Inspection on 13/07/07 for Shirwin Court

This inspection was carried out on 13th July 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Shirwin Court 21/09/06

Shirwin Court 23/11/05

Shirwin Court 19/05/05

Shirwin Court 21/09/04

Shirwin Court 19/04/04

Shirwin Court 02/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Shirwin Court 46 Poplar Avenue Edgbaston Birmingham West Midlands B17 8ES Lead Inspector Jill Brown Key Unannounced Inspection 13 July 2007 08:45 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 Shirwin Court DS0000017022.V335841.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. Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirwin Court Address 46 Poplar Avenue Edgbaston Birmingham West Midlands B17 8ES 0121 420 2398 0121 686 3727 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) Mr Rahmatullah Hissaund Mrs Bibi Hissaund Mr Rahmatullah Hissaund Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is able to accommodate ten people by reason of old age of which eight may have mild Dementia. No residents with Dementia are to be admitted to the second floor accommodation. 21st September 2006 Date of last inspection Brief Description of the Service: Shirwin Court is a privately owned double fronted property that has three floors. The home offers accommodation for 10 older people. The home is situated in Edgbaston close to the Hagley road. From the Hagley road there is public transport available to the centre of Birmingham. Local shops and other amenities are available within walking distance to Bearwood shopping area. The home has 6 single and 2 double bedrooms that are located on all three floors. There are stair lifts between each floor. The top flight of stairs is steep and narrow and can only be negotiated by mobile residents. Communal toilet and bathing facilities are available on the ground and first floors. The second floor bedrooms have toilets but the en suite showers are not useable as they cannot be restricted to 43 degrees Centigrade. One of the bathrooms has an in-bath lift for assisted bathing. Not all toilets are large enough for staff to offer assistance. The home has a large well-furnished lounge that overlooks a pleasant garden with shrubs, patio and garden furniture. The separate dining room is used by residents for activities as well as for meals. The home has a ramp and handrails to the front door. Parking is only available on the road. The home charged between £314.00-£346.00 per week up until April 2007 and were waiting to hear the final fees for this year. There are additional charges for, hair dressers, toiletries and magazines and newspapers; the cost of these varies with personal preference. The home will arrange a chiropodist at a cost of £8.00 per session. Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited the home on a day in July without prior notice. A key inspection was undertaken which looked at all of the key standards. The inspection took place over seven and half hours. The home had 8 residents at the time of the inspection, vacancies only been found in the shared rooms. During the inspection 2 residents were case tracked. This case tracking involved talking to the residents looking at all the records and information about them, looking at their medication, their rooms and talking to professionals and carers. This was to help the inspector make a judgement about the care given. A number of residents in this home were unable to express their opinions clearly because of dementia. Observations were made about these residents wellbeing during the inspection. The inspector also took information we had received from all sources since the last inspection. Information was given to us in a pre inspection questionnaire, which the home completed. The home had received no complaints about their service. What the service does well: The home has detailed assessment format that assists them in drawing up a care plan. Assessments of residents were checked on a monthly basis and rewritten six monthly. Care plans changed when resident’s health and abilities changed. For example one resident had a care plan to manage swollen legs another indicated that the residents abilities had improved. Residents can be assured on admission that arrangements will be made to have their physical health checked and appointments made for health professionals such as chiropodist, optician and so on if necessary. Residents’ personal hygiene needs were met. Female residents had the opportunity have their nails painted and wear jewellery if they wanted. The hairdresser comes to the home regularly. There is a family atmosphere between residents and between residents and staff. Residents spoken to were happy with the care they received. Recent reviews of resident’s care with social workers showed a high level of satisfaction with the service with comments such as: -‘I have no concerns whatsoever but would like to go out more.’ Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 6 From the reviews held relatives feel welcome in the home. Residents were happy with the traditionally English food provided. Residents said: ‘I’m a lot better since I came here I couldn’t eat. I was about 6 stones but they mashed my food up and now I weigh 9 and a half.’ ‘I like fish but the ham is so nice that they get here is really good not cheap its very nice with vegetables.’ The home has a stable staff group that know the residents well and this helps to ensure that residents are protected. The building is organised in a homely way with furniture of different styles to meet the needs of residents. The manager and owner of the home has been managing care homes for a number of years is a Registered Mental Nurse and has completed the Registered Managers Award. Certificates of maintenance and inspection of Gas, electrical and fire safety were in good order as were other health and safety checks. What has improved since the last inspection? What they could do better: Although detailed assessments are written within a couple of days of a resident’s admission more detailed records of visits to see potential residents and of the preadmission visit would assist this process. Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 7 Risk assessments of residents that smoke were not detailed enough and this means that residents access to cigarettes was restricted without the risk being demonstrated. Care plans were not always written for areas of need that the home was managing for example helping a resident to increase weight. Accident records were not cross referenced so that the managers can assure themselves that any pattern of injuries and accidents can be resolved. The system of medication administration needed improvement access to ensure medication when administered was safe, that records of medication were correct and enough safeguards were in place. Care plans and assessments do not record residents preferred lifestyle. All the residents get up early and there is no evidence to say this is what they wanted on admission. One residents review said that the resident felt rushed in the morning. Residents spoken to were happy with the arrangements but it was unclear if they had only adjusted to the home’s practice. Environmentally the home has improved however, locks on residents door need to be able to allow residents to lock their room if they are not in it and they should be offered a key. All residents should have lockable storage. The resident call alarm should be looked at for replacement. The call switches are not identified as such. Staff do not have to come into the room to cancel the call alarm and this put residents at risk. The manager needs to ensure that the staffing remains sustainable as staff were doing extra hours to mange the previous deputy manager’s hours. The quality assurance systems needed improvement to show how residents are consulted and how this improves the service for residents. The management of residents’ money was not robust enough to give a good trail of how residents’ money was spent. Invoices given for the whole resident group for hairdressing, toiletries and so on were not available and this means that the accounts were not auditable. 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. Shirwin Court DS0000017022.V335841.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 Shirwin Court DS0000017022.V335841.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Information is given to residents and their families and this protects residents’ rights. Information is collected about residents needs, this is added to and reviewed routinely antis ensures residents needs are met. EVIDENCE: Two residents care files were looked at. Both residents had a contract showing the cost of placement. A standard letter had been produced that stated the resident’s needs could be met should the resident decide to come to the home. These details protect residents and their families. Residents were admitted following an assessment visit by the manager, these visits may be at the person’s home or if necessary a hospital. Potential Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 10 residents were encouraged to visit the home before deciding to come to the home. These visits are recorded but more detail was needed to show that the home had considered the health and lifestyle needs of the residents. There was no assessment information available from the social worker on one resident. The home completed a standard group of assessments in a book format within days of the admission. This gave information when completed on levels of risk and dependency and covered such areas as Communication, Mobility, Mental and Physical Health as well as nutrition, mobility and skin risk assessments. This information helped the home draw together a care plan for the resident. The resident’s assessment is checked on a monthly basis and rewritten on a six monthly basis. The outcome of these reviews and checks prompted changes needed to the care plan. The home records residents’ ethnic background, communication needs and religion and this information helps to make care plans sensitive to the individual. Residents were from the white Uk or white Irish background the staff group is culturally diverse. Half of the resident population is male but only the manager is male this means the male residents do not have a choice of receiving their care always from a man. Shirwin Court DS0000017022.V335841.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments is not always underpinning the care residents were receiving and this could to needs not being met. Although residents had access to health professionals, medication administration needed improving to ensure health needs are met. EVIDENCE: The care plans looked at indicated what help residents needed and further information was added when needs had changed or when residents had improved in their abilities. For example care plans said such things as ‘now takes themselves to the toilet.’ A care plan was devised for a resident that had temporarily got swollen legs. Care plans have information of how to approach a resident and this can be important when residents are new to the home or when a resident has short-term memory loss. Examples of this were; the name the resident prefers to be called and ‘tell the resident what needs to be done and what to do in a calm friendly manner.’ Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 12 A number of residents in the home smoke and their ability to do safely and within their means were not formally risk assessed. Residents were not always in possession of their cigarettes and lighters yet the risk assessments did not demonstrate why they were unsafe to have them. Daily records showed following admission that a resident was seen by the practice nurse, a dentist, had a session with a chiropodist, saw an optician and was assessed by a continence nurse. Other records showed that residents in the home had routine visits from these services where needed. Residents at the home were observed to have their personal hygiene needs attended to. Residents were weighed monthly on a routine basis and where there were concerns about residents weight this was attended to this. This however was not always reflected in the residents care plans. Residents had reviews with social workers on a yearly basis comments from residents and relatives in these reviews were: (The resident) says they feel settled and enjoys Shirwin Court, everyone feels that (the resident) is physically well and their abilities have improved. (The relative) was happy with the quality and level of care. A resident said in a review ‘I have no concerns whatsoever but would like to go out more.’ Another resident’s relatives were very happy with the care given. A review suggested that a resident felt rushed in a morning. (See standard 14) This was linked to the resident requiring more assistance than previously. Three accidents had been recorded in the accident book since the last and removed. There was no coding on the slip remaining to cross-reference these accidents. Copies of notifications were found in the home but we had not received them. The inspector spoke to resident about their fall they said that the girls were doing their checks on residents and found him. He was in hospital very quickly. He was there four days but asked to come back the care was better in the home. A comment card we received from a GP practice suggested that there are no major concerns about the home’s practice. Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 13 The systems for medication administration could be improved to ensure that they are more auditable. A system of medication storage in the form of a cassette that houses 14 days worth of a resident’s tablets is used. The tablets are kept in small compartments for morning, lunchtime and so on for each day. This system was good enough because the compartments were not sealed so medication cannot accidentally come out the wrong compartment. Tablets in the cassette were not described as to name shape and colour on the outside of the cassette. Some medication was on the prescription and in the cassette but not named on the outside. This means if for any reason there is a tablet missing it is hard to identify which medication it is. A copy of the prescription is kept by the home and this helps to check that right medication has been dispensed. A medication was prescribed as ‘take 1 or 2 four times a day’ but was being treated as an ‘as required medication.’ This medication came in separate box from the cassette but was being put into the cassette. There was no protocol for ‘as required medication’. Medication was not checked by a second person when it came into the home and an error was found in the transcribing of the number of tablets on to the Medication administration record. Residents were seen to have good contact with staff and the owners throughout the day. Residents were encouraged to have conversations with each other as well as with the staff. All residents are in singly occupied rooms. Shirwin Court DS0000017022.V335841.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the range of activities for residents had improved further development was needed to meet the needs of residents with dementia. The meals and arrangements for visitor met the needs of residents. The records did not show that residents were able to retain their daily routines and this affects residents control over their lives. EVIDENCE: Since the last inspection the owners have redeveloped the back garden and this has become like another room to the home. Residents spend a lot of time out there weather permitting. One resident spent 13 days out of 26 in the garden in June. Residents are growing salad crops and sunflowers; some of the lettuces have been used for tea. Residents that are able assist with setting tables and clearing away. As a small home residents have contact with staff at regular intervals throughout the day. A list of activities was displayed in the dining room. Residents’ daily records show that residents go in the garden, watch TV, have films shown, engage in sing- along, discussions and do some passive exercises. Residents, that are able, read and do word searches and Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 15 crosswords. One resident attends a day centre. There was an effort to try and make events out of day to day occurrences such as: - one day of Wimbledon fortnight the residents sat down to watch the tennis with choc ices and strawberries and this type of event should be encouraged. Female residents observed had their nails painted. Individual activity plans were not in place for residents with dementia and this is important at ensures that activity meaningful to the particular resident is carried out. The home welcomes visitors and the information from reviews held recently suggests that relatives are happy with the service provided. All the residents get up early and the residents spoken to seemed happy with this. A resident said ‘I’m awake at 05.30 sometimes earlier I get up and have a cup of tea with the girls.’ Assessment and care plan information did not show residents preferred time of rising so the home were not showing that the resident’s choice and preferred lifestyle was being maintained from admission. A comment from a resident about being rushed in the morning may be an expression of this. Residents were able to go back to their rooms during the day if they wished to and were safe to do so. Two weeks of menus were sent to us before the inspection. The food provided was of a traditional English type. Residents have cereals and toast and option to have fruit in the morning. Lunchtime menus were roasts, shepherds pie, sausage dinners and so on. At teatime there it was often sandwiches but usually also an option of something on toast or soup. There tends not to be a formal choice at lunchtime but an alternative is prepared if residents want something different. On the day of the inspection residents had the choice of fish or ham dinner. A resident spoken to said ‘I like fish but the ham is so nice that they get here is really good not cheap its very nice with vegetables.’ Another resident said ‘I’m a lot better since I came here I couldn’t eat. I was about 6 stones but they mashed my food up and now I weigh 9 and a half. I used to have to use the stair lift but now I can manage the stairs.’ There were good stocks of food in the kitchen. The home has devised a record for showing how much residents have eaten but this needed to be completed better to ensure that accurate record was maintained. The dining room had enough places to meet the number of residents. Plants and silk flowers were on the tables. Shirwin Court DS0000017022.V335841.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives were happy with the care provided and had no complaints. Residents are protected from abuse well trained staff that know them. EVIDENCE: The home and we have received no complaints since the last inspection. There is a complaint procedure available to residents. Improvements could be made in collecting residents’ views about the service. There have been no issues of an adult protection nature since the last inspection. Residents spoken to were happy with the service provided. Staff attended a half-day course on adult abuse awareness. The staff group are long standing and know the residents that they are caring for. Residents have an inventory made of their belongings within a couple days of admission. Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have the benefit of a home that is homely and comfortable further improvements were needed to assure the safety of residents. EVIDENCE: A tour of the building was undertaken and the following was found: The main lounge at the back of the house was comfortable and clean with chairs of differing heights to suit residents’ needs. There are enough chairs for the number of residents and there are further easy chairs in the dining room. There is one settee, which is used by a particular resident. The back lounge leads onto a garden area that has been redeveloped since the last inspection. The paving stones had been relayed to be more even. There Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 18 was more comfortable furniture comprising chairs, a swing and two benches in an enclosed patio area. There is a ramp to this patio area. Residents’ bedrooms varied in size and style. Some residents rooms are very personalised with resident’s belongings others less so. Residents bedrooms were clean and mostly odour free. The mattresses and bedding checked was clean and fit for purpose. The locks on bedroom can be locked from the inside to maintain the residents privacy and can be opened from the outside in an emergency. These locks do not provide security for residents’ belongings. A number of bedrooms do not have lockable storage space for valuables. Call alarms are cancelled at the main panel meaning staff do not have to enter the residents’ bedrooms to switch the alarm off. The call switches are not prominent in rooms and some visual sign was needed to ensure that residents know what they are and what they are to be used for. There are toilets and bathroom facility on the ground floor and on the first floor. The ground floor facilities are quite small and do not allow room for staff to assist residents easily. The kitchen was very clean with good storage space. There were good stocks of food. There is a cleaning rota for the kitchen. The staff were using the recommended risk assessment processes to ensure the safety of food in the kitchen. Carpets had been cleaned as a result of the last inspection this will need doing again shortly. The kitchen and the laundry area had numbered locks put on since the last inspection to prevent residents walking into these areas unsupervised. Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The level, recruitment and training of staff is appropriate to meet the needs of the residents. EVIDENCE: The level of staff in the home was appropriate to the needs of the residents there were two staff on duty on the day shift and one on duty on a night. Residents spoken to were happy with the amount of staff on duty. Staff were seen throughout the inspection talking to and interacting with residents. The deputy manager was working now at another home and existing staff were increasing their hours to cover this however this may not be appropriate long term. These extra hours were used to cover the home for sickness and holidays and these are no longer available. Staff have been trained to meet the needs of older people. The pre inspection questionnaire stated that 5 out of 7 staff have the National Vocational Qualification (NVQ) level 2. However without deputy it will be 4 out of 6, which still ensures over 65 of staff have at least the NVQ 2 in care. There has been no new staff recruited since the last inspection. Staff files looked at had the appropriate application form, checks from the Criminal Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 20 Records Bureau references and so on. The induction training given to staff would not now meet the common induction standards recommended by the Skills for Care organisation the manager did not have the standards available. The staff files looked at showed that staff had been having training to update their practice in key areas such as moving and handling, adult protection and so on. The manager did not have a matrix of the courses that the staff team have undertaken. Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and safety aspects of the home had improved and met the needs of residents. The management of residents’ money and systems for collecting and acting on residents’ views needed improvement. EVIDENCE: The owners that manage the home have completed the Registered Managers Awards and copies of these certificates have been sent to us. The deputy manager has started working at another residential home and the arrangements for staffing will need to reflect this change. Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 22 A Quality Assurance system has been purchased but has yet to implemented. Some work is required to select the parts of the Quality Assurance system that are appropriate for a small sized home. There were few recent records of the manager gaining residents views on the service provided using these to improve the service. Two residents money were looked at in detail and the following found: The transactions of residents’ money are recorded in exercise books money is kept in the home’s safe. Residents pay, out of their personal allowance, for hairdressing, chiropody, toiletries, and clothing and if required cigarettes. The home gets an invoice for hairdressing and chiropody for all the residents that have that service. Copy of this receipt is not kept with the financial records for each resident. A separate receipt was given by the home but this does not give enough of an audit trail. Items such as toiletries and cigarettes are bought in bulk so that residents ‘ have the best deal’ however the individuals are charged to the pound, there was no receipt of the bulk buying to check the amounts and this is not acceptable. Residents that have run out of money are funded by the home for hairdressing on until more money becomes available. The money held matched the records kept for the two residents looked at. Certificates of maintenance and inspection of Gas, electrical and fire safety were in good order as were other health and safety checks. A fire drill was due and fire training had been given in the last fortnight. Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 23 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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 2 X 2 X 3 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 2 X 1 X X 3 Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Care plans must cover all areas of identified need. This is to ensure residents receive the care they need consistently Risk assessments must be undertaken for residents that smoke and restraints used clearly identified. This is to ensure that all areas of concern with smoking are considered and actions to minimise risk are appropriate. A safe system of administering medication must be put in place that is audited for compliance including: All hand written MAR must be checked by another person and must have two signatures confirming this. Outstanding since 31/10/06 The home must ensure that the system of medication allows a quick method of auditing. Outstanding since 31/12/06 and Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 25 Timescale for action 30/08/07 2 OP7 13(4)(c) 30/08/07 3 OP9 13(2) 30/08/07 31/10/06 Medication in the cassette must be named and described. A protocol of administration for each medication and each resident that is prescribed ‘as required.’ Medication coming into though home must rechecked by two people. Medication is only given in the way prescribed. This is to ensure that residents have medication administered in a way, which promotes their health and ensure medication is accounted for. A risk assessment of the performance of the resident call alarm must be undertaken to determine its continued suitability in ensuring residents receive help when needed. This is to ensure that residents are able to call for help when needed and an appropriate response is given. The records of transactions on residents money must be an accurate amount of the money spent and receipts must be available of the items bought or the service received. This is t ensure that residents money is auditable and used in the best interests of the resident. All staff must have the benefit of fire drill at suitable intervals. This is to ensure that all staff are aware of the emergency plan Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 26 4 OP22 23(2)(n) 12(1)(a) 30/08/07 5 OP35 17(2) schedule 4(9)(a) 30/08/07 6 OP38 23(4)(e) 30/08/07 and act appropriately in the case of fire. 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 OP3 Good Practice Recommendations More detailed records of information collected by the manager at visits to residents and resident visits to the home prior to admission should be kept. The manager should get the social workers assessment if the resident is being funded by a local authority and record when this has been requested and not given. All residents that are unable to motivate activities for themselves must have an activities plan and the activities they have enjoyed recorded in their daily record. Outstanding since 30/11/06 Residents care plans must encourage residents choice and residents preferred lifestyle. The home must ensure there is a comprehensive record of the type and amount of food a resident eats. Partly met 30/11/06 Arrangements should be made to improve the toilet facilities to allow residents to be assisted if needed. It is strongly recommended that the call system be replaced with one that has to be cancelled within the residents’ bedrooms. Resident call alarm switches must have some sign to show their presence. 7 8 9 OP24 OP30 OP33 Bedroom door locks must allow the resident to lock the door when they are not in the room to keep their valuables safe. A matrix of staff attendance at training available in the home. The home should improve the ways they collect residents views to improve the service and this should result in an annual report. 2 OP12 3 4 5 6. OP14 OP15 OP21 OP22 Shirwin Court DS0000017022.V335841.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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