Inspection on 29/10/07 for The Shaw

This inspection was carried out on 29th October 2007.

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.

Other inspections for this house

The Shaw 25/07/06

The Shaw 13/01/06

The Shaw 12/09/05

The Shaw 21/03/05

The Shaw 12/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE The Shaw 169 Tollers Lane Old Coulsdon Surrey CR5 1BJ Lead Inspector Peter Stanley Key Unannounced Inspection 29th and 30th October 2007 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.V350291.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. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 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 F/P 01737 556 386 marian.drake@ccht.org.uk Central & Cecil Housing Trust Marian Eileen Drake Care Home 25 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (12) of places The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2006 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. An organisation called Central and Cecil Housing Trust owns the home, this being a registered charitable organisation. The home provides residential care for older people. Following an application in 2006, the home has been re-registered (on 13 September 2006) with the Commission for Social Care Inspection so as to provide care for up to 13 older persons with dementia, and 12 older persons. The home has, therefore, been modified so as to provide specialist care for up to older persons with dementia within a separate unit on the second floor. The home has a total of 25 single rooms, some of which have en suite facilities. The home’s accommodation is set out over two 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. Fees charged range from £470.00 to £550.00 per week. Additional charges may be payable for some extras such as hairdressing, newspapers and chiropody but would be discussed prior to admission. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection of the home was completed over two days, 29 and 30 October 2007. The inspection involved discussion with the home’s registered manager, Mrs Marion Drake. The inspector examined a wide range of documentation which included staff and service user records, care plans, incident and accidents records, health and safety documentation, staff rotas, training records, accident and incident logs, and policies and procedures. Information was also available from the Annual Quality Assurance Audit, which is completed by the home’s providers. The inspector case-tracked the records of six recently admitted service users, speaking with two of these. The inspector also met with a number of other residents, with one relative of a recently admitted resident, and with staff members on duty. As a result of this inspection, the inspector has made 8 requirements and 6 recommendations. The feedback from this inspection evidences generally widespread satisfaction, by residents, with the quality of care and support being provided. The home has had a consistently good record in providing care for older people, and is regarded as providing a very pleasant, homely and caring environment. Residents expressed many appreciative comments regarding the home and the caring attitudes of staff, and the inspector observed residents being treated with respect, kindness and understanding. There was evidence of choice and flexibility in daily routines, with extensive and varied daily activities and flexibility of routines. Generally, residents are being consulted and involved in decision-making, whether in planning menus, arranging outings or regarding decisions that affect their individual and collective well-being. However, residents’ meetings must be held on a two monthly rather than a three monthly basis, and should not, as at present, be combined with those for relatives. The inspector identified the need for some key policies and procedures to be reviewed. This included those for the privacy, dignity and rights of residents, vulnerable adults protection and whistle blowing, none of which have been reviewed since 1999. Review of these and other key policies should be prioritised and then undertaken on an annual basis so as to ensure that they are up to date and consistent with current guidelines, legislation, and good practice. The new dementia unit presented as a pleasant and homely environment, with a lot of thought and planning having gone into the design and layout. Staff The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 6 presented as caring and supportive, with residents presenting as generally settled and well supported. Most staff have completed dementia training. However, there was one incident that was witnessed by the inspector which was concerning, and which reflected on issues of staff awareness and training. The inspector has, therefore, made a requirement and a recommendation relating to dementia care. These relate to the need for training in challenging behaviour to assist staff to adopt appropriate strategies. The inspector also recommends that the staffing of the unit should include a small core group of senior and experienced care staff, with specialised skills and knowledge in dementia, who work predominantly or solely on the unit. This would assist in developing a detailed understanding of individual needs and behaviours, and in providing consistency of care. The inspector also identified the need for an additional waking staff member for the overnight shift. Given the increased level of vulnerability, and the associated risk of wandering, presented by residents with dementia, on the dementia unit, the inspector felt that the existing staffing level of 2 waking night care staff for the home is no longer sufficient, and needs to be increased from two to three. The inspector would like to extend his thanks to the registered manager, staff and residents for their assistance in helping to facilitate this inspection. What the service does well: Prospective residents are being provided with the up-to-date information required with which to make an informed choice regarding the suitability of the home. Prospective residents, their friends and relatives are able to visit to assess the suitability of the home. The home is able to demonstrate that it is obtaining full information regarding the health and support needs of prospective residents prior to their admission. Residents are being provided with a wide and varied range of opportunities for leisure and social activities. These are in accord with their social, cultural and religious interests and needs. Residents are being encouraged to maintain contact with their family and friends, with visitors being made welcome at the home. Residents have some opportunities for accessing links with the local community. