763.R01.S.doc Timescale for action 31/07/06 2. OP7 15(1)(2) 31/07/06 3. OP8 15(1) 31/07/06 4. OP9 13(2) 31/07/06 5. OP9 13(2) 06/07/06 Page 28 Shire Oak House Version 5.2 6. 7. OP9 OP21 13(2) 23(2)(j) 8. OP24 23(2)(b) 9. OP24 16(2)(c) 10. OP25 13(4)(a) 11. OP25 23(2)(p) 12. 13. 14. OP26 OP26 OP30 16(2)(j) 16(2)(j) 18(1)(c) the administration of medication. There must be no unexplained gaps on the Administration Record Charts. The medication trolley must be kept clean. There must be 1 assisted bath to 8 service users (this can include the shower if it meets service users’ needs). There must be an assisted bath available on the first floor. (This can be provided by adapting the existing unassisted first floor bathroom). All those areas listed in individual rooms in the Environment Standards must be attended to. The home must carry out an audit of mattress covers and replace all those that are torn and crinkled with good quality mattress covers. Water temperatures at outlets accessible to residents must not exceed 43 degrees. Water temperatures must be regulated, risk assessed, regularly checked and recorded. (Although there is evidence that these temperatures are being checked, recording is not robust enough). The home must ensure that they have sufficient fans and air conditioning units for use during periods of exceptionally hot weathers. When not in use mops must be inverted and dried (not left in damp buckets). Several air extractors need cleaning. The registered manager must forward to the Commission an up to date Training and Development Plan. A copy of the individual training 06/07/06 31/08/06 31/08/06 31/07/06 06/07/06 07/07/06 06/07/06 31/07/06 31/07/06 Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 29 15. OP38 18(1)(c) and development assessment and profile for each member of staff must be available in their files. All staff must receive regular and 30/09/06 refresher training in first aid, food hygiene and fire safety. The home must ensure that there is a person trained to the “Appointed Person” level in first aid available on each shift. Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 30 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 OP4 OP8 OP9 Good Practice Recommendations It is recommended that care staff receive training in epilepsy care. It is recommended that seated scales be purchased. The home is recommended to ensure that the cupboard being used for the storage of controlled drugs is in line with the requirements of the Misuse of Drugs (Safe Custody) Regulation 1973 as amended. It is recommended that the home purchase some portable telephones, so that service users can make and receive calls in their rooms. It is recommended that more specialist activities be provided for those service users with dementia. It is recommended that the home pay particular attention to seeking the views of service users and their relatives with regard to social activities. It is recommended that discussion take place with service users, their relatives and staff about the Complaints Procedure. All should feel comfortable to voice their complaints, concerns or suggestions for improvements at the home. 3 4 5 6 OP10 OP12 OP12 OP16 Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shire Oak House DS0000020828.V298763.R01.S.doc Version 5.2 Page 32 - 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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