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Inspection on 06/02/06 for Shortwood House Care Home

Also see our care home review for Shortwood House Care Home for more information

This inspection was carried out on 6th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is found very clean and well maintained. A homely atmosphere is created with two sitting rooms, one of which is linked to the dining room. There is an experienced, stable staff group, who are supported with appropriate training. Service users are complimentary about the care given by staff. Activities are appropriately provided and considerable choice is given at each meal.

What has improved since the last inspection?

Care planning has developed and relatives have signed agreements when plans were reviewed.

What the care home could do better:

Medication is well organised, but a written policy and procedure must be made available for staff to follow. There was no facility for proper storage of medicines that need to be refrigerated and this has been recommended before. The office door needs a new lock and assessments of risks within the environment should be written down with clear actions that staff need to take to reduce or diminish risks to themselves and service users.

CARE HOMES FOR OLDER PEOPLE Shortwood House Care Home Shortwood House Residential Home 145 Beardall Street Hucknall Nottinghamshire NG15 7HA Lead Inspector Meryl Bailey Unannounced Inspection 6th February 2006 10:00a 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.V271783.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.V271783.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.V271783.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: Shortwood House is situated within walking distance of Hucknall town centre. Care and accommodation are provided to a maximum of twelve residents over the age of 65years. Accommodation is on two floors. There are ten single bedrooms and one shared room. All areas are accessible to wheelchair users with a passenger lift providing access to the upper floor. A small garden provides an outdoor sitting area. Shortwood House Care Home DS0000008789.V271783.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector during one morning and lasted just over four hours. There were nine people resident in the home on the day of the inspection. A further person was in hospital and there were two vacancies. The manager and two care staff were on duty. The inspector looked around the communal areas and bathrooms, but did not inspect any bedrooms. The evidence was gained through speaking with residents, a visitor, the manager and staff on duty, from observation and from examining written records. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shortwood House Care Home DS0000008789.V271783.R01.S.doc Version 5.0 Page 6 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.V271783.R01.S.doc Version 5.0 Page 7 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): These standards were not assessed at this inspection. EVIDENCE: Shortwood House Care Home DS0000008789.V271783.R01.S.doc Version 5.0 Page 8 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 and 9 Care is planned and needs are meet. Medication is organised, but a full policy and procedure is not yet available. Appropriate, secure cold storage should be provided. EVIDENCE: The written information relating to two service users was examined. There was evidence of care being planned, with some clear instructions to staff about specific action they should take to meet needs. Morning and evening routines were particularly clear aswell as support required with meals. Some information had not been fully completed for the service user most recently admitted, but for the other there was comprehensive information covering all areas of need and the plans had been regularly reviewed on a monthly basis. Medication was well organised in practice, with advice and guidance being given by the Boots pharmacist, who was present on the day of this inspection. However, the written policy and procedure for the management of medicines had not been produced and this is an outstanding requirement. Also, it was noted that there were eye drops in an open plastic box in the main refrigerator. Ideally a separate fridge should be made available for medicines Shortwood House Care Home DS0000008789.V271783.R01.S.doc Version 5.0 Page 9 that need to be stored at temperatures below 5°C, but the minimum safety measure would be a lockable box secured within the main refrigerator. The pharmacist confirmed training was planned for staff and a certified course was planned for the manager and senior staff. Shortwood House Care Home DS0000008789.V271783.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, 14 and 15 A range of appropriate activites are available and service users are encouraged to exercise choice. Meals are balanced and planned to suit individual preferences and diets. EVIDENCE: There were activities planned for each day. During the inspection service users were encouraged to play darts, with the dartboard being taken to each player individually so that they could throw from a sitting position. Other activities included memory game, gardening, floor basketball, Bingo, dominoes and movement to music. Service users said they enjoyed the activities and the choice of two lounges with television available. A river cruise was also planned for 13/04/06. Information about these activities, staff on duty and the menu was posted on a notice board in the dining room. Choice and decision making were addressed within the care plans and individuals had stated their choices, including whether they wished to hold the key to their bedroom. The lunch menu was Shepherd’s Pie with two further choices available: option 2 Egg Salad; option 3 Jacket Potato. Staff and service users confirmed that there are always different options given each day and if they prefer service users can request something not on the menu. Service users said they were always satisfied with the quality of the food provided. Shortwood House Care Home DS0000008789.V271783.