CARE HOMES FOR OLDER PEOPLE
Shortwood House Care Home Shortwood House Residential Home 145 Beardall Street Hucknall Nottinghamshire NG15 7HA Lead Inspector
Selwyn Marston Unannounced Inspection 27th October 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 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. Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Shortwood House Care Home Address Shortwood House Residential Home 145 Beardall Street Hucknall Nottinghamshire NG15 7HA 0115 9520950 0115 9539968 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 Colette Louise Thomas Mr Michael Shaun Thomas Mrs Colette Louise Thomas Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 08/11/04 Brief Description of the Service: Shortwood House is an adapted family home situated within walking distance of Hucknall town centre. The home is registered to provide residential care only for up to twelve service users who fall within the category of old age. There are 10 single bedrooms, one with en-suite facilities and 1 double room. There are two bathrooms, one with assisted bathing facilities. A passenger lift provides access to two floors. The home is small and comfortable, and has private, accessible gardens to the rear of the property. Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced. The main method of this inspection was ‘case tracking’. This involved at ‘tracking’ if the service users needs were being met. The inspector spoke to staff and service users. Other documentation was also inspected, for example health and safety documentation. 4 bedrooms were viewed with the service user’s permission. Relatives were also interviewed during the inspection. What the service does well: What has improved since the last inspection?
The risk assessment for alcohol now includes consideration of any medication used. Declarations of health are present on staff files. The provider/manager have updated their knowledge on POVA first checks. Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 6 There is a policy on how death and dying will be handled in the home; this now includes the end of life of service users, terminal illness and obtaining GP commitment for primary care team support. The Adult Protection Policy now contains the reporting procedures in line with the Nottinghamshire Committee for Protection Of Vulnerable adults. It also contains details of how CSCI will be informed of any incidents in line with regulation 37. Regular formal supervision of staff has been commenced since the last inspection and is undertaken by the registered manager. 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. Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Assessments take place prior to the admission of a service user. Some contracts are in place but this needs improving to ensure that all service users have contracts on their files. EVIDENCE: Out of the three service users files inspected one file had a contract where it was evident that service users and their relatives had been involved with the drawing up and had agreed with them. The other two files did not contain contracts. The contract did not have a statement included regarding rights and obligations of the service user and registered provider and who is liable if there is a breach of contract. On all three files there was an assessment in place, which had been completed prior to the service users admission. Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 9 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): 7,9,11 Care plans were in place and there was evidence that service users and their relatives knew about them. Documentation should be improved to strengthen the care planning process. EVIDENCE: Three service users were case tracked as part of the inspection. Care plans were found to be in place but the detail was not always sufficient in these to ensure that staff would know how to meet the needs of the service users. Reviews on the plans were documented monthly. There was evidence that service users had been involved in their care plans regarding making their likes and preferences known but there were no signatures of service users or their relatives on the plans. At the previous inspection requirements were set with regard to the handling of medicines in the home, this standard was not inspected on this occasion therefore the requirements will be carried over to this report and will be inspected at the next inspection. There is a policy on how death and dying will be handled in the home; this now includes the end of life of service users, terminal illness and obtaining GP commitment for primary care team support. Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 10 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 Contact with relatives is good. There was evidence that activities do take place according to service user’s needs. Documentation however needs to be improved in this area. EVIDENCE: There was evidence that the service users can receive visitors and one relative said that they visited twice a day. There is an activities book, which is maintained by the registered manager, this book evidenced activities taking place but was not fully up to date at the time of the inspection. The manager felt that there had been some improvements in this documentation since the last inspection but that recently this has slipped. Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 11 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): 18 Policies and procedures have been improved on adult protection in order to keep service users safe. EVIDENCE: Although standard 18 was not fully inspected it was noted that the home has now developed the abuse policy following a recommendation set at the last inspection. It now contains the reporting procedures in line with the Nottinghamshire Committee for Protection Of Vulnerable adults. It also contains details of how CSCI will be informed of any incidents in line with regulation 37. Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 12 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): 24,26 Service users live in comfortable bedrooms with their own belongings around them. The home was clean and pleasant. EVIDENCE: The inspector viewed four service users bedroom with their permission and these were found to meet the National Minimum Standards. The rooms were well personalised and the service users had their belongings around them. The home was clean and fresh smelling. Appropriate equipment, sluicing facilities and policies and procedures were in place. Infection control and MRSA policies are in place. There was some Clutter down the side of one of the washing machines which could present a health and safety hazard. Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: These standards were not inspected on this occasion. Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 14 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): 31,36 The manager is seeking to achieve the required qualification that meets the National Minimum Standards. Staff are appropriately supervised. EVIDENCE: The owner / manager has above ten years experience in managing a care home [since 1991] and now has to achieve NVQ 4 in Care and a qualification in management to NVQ 4 or equivalent by 2005. Regular formal supervision of staff has been commenced since the last inspection and is undertaken by the registered manager. Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 15 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 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 x x x x x 3 x 2 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x 3 x x Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 16 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 2 3 4 Standard OP2 OP7 OP7 OP9 Regulation 5 15,24 15 12,13,17 Requirement There must be a contract for each service user. Evidence of service users or relatives signatures must be included on care plans. More detail must be provided in the service user care plans The registered manager must review the medicines management policies to the Royal Pharmaceutical guidance. This is an outstanding requirement and must be met within the timescale to avoid enforcement action Service users social needs must be fully addressed and documentation of participation in activities in care plans. This is outstanding from the last inspection The ‘clutter’ down the side of the washing machine needs to be removed. Timescale for action 31/01/06 31/01/06 31/01/06 15/12/05 5 OP12 14,15,24 31/01/06 6 OP26 23 15/12/05 Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 17 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 OP20 Good Practice Recommendations The contract should have a statement included regarding rights and obligations of the service user and registered provider and who is liable if there is a breach of contract. This is outstanding from the last inspection. A medicine fridge should be purchased. This is outstanding from the last inspection. Where medicines training is not accredited, competency levels of staff should be assessed. This is outstanding from the last inspection. 2 3 OP9 OP9 Shortwood House Care Home DS0000008789.V260441.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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