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 7 Residents receive a wholesome, nutritious and appealing diet, with choice and flexibility being offered, in pleasant surroundings. Residents and their relatives can be assured that the home has an appropriate complaints policy and procedure in place, and that their complaints will be listened to, taken seriously and acted upon. Residents are living in a safe, well-maintained environment, with access to safe, sufficient and comfortable facilities. Residents’ rooms are safe, comfortable and pleasantly decorated, reflecting residents’ personal identities, and being suited to their individual needs. The home presents as being clean and pleasant, and to be maintaining good standards of hygiene. What has improved since the last inspection? What they could do better: Generally, residents are able to exercise choice and control in their day-to-day activities and routines. Residents’ meetings must not, however, be held jointly with those for relatives, and must be held on a 2 monthly rather than a 3 monthly basis. Whilst the home is providing a safe environment for residents, with appropriate training in abuse and adult protection taking place, the home’s policies and procedures are out of date, and need to be reviewed and updated. Generally, the home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s residents. However, for the welfare and safety of residents at night to be assured, duty cover needs to be increased from 2 to 3 waking night staff. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 8 Generally, residents can be assured that staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of residents. However, all staff who work on the dementia unit need to complete training in challenging behaviour. Generally, residents are being safeguarded by satisfactory staff recruitment policy and procedures. However, the providers are reminded that all the necessary documents pertaining to staff recruitment must be held in the home and available for inspection. 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. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 9 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.V350291.R01.S.doc Version 5.2 Page 10 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): 1 to 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are being provided with the up-to-date information required with which to make an informed choice regarding the suitability of the home. Prospective residents, their friends and relatives are able to visit to assess the suitability of the home. The home is able to demonstrate that it is obtaining full information regarding the health and support needs of prospective residents prior to their admission. Generally, residents can be assured that their needs will be met. However, the assessed needs of one resident would seem to indicate that her needs are not being appropriately met by her placement in the dementia unit. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 11 EVIDENCE: The home was re-registered on 13 September 2006 so as to provide care for up to 13 older persons with dementia, and for up to 12 older persons, not falling within any other category. Some of the home’s residents had, during the course of their residence at the home, developed a diagnosis of dementia. This led the home to restructure its services and open a dementia unit. The home has a Statement of Purpose and Service User Guide in place, which provides detailed information about the home and its’ aims and objectives. These documents need to be updated so as to reflect the current services provided. The Statement of Purpose was last reviewed in June 2006 and requires updating, whilst the Service User Guide was reviewed in October 2007, a draft version of which currently exists. A new handbook is in the process of being compiled for future use. An assurance has been given that all residents and relatives are being issued with an up-to-date copy of the Service User Guide. Each resident is issued with a statement of terms and conditions (Licence Agreement). This presents as a rather legalistic and technical document, and would benefit from being reviewed and produced in a more user-friendly format. Service user contracts are also agreed with social services, involving the statutory agency, the home and the service user. Following referral, the potential resident is invited to visit the home to look around and get the feel of the home, and to stay for lunch or tea. 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. The Shaw uses its own pre-admission assessment tool with an assessment being completed by the manager or by one of the senior staff. Areas covered in the assessment include details of the person’s medical history and personal care needs, their hobbies, social and cultural needs, their dietary preferences, likes and dislikes, and wishes regarding the eventuality of their illness or death. Mobility needs are assessed with risk plans completed for the prevention of falls. For persons with a diagnosis of dementia, full information is obtained regarding their mental health and associated behaviours. Such assessments help to ensure that the home only admits residents whose mental health and personal care needs can be met appropriately. A review meeting is held following the first six to eight weeks of the resident’s admission. This assesses the progress of the placement, and the views and wishes of the resident regarding the placement, and includes the resident, his/her relative(s), the key worker and the care manager. The home completes subsequent reviews at 6 and 12 months following admission. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 12 The home has had 10 new admissions since the last inspection on 25 July 2006, four of whom have subsequently died due to terminal illness. The inspector completed file checks for the new admissions and found evidence of assessments, risk assessments, care plans, care management and CPA assessments and care reviews. The inspector spoke with two of the residents who have been recently admitted, and to the relative of another recently admitted resident. The views expressed indicated that their experience of the home has been a positive one and that all three residents have settled well since moving to the home. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 13 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 to 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care plans, detailing their health, personal and social care needs are being drawn up with the involvement of residents and their relatives. These are being reviewed on a regular monthly basis. The home is ensuring that residents’ health care needs are being fully met. Generally, residents are being protected by the home’s medication policies, procedures and training. However, some care staff, who are presently administering medication, must not do so until they have completed their accredited medication training. Generally, residents are being treated with respect and their right to privacy is being maintained. However, the home’s policy and procedures in this area must be reviewed and updated. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 14 EVIDENCE: The inspector examined the care records for six residents who have been admitted within the last year. These included a detailed care plan that was initially based on the pre-admission assessment, and which addresses the health, personal and social care needs of each resident. The plans are based on information from assessments and risk assessments, and are initially drawn up in consultation with the individual and his/her relatives/advocates. Care plans include details as to how staff should support them, and as to where the person is independent in meeting their own needs. Daily care records indicate that individuals are being consulted about the care that they receive. Records show that residents’ care plans are being reviewed on a regular monthly basis so that any changing needs are identified, and appropriate changes made. Care plans are being signed by the resident, or by their close relative, to ensure that the details are a true record. The health care needs of residents are evidenced from records as being generally well met. Residents’ health and physical condition are being regularly monitored, with professional medical help being sought as and when the need arises. Weight monitoring charts are also maintained. The home is covered by a local GP practice, with service user records detailing visits from the GP, district nurse and other health and care professionals. Residents attend for hospital visits and other appointments as required, including optician and dental appointments. A chiropodist visits the home every 8-9 weeks. The home has contact with the local community mental health team, with contact taking place, following referral from the GP, with the psycho-geriatrician, and community psychiatric nurses (CPNs), as and when this is required. Risk assessments, that seek to protect resident’s health and safety, are being recorded and reviewed three monthly in respect of residents’ mobility, skin care and nutrition (including weight monitoring) and other relevant areas. Individual mobility risk plans could be written in a more understandable format for which a recommendation has previously been made. Risk levels are identified through a score type summary, it not always being clear what support residents require with any mobility needs, or in preventing the risk of a fall. More details are needed so that staff have full information on supporting a resident. The home has a medication policy and procedures in place. The home uses the Monitored Discharge system, supplied by “Boots” chemist, for administering medication. All medications are kept in a locked medication cabinet, with a new medication fridge having recently been purchased . While any resident who wishes to take full responsibility for their own medication is, subject to a risk assessment, able to do so, none is doing so at the present time. Advice is available from a pharmacist concerning the home’s policy on the safe handling The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 15 and administration of medicines. The home receives periodic visits from the pharmacist to complete an audit of the home’s procedures and medication practices. The home has generally good procedures in place for the recording, storage and disposal of medication. The inspector examined medication records and spoke with a senior care worker with responsibility for administering medication. Records that were checked were found to be in good order. As good practice, one of the senior staff carries out an in house medication audit each week to ensure that safe practice is maximised. The inspector discussed the need for a safeguard to be built into present procedures by having two staff members, one administering and one observing. This is in line with good practice, and is designed to ensure that medication is being administered safely and that error does not occur. The observer should sign to verify that the correct medication and dosage has been administered, this being recorded on a separate sheet. This has been included as a recommendation. 