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): 16 A complaints procedure is in place. EVIDENCE: The complaints procedure was displayed and service users said if they had concerns they would discuss with senior staff or the manager. No complaints had been recorded and none have been received at the Commission. Shortwood House Care Home DS0000008789.V271783.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): 19 and 26 Service users live in clean, comfortable surroundings, with good standards of maintenance and hygiene. EVIDENCE: A tour of the premises was made though individual bedrooms were not seen. Service users said that they fell comfortable in their own rooms and in the lounges. All areas appeared well maintained with the exception of a broken lock on the office door (see Standard 37). The home was found clean and fresh throughout. The laundry room was free of the clutter that had been found at the previous inspection. Initially, there were no paper towels in the laundry for staff use, but these were provided immediately during inspection. Shortwood House Care Home DS0000008789.V271783.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): 27, 28, 29 and 30 Sufficient staff are available to meet the needs of the current service users at all times. Staff are supported with vocational training and relevant in house training. The recruitment practice safeguards service users. EVIDENCE: The staffing rota showed two shifts if two care staff on duty between the hours of 8am and 10pm. During the night one of the staff is asleep on call and another is awake. The manager is available most days in addition to this. Two of the care staff have achieved the National Vocational Qualification at level 2 in care and three further staff are half way through the course at West Notts college. Five other care staff are not currently pursuing a National Vocational Qualification. The records of two staff were checked and found to contain satisfactory references with appropriate checking through the Criminal Records Bureau having been carried out. Regular staff meetings were held and a training plan was posted on a staff notice board. Training during 2005 had included: Incontinence; Fire safety; Adult Abuse Awareness; Dementia; and Moving and Handling. Three staff still needed Abuse Awareness training and this was planned together with updated training in Food Hygiene; Fire safety; Infection Control; and Health and Safety. Further training was planned in Dementia Care with training videos and booklets from the Alzheimer’s Society. Shortwood House Care Home DS0000008789.V271783.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, 33, 37 and 38 A registered manager runs the home and the quality of the service is monitored. The health and safety of service users is promoted, but all risks should be thoroughly assessed and further action should be taken. EVIDENCE: One of the providers is also registered as manager. She is currently undertaking the National Vocational Qualification at level 4 in Health Care and plans to continue with the Registered Managers Award. There are systems in place to monitor the quality of the service at Shortwood House. There are regular staff and resident meetings and these are minuted. Questionnaires have been used in the past and will be used again to seek views on the service. Shortwood House Care Home DS0000008789.V271783.R01.S.doc Version 5.0 Page 15 Records relating to service users were up to date and other records seen were well maintained, though , as reported under Standard 19, the lock of the office door was broken and must be replaced to keep all records secure. A fire log was kept and showed up to date weekly alarm tests and monthly checks on doors and other equipment. Training was completed or planned in all safe working topics. There was a security policy in place which was specific about some action needed to reduce risks such as the laundry door must be kept locked. However, there were no recorded risk assessments regarding all possible risks within the building and grounds. It is recommended that these be carried out and appropriate be action taken to alarm fire doors and replace or remove the old side gate for example. Shortwood House Care Home DS0000008789.V271783.R01.S.doc Version 5.0 Page 16 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Shortwood House Care Home DS0000008789.V271783.R01.S.doc Version 5.0 Page 17 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 OP9 Regulation 13(2) Requirement The registered manager must review the medicines management policy to the Royal Pharmaceutical guidance. This remains an outstanding requirement and the manager agreed to submit a copy of the policy to the Commission by the date shown. Replace or repair the lock on the office door to ensure all records are held securely. Timescale for action 17/02/06 2. OP37 17(1)(b) 17/02/06 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. Refer to Standard OP9 OP38 Good Practice Recommendations Purchase a small refrigerator for medicines. This remains an outstanding recommendation. Carry out full risk assessments of the environment and take appropriate action to reduce or diminish risks to service users and staff. Shortwood House Care Home DS0000008789.V271783.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 © 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 Shortwood House Care Home DS0000008789.V271783.R01.S.doc Version 5.0 Page 19 - 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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