CARE HOMES FOR OLDER PEOPLE
The Shaw 169 Tollers Lane Old Coulsdon Surrey CR5 1BJ Lead Inspector
Claire Taylor Unannounced Inspection 13th January 2006 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 The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 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. The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Shaw Address 169 Tollers Lane Old Coulsdon Surrey CR5 1BJ 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) 01737 556 577 01737 556 386 rona.bourke@ccht.org.uk Central & Cecil Housing Trust Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th September 2005 Brief Description of the Service: The Shaw, located in a semi rural residential area of Old Coulsdon, is a detached property situated in its own grounds and within easy reach of the local village. It is registered as a care home for older people with the Commission for Social Care Inspection to provide care and accommodation for up to 25 service users. Central and Cecil Housing Trust own the home and is a registered charitable organisation. There are 25 single rooms, some of which have en suite facilities. Accommodation is set out over three floors with a lift to service each. Communal areas consist of three dining rooms and two lounges. A loop system has been installed for the benefit of those residents who have hearing impairments. There is a large well-maintained garden planted with mature shrubs and trees, flowerbeds and hanging baskets / window boxes and a water feature. There is a large well-equipped kitchen and adequate laundry area. Ample space for parking vehicles is available at the front of the property and the home is situated within easy reach of nearby transport links such as buses. The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year 2005/6. It was an unannounced inspection that began at 9.30am and lasted six hours. Inspection time was spent talking to several residents and staff, two visiting relatives and one of the senior staff on duty, Kim Maw, who facilitated most of the inspection. The owning organisation employs an NVQ Assessor who was also visiting some of the care staff on this occasion. All those who contributed to the inspection process are thanked for their time and assistance. A brief walk round the premises took place and several bedrooms were viewed with the permission of the residents. Various records were checked concerning residents’ plans of care, staff files and the home’s general administration systems. Following the recent resignation of the home manager, two senior care staff were deputising until the organisation recruits a new manager. Prior to this inspection, the Commission had been notified of the current management arrangements. The Commission for Social Care Inspection had received an anonymous complaint since the last inspection. Two inspectors carried out an unannounced inspection on the 25th October 2005 and a summary of the findings from the investigation forms part of this report. There were four elements to the complaint of which three were not upheld. One was partially substantiated due to the home awaiting the installation of a new call bell system. By the time of this inspection, this had been completed. What the service does well:
As at previous inspections, this home continues to maintain good standards and offer a quality service to the people who live there. Residents spoken to were once again, all very positive about the facilities and the high level of care provided by the staff team. They indicated that staff treat them with respect and seek to ensure dignity and privacy particularly when personal care is being provided. Examples of such comments included “the staff are pleasant and kind”, “I am being well looked after here”, “ I can go to the lounge or stay in my room as I choose” and “my family are able to visit at any time”. Relatives spoken to also have confidence in the home; “My “…..” is very happy at the Shaw and staff are very caring.” All residents have an individual care plan based on a thorough needs assessment and records are kept up to date and in good order. Staff working in the home appeared respectful and accommodating when communicating with residents. Systems are in place for supporting residents to exercise choice and control over their lives. Individuals are encouraged to retain as much personal independence as possible. There is a stable staff team who have a variety of skills and knowledge relevant to the setting and residents’ needs are therefore well understood. Activities are arranged to suit the needs of the residents and provide interest and stimulation both within the home and out in the local community. A notice
The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 6 board is used for the purpose of informing residents about activities, social events/ functions and meal options available each day. The Shaw provides a pleasant and homely environment for its residents, some of who have lived there for many years. The premises were once again in very good decorative order and clean and tidy. Furnishings and fittings are of good quality and in meeting with residents’ needs. 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 Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 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 The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 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, 4 and 5. Standard 6 is not applicable to this home as it does not provide intermediate care. Residents and their representative are given information in advance of admission to ensure they are able to make an informed choice. Pre-admission assessments are completed to ensure that residents are appropriately placed and can therefore receive the care that meets their needs. The home’s registration category needs amending to include those specified residents who have dementia to remain in the home whilst their needs can continue to be met. EVIDENCE: There has been one new admission since the last inspection (September 2005). The Shaw uses its own pre-admission assessment tool and assessments had been completed appropriately for the resident at the point of their admission. Due to the manager recently leaving the organisation, one of the senior staff would undertake any assessment of a potential new resident. Areas covered include hobbies, social/ cultural needs, dietary preferences, medical history and personal care. Mobility needs are assessed with risk plans completed for the prevention of falls. Such assessments help to ensure that
The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 10 the home only admits residents whose personal care needs can be met appropriately. As previously required, a review meeting had been held six weeks after the newest resident’s admission. Discussion with residents and care records indicated that the home was meeting their assessed needs. Prospective residents are actively encouraged to conduct pre admission visits to the home when possible. Contact is also encouraged to ensure that relatives, who may view the home on behalf of prospective residents, are satisfied that their specific needs can be met. One new resident and their relative spoke positively about the move and that they were provided with good support to settle in to the home. Some of the residents have been diagnosed with dementia and have developed the condition during the course of their stay at the home. At present the home’s registration category does not allow for people with dementia. The registered provider must therefore apply to the Commission for a variation in its registration category for the named residents. This will enable the specified residents who lapse in a mild form of dementia to remain in the home whilst their needs can continue to be met. The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 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, 9 and 11 Care planning is well organised and regular informal reviews ensure that staff are aware of each residents’ current needs. The arrangements for the management of residents’ medicines were appropriate although pharmacy visits need to be organised to maximise safe practice. Residents and their families have been consulted about ageing, illness and death in order that their beliefs would be observed and choices respected. EVIDENCE: Files demonstrate that residents have a comprehensive plan of care that is based upon a detailed needs assessment. Care plans fully address the health; personal and social care needs of each individual resident. As previously required, review notes showed that residents’ care needs were being reviewed monthly with amendments made where needs have changed. Risk assessments, that seek to protect resident’s health and safety were also recorded in respect of residents’ mobility, skin care and nutrition (including weight monitoring) and other relevant areas; they were also evaluated regularly. The arrangements for resident’s medicines were secure and appropriately documented. Medication is reviewed at regular intervals and according to changing needs of residents. Adequate staff are trained to administer medication and records were accurate and in accordance with the
The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 12 residents’ individual prescriptions. The home uses a monitored dosage system, supplied by “Boots” chemist. A pharmacist usually visits the home every three months to provide advice and carry out a medication audit but staff explained that the home had not received a visit for some months. This needs to be arranged and a requirement was therefore set. Residents’ wishes in respect of what will happen in the event of their death are obtained and recorded on their files. Families and representatives are also involved. The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 13 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 and 14 Social activities are well organised, creative and provide stimulation and interest for people living in the home. Wherever possible, residents are able to exercise choice and control in their day-to-day routines, and receive appropriate support from staff to achieve this. Standards 13 and 15 were assessed as met at the September 2005 inspection. EVIDENCE: One of the senior care staff takes responsibility for arranging activities and has recently written a proposal to convert the smaller dining area into an activities room. This would be beneficial to the residents as activities currently take place in the main lounge and a second facility would allow for a quieter activity area. A notice board in the hall displays up to date information about activities and social events/ functions. Those offered for the week included a quiz, video and “golden oldies” music. Residents participated in a reminiscence session during the morning. The home arranges for some residents to have their newspapers delivered daily. Other activities provided include discussion groups, bingo, singing and art and craft activities. Visitors from a local church group visit monthly to socialise with residents. Individuals have the opportunity to participate in Holy Communion as their faith so determines. Community outings such as visits to tearooms, concerts and garden centres are organised. Photographs are displayed in the hall of recent events, which have included a 100th birthday party and Christmas celebrations. The activities
The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 14 programme was well documented, enabling staff to identify those which had been especially successful. Minutes of monthly residents’ meetings were available and detailed that staff consult with individuals regarding issues in the home including activities and menus. Staff in charge explained that the home was in the process of buying a larger television; this had been suggested to residents and their relatives who have agreed to pay a contribution towards the purchase. The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 15 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 An appropriate complaints procedure is in place to ensure that the views of residents, their families and friends are listened to and acted upon. As previously required however, records of all complaints made should be available in the home so that residents, relatives and staff are made aware of issues and any actions taken. Standard 18 was assessed as met at the September 2005 inspection. EVIDENCE: A copy of the Complaints procedure and log record is kept on the residents’ notice board with a book available to document any complaints or concerns. The home also facilitates regular meetings to enable residents to bring matters of concern in order that appropriate action can be taken. One requirement remains outstanding in that details of all complaints made about the home or services provided must be kept in the home. This will ensure that residents, their relatives and staff are made aware of any findings and actions taken. The Commission had received and investigated one anonymous complaint since the September 2005 inspection. There were four elements to the complaint of which only one was partly substantiated. Two inspectors carried out an unannounced inspection on the 25th October 2005 and findings from the complaint investigation are outlined as follows. The complainant’s first concern was that there was not enough staff on duty was not upheld. Rotas showed that staffing levels allow for 3 staff allocated during the day shifts and 2 on at night. This is in meeting with the assessed needs of the current residents. There was no evidence to suggest that service users were woken early or got out of bed at a time when they did not wish to. Only two residents were awake and dressed at 6.35am and confirmed that it was their choice to get up early in
The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 16 the mornings. The third part of the complaint indicated that residents’ call buzzers were not working. Records evidenced that the home was awaiting the installation of a new call bell system and in the interim; staff were carrying out checks on each resident’s call bell at half hourly intervals. There was no evidence to suggest that staff were unresponsive to residents’ requests for help. The complainants concern was therefore partially upheld but as mentioned earlier, the new call bell system had been installed by the time of this inspection. Finally, the complainant’s concern that untrained staff were being left in charge of the home was not upheld. The senior staff on duty at the time had an NVQ level 2 qualification and been working in the home for 21 years. In addition, rotas checked showed that regular trained staff were allocated as shift leaders on night duty. Files were checked at the home’s previous inspection and showed that staff have undergone relevant training to the home’s operation and in meeting the service users needs. I.e. moving and handling; food hygiene; first aid; fire; NVQ Level 2 and 3 for some staff; elder care and dementia training. A schedule for planned training was also in place for staff individuals. Three other requirements were identified The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The Shaw is maintained, decorated and furnished to high standards enabling residents to live in clean and comfortable surroundings. The home’s health and safety arrangements protect residents and staff from avoidable harm although appropriate fire door closure systems must be installed to bedroom doors where necessary. EVIDENCE: As required at the last inspection, a fire safety inspection has been carried out by the London fire and emergency planning authority. Records showed that the registered provider had addressed most of the requirements set including the completion of a fire risk assessment for the premises. During the complaint visit, various bedroom doors were wedged open with wooden blocks or held ajar by the resident’s stool or chair. A requirement was set for this to be addressed as it contravenes fire regulations and could compromise the residents and staff safety in the event of a fire. During this inspection, doors were not propped open and risk assessments had been written up for two residents who choose to keep their doors open at night. Appropriate door closure systems (i.e. magnetic door release devices) still need to be installed however that connect directly to the fire alarm system.
The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 18 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): 28, 29 and 30 There is a competent and well-trained staff team who clearly understand the needs of the elderly people living there. The home’s recruitment practices are robust and protect the residents against the employment of unsuitable staff. Standard 27 was assessed as met at the September 2005 inspection. EVIDENCE: Eight staff have trained and achieved the qualification of NVQ level 2 in care. This easily meets the required target set by the National Minimum Standards for 50 of the staff team to be trained to this level. Three staff are currently studying for their NVQ level 3 qualification. An NVQ assessor, employed by the owning organisation, was visiting two care staff during the inspection. Inspection of two recently employed staff personnel files contained all the required documentation including a Criminal Records Bureau / ‘POVA first’ check as well as evidence of induction training. A training programme is available that provides a variety of courses for staff to update their skills and knowledge along with recognition of mandatory training that they must attend. Training undertaken since the last inspection has included first aid, adult protection and moving and handling. During the complaint visit, a requirement was set that the full names of staff and their designation must be recorded on the home’s duty rota. This had been addressed. The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 19 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 and 35 Although the Shaw did not have a registered manager at the time of this inspection, the home was being appropriately managed. The home’s financial procedures are thorough and protect the interests of the residents. Standards 33 and 38 were assessed as met at the September 2005 inspection. EVIDENCE: The Commission was advised that the former home manager had recently left and there were temporary management arrangements in place until the vacancy is filled. Two senior care staff were therefore taking on managerial responsibility as an interim measure. Where a service user is unable to independently control their own financial affairs the home would seek either family members or independent person’s (e.g. solicitors) to take on this responsibility. Service users have a lockable facility in their own bedroom in which to safely hold their own valuables if they wish. Full records and receipts are kept for any transactions that are made for service users who have personal finances kept by the home. These accounts are checked randomly as a part of the monthly visits that occur as required by Regulation 26.
The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 20 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 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X X The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes- 2 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 OP4 Regulation 12 Requirement Timescale for action 28/02/06 2. OP9 13(2) 3. OP16 17(2) Sch.4 (11) The registered person must apply to the Commission for a variation to amend the home’s conditions of registration. The home’s registration category must accurately reflect the needs of all the service users currently accommodated in the home (i.e. those specified service users who have a diagnosis of Dementia). (Timescale of 30/11/05 not met) The registered provider must 31/03/06 ensure that the home receives regular visits from the supplying pharmacist and in accordance with the Royal Pharmaceutical Guidelines. Records and outcomes of all 31/03/06 complaints need to be made available in the home to ensure that residents, their relatives and staff are made aware of any findings and actions taken. (Timescale of 31/10/05 not met) The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 22 4. OP19 16(2)(j) 23(5) 5. OP19 23(4 a) The home arranges for a visit from the Environmental Health Department to evidence that the premises comply with requirements. The registered provider is also required to submit a copy of the report and any findings to the Commission. (Timescale of 30.6.05 and 30.11.05 not met although it is acknowledged that the home has made efforts to arrange a visit) Residents’ bedroom fire doors must be fitted with an automatic door closure that is linked to the fire alarm system. 31/03/06 31/03/06 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. Refer to Standard OP7 Good Practice Recommendations The manager should ensure that the resident, wherever capable, and/or relative/ representative signs their care plan. The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 The Shaw DS0000025855.V277382.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