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 residents’ individual prescriptions. The home uses a monitored dosage system, In response to the last inspection, the pharmacist visited in February 2006 to complete an audit of the procedures and medication practices. Some areas were identified for attention and the home had addressed the necessary recommendations. The home has an ongoing programme of medication training. The home has recently inducted, monitored and tested some care staff in the administration of medication. The inspector was advised that all staff have completed their inhouse medication training, but that some staff have not yet completed their accredited medication training. The inspector confirmed that staff must not administer any medication until they have completed their accredited medication training. The manager advised that this training has been prioritised for those staff who have not yet completed this, and provided an assurance that they would not any longer administer medication until this training has been completed. The home has a policy and procedures in place for maintaining the privacy, dignity and rights of residents. However, the home’s AQAA indicates that this policy has not been reviewed since January 1999. Given the length of time since it was last reviewed, and the extension of the home’s registration to care for older persons with dementia, it is especially necessary that all aspects of the home’s policy are reviewed and updated. A requirement applies. Respect for residents’ privacy and dignity was noted, with residents’ wish to spend time in their own rooms being observed, and staff being seen to treat The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 16 residents with kindness and respect. Staff were seen to knock on residents’ doors before entering. Individuals are able to receive visitors, and to receive assistance from staff with their personal care, in the privacy of their own bedroom, when required, or in other relatively private areas within the home . The inspector noted that a number of rooms did not include a lockable drawer or facility for storing personal possessions and valuables. The manager advised that 25 new bedroom bedside cabinets, which include a lockable drawer, have been ordered. Staff were observed to interact with residents in a caring and respectful manner, and there was evidence of generally good and trusting relationships between staff and residents. The inspector spoke with a large number of residents during the inspection. Views expressed indicated that staff are generally respectful of residents’ privacy and dignity, and are mindful of individuals’ needs and rights. Feedback also indicated that relatives and friends are made welcome at the home and that they are able to see them in the privacy of their own rooms, or take them out for lunch, tea or outings. For those individuals who have no visiting relatives, staff try to take out occasionally to a local café or shops. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 17 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): 11 to 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are being provided with a wide and varied range of opportunities for leisure and social activities. These are in accord with their social, cultural and religious interests and needs. Residents are being encouraged to maintain contact with their family and friends, with visitors being made welcome at the home. Residents have some opportunities for accessing links with the local community. Generally, residents are able to exercise choice and control in their day-to-day activities and routines. Residents’ meetings must not, however, be held jointly with those for relatives, and must be held on a 2 monthly rather than a 3 monthly basis. Residents receive a wholesome, nutritious and appealing diet, with choice and flexibility being offered, in pleasant surroundings. EVIDENCE: The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 18 The home is evidenced to be providing a good and varied range of recreational activities for the residents, offering stimulation and interest for individuals. There is a well-structured activities programme, which is organised by the home’s administrator and activity coordinator. The programme is publicised on the home’s two notice boards, one in the main hall on the ground floor, the other being situated in the dementia unit. These display up to date information about activities and social events or functions. Residents from both parts of the home attend events and entertainment in the main ground floor lounge. On the first day of inspection a musical entertainment session was being held, comprising of a visiting pianist and flutist, playing melodic tunes which included some lively Irish jigs. Judging from the good attendance and the enthusiastic response, this proved to be very popular with the residents. Activities also include quizzes, sing-a-long sessions, discussion groups, bingo, and organised community outings. Reminiscence sessions are also held for individuals who have memory difficulties and there is a loop system in the home to assist people with hearing impairment. There are activities arranged according to residents’ specific needs, which includes art and drawing sessions. A mobile library visits the home to provide “talking books” for those with visual impairment. Occasional outings are arranged to a local garden centre and farm, and other places of interest. There are occasional showings of films on the home’s 50” widescreen television in the main lounge, the home having been licensed to give public showings of films on dvd and video. The manager and staff maintain good communication links with relatives, friends and visitors. There is involvement by a Friends Group, of relatives and friends, with fortnightly visits taking place. Visitors from a local church group visit monthly to socialise with residents. Individuals have the opportunity to participate in a religious service if they so wish. Residents of other faiths are supported to follow their chosen religion or beliefs. A visiting relative mentioned that her mother enjoyed a game of cards, but did not have anyone to play with. This type of activity can assist in maintaining good emotional and mental functioning. The inspector would like to see the opportunity being provided for cards and board games for those residents who would enjoy this type of activity. A recommendation applies. The views expressed by a number of residents indicate that individuals feel that they are consulted, and are able to exercise choice in their daily routines and activities. Where there are stated preferences of food or activity, the home endeavours to meet these. Some residents choose to have breakfast, lunch or tea in their rooms. Residents are able to spend time in their rooms as they please, or to arrange to go out with friends, relatives or with a staff member. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 19 The home is presently holding joint residents and relatives meetings on a 3 monthly basis. Given the need for proper consultation and the respect for residents’ rights, residents must have their own meetings where they can, in confidence, freely discuss issues and express their own views, wishes and preferences regarding their day-to-day lives. These meetings must not, therefore, include relatives, friends, representatives, or any other stakeholders, and must be held on a regular 2 monthly basis. A requirement applies. The inspector understands that the home has previously had separate 3 monthly meetings to consult with relatives and obtain their views. The manager advised that the providing organisation is looking to arrange a separate relatives forum to include all their homes. The daily menu is written on both the home’s notice board and on the notice board in the dementia unit. Alternative options are offered. Residents are provided with three meals a day including a cooked lunch as well as regular snacks and drinks. Breakfast can be served in bedrooms if individuals so wish and other meals may be taken outside of mealtimes according to choice. The inspector observed residents eating their lunchtime meal in the main dining room, the food presenting as bring good and nutritious, with fresh vegetables. Staff presented as being attentive to individual residents and as previously observed, there was evidence of a relaxed and unhurried atmosphere. The home employs cooks from a contracted catering firm and menus are planned in consultation with the residents. Menus are discussed at residents’ meetings, with any new ideas or food preferences being aired. Occasional themed-type meals are arranged. Since being divided into two resident groups, an additional small dining room has been provided for residents on the dementia unit. This provides a very pleasant environment, with nicely set out tables and chairs with new crockery, cutlery and brightly coloured placemats. Comments made by residents, during the inspection, indicated that the food, which is served, is very well regarded, and is accommodating of individual tastes and preferences. The dietary needs of residents are being recorded in their care plans, with residents’ weights being monitored on a monthly basis. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 20 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 and 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 can be assured that the home has an appropriate complaints policy and procedure in place, and that their complaints will be listened to, taken seriously and acted upon. Whilst the home is providing a safe environment for residents, with appropriate training in abuse and adult protection taking place, the home’s policies and procedures are out of date, and need to be reviewed and updated. EVIDENCE: The home has a complaints policy and procedure. This was reviewed in 2006, and is available for residents, relatives and other visitors to access. Copies of the procedure are located in the main entrance hall as well as a suggestions box. Details of complaints are being logged in a complaints book, just one complaint having been recorded since the last inspection. The inspector looked at the complaint record and noted that this had been addressed in an appropriate way. The inspector also noted a number of cards and comments The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 21 from relatives and friends expressing their appreciation of the home, and the care being provided by staff. Staff are encouraged to identify any concerns which arise, and to take appropriate actions to address these. These are not currently being recorded other than in a resident’s daily notes. The inspector recommends that brief details of any concerns should be logged in a concerns log. This would assist the manager to readily identify any recurring problems or concerns that may be affecting residents or particular individuals, and to identify any appropriate actions that may be required to effectively address these. While policies and procedures relating to residents’ protection are in place, the policies for the protection of vulnerable adults, and whistle blowing have not (as recorded in the home’s AQAA) been reviewed and updated since 1999. This was confirmed as correct with the registered manager. Given the long period of time that has elapsed, and the need for consistency with current statutory adult protection practice and procedures, both policies and sets of procedures must be updated as a priority, and copies distributed to all staff who work in the home. A requirement applies. Staff receive training on abuse awareness as part of their induction, and attend statutory training on the protection of vulnerable adults. The manager advised that 8 out of 20 staff have yet to complete this training, and that they have all been placed on Croydon’s waiting list. During the course of the inspection, staff were seen to be respectful and caring in their interaction with residents. Views expressed by residents indicated that they have good relationships with staff, and that they feel safe, settled and secure in their environment. No adult protection concerns have been reported since the last inspection. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 22 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 to 21, 23 to 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a safe, well-maintained environment, with access to safe, sufficient and comfortable facilities. Residents’ rooms are safe, comfortable and pleasantly decorated, reflecting residents’ personal identities, and being suited to their individual needs. The home presents as being clean and pleasant, and to be maintaining good standards of hygiene. EVIDENCE: The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 23 The accommodation provided for the home’s residents presents as being safe, warm and comfortable throughout. Generally, the home is in a good state of interior decoration and the premises have been well maintained and comply with both fire and health and safety requirements. Since the last inspection the home has been restructured so as to include a self-contained, 13 bed dementia unit on the second floor. This includes a separate dining room and kitchen area, and a small, comfortable lounge, both of which are pleasantly furnished and decorated. The unit has been carefully planned and deigned so as to create a homely atmosphere. An illustration of this is the installation of an attractive fire place and hearth in the lounge. Whilst not having any utility value, this provides an attractive focal point, transforming the lounge into a much more homely environment. There is a white notice board in the reception area where details of the day’s menu and activities are displayed. The home is pleasantly decorated, furnished to high standards, and is fully accessible to all its residents via a passenger lift. There are many “homely” touches such as plants, photographs and flower arrangements. Adaptations have been provided throughout to aid those with reduced mobility. Radiators have had protective safety guards fitted. A loop system has been installed for the benefit of those residents who have hearing impairments. A documented record of maintenance is kept and there is a “handyman” employed for the home to carry out essential repairs. Home improvements include the provision of new armchairs in both lounges, new carpets to the rear staircase and installation of magnetic fire door closures. New flooring has been fitted in the corridors and lounges, corridors and in five bedrooms (Rooms 13, 14, 15, 18 and 19). New lampshades and bedding have been purchased, together with a standing hoist. A new dishwasher, hot water urn and various crockery items have been purchased, bio-filters (clean air system), laundry and cleaning trolleys. The inspector completed a tour of the premises and found the home to be pleasant and clean throughout. Residents who spoke with the inspector presented as being happy and settled in their surroundings, and satisfied with the facilities being provided. The communal areas provide a pleasant, homely environment, being well lit and at a comfortably warm temperature. There are two lounges, one of which is in the dementia unit. The lounges provide adequate space for the residents to sit, and were comfortable and pleasantly furnished. The home has recently purchased 25 new Queen Anne armchairs. Both lounges have television, the main lounge having a 50” widescreen television. Television is not, however, allowed to intrude too much during the day, so as to allow residents to converse with each other, read and engage in activities. There are three The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 24 dining rooms, including one in the dementia unit, which provide pleasant areas in which to take meals. At the rear of the home, there is a large well-maintained garden that is accessible to all the residents and which is much enjoyed in the summer months. This is planted with mature shrubs and trees, flowerbeds and there are hanging baskets, window boxes and a water feature. There is a large wellequipped kitchen, and an adequate laundry area. A new sluice machine has been installed. Residents’ bedrooms are pleasantly furnished and laid out, being personalised with photos and mementoes so as to reflect the personal tastes and identities of their occupants. The manager advised that seven bedrooms (Rooms 5, 7, 8, 12, 18, 21, and 23) have been recently redecorated, and that 25 bedside cabinets have been ordered for residents’ rooms. These will include a lockable drawer for the secure safekeeping of personal monies and valuables. Some rooms were observed not to include a lockable drawer or facility at the present time. Rooms are of a sufficient size to meet residents’ minimum space requirements, some rooms being particularly spacious. While not all bedrooms include ensuite washing and toilet facilities, there are a sufficient number of separate bathrooms and toilets to meet the needs of all the home’s residents. These are being maintained in a clean, safe and hygienic state, and include handrails, bath seats and bath hoists. As highlighted at previous inspections, the premises present as being clean, tidy and free from offensive odours. Good hygiene practices are observed and well-managed systems are in place to prevent or control the spread of any infection. There are policies and procedures to manage infection control with cleaning rotas being maintained. Two staff are presently undertaking a distance learning course on infection control. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 25 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 to 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally, the home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s residents. However, for the welfare and safety of residents at night to be assured, duty cover needs to be increased from 2 to 3 waking night staff. Generally, residents are being safeguarded by satisfactory staff recruitment policy and procedures. However, the providers are reminded that all the necessary documents pertaining to staff recruitment must be held in the home and available for inspection. Generally, residents can be assured that staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of residents. However, all staff who work on the dementia unit need to complete training in challenging behaviour. EVIDENCE: The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 26 The home has 7 senior care staff, 13 care staff and 3 ancillary staff (a cook and 2 cleaners). Generally, the home has sufficient numbers of staff with which to meet the needs of service users throughout the day. The inspector examined staff rotas. These indicated that there are 2 care staff and 1 senior care worker on duty in each unit for the morning shift, with 1 care worker, and a senior care worker on each unit for the afternoon shift, with 1 back-up staff member (a ‘floater’) covering both units. However, it was noted that the night shift comprises of just 2 waking night staff (1 senior and 1 care worker), covering both units, from 8pm to 8 am. This was discussed with the manager and a senior care worker, it being acknowledged that staff could be stretched at times when problems arose. Given the increased level of vulnerability, and the associated risk of wandering, presented by residents with dementia, on the dementia unit, the inspector felt that this level of staffing no longer constitutes sufficient cover, and that a third waking night worker is required. A requirement therefore applies. The organisation that owns the home (Central and Cecil Housing Trust) operates comprehensive recruitment policies and procedures that are specific to regulatory checks and probationary terms for staff. The inspector examined a number of staff files for staff that have been recruited since the last inspection. Files included evidence of identity, training and qualifications, references and a job contract. However, health declarations and references were not on file and had to be faxed across from head office. The manager explained that CRB and POVA checks for new staff are now being held centrally at the head office. CRB reference numbers had been noted on staff files, and copies of the certificates were faxed across for inspection. The providers are reminded that all the necessary documents pertaining to staff must be held in the home and be available for inspection. Inspection of files evidences that, generally, staff have the relevant qualifications and skill mix with which to meet residents’ needs. The registered manager, Marion Drake, is working towards completion of the NVQ Level 4 and RMA (Registered Managers Award). The home currently has 20 care staff, of whom three have an NVQ Level 3 social care qualification, and nine, an NVQ Level 2. The inspector was advised that three other care staff have registered to do an NVQ Level 2. All staff are required to complete a ‘Skills for Care’ induction programme and to attend basic mandatory training courses, including adult abuse and dementia. Training needs are identified within one-to-one staff supervision and appraisal sessions, with probationary assessments taking place at 3 and 6 months following appointment. Appraisals take place on a 12 monthly basis, both these and probationary assessment reports being evidenced on staff files. Personal staff development plans are used to identify individual staff training needs. A wall chart in the manager’s office records the training that all staff have completed or are due to complete. A comprehensive training programme The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 27 provides a range of opportunities for staff to update their skills and knowledge along with recognition of mandatory courses that they must attend. Files that were examined include evidence that staff have undergone relevant training. These include courses in moving and handling, medication, adult protection, food hygiene, first aid, and fire safety. Two staff members are currently undertaking a distance-learning course in infection control. With the opening of the dementia unit, in September 2006, the home has been accessing training for staff in dementia care, with 13 out of 20 staff having so far completed this. The manager advised that ,at the present time, care staff divide their shifts more or less equally between the two units. The inspector recommends that a small core of staff, with relevant skills and understanding of dementia, (including perhaps 2 or 3 senior care workers), should be working solely or predominantly on the dementia unit. This would assist in developing specialised knowledge and expertise, and an increased understanding of individuals’ behaviours and needs, and would provide a basis for more clearly focussed support and consistency of care. During his inspection the inspector witnessed a difficult situation on the dementia unit involving two residents who were sat next to each other in the residents’ lounge, one of whom presented as being verbally aggressive. The other resident presented as visibly upset by the interaction that took place, and as a result needed to be comforted, reassured, and moved to another part of the lounge. The inspector feels that staff need to be more aware of those residents who may present challenging or difficult behaviour, and to develop strategies whereby this behaviour can be more effectively pre-empted and managed. The incident was addressed with the manager, with an accompanying recommendation being included in this report. With this in mind, the inspector identified the need for training in challenging behaviour for all care staff who work on the dementia unit, with an emphasis in the training on the behaviours that may be exhibited by people with dementia, and the types of strategies that can assist in managing difficult situations. A requirement applies. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 28 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 to 33, 35 to 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a home that is being managed competently and in their best interests. The management approach is evidenced to be open and enabling, and conducive to creating a positive and inclusive atmosphere in the home. The home is able to demonstrate that it is meeting residents’ needs and is fulfilling the home’s aims and objectives. Through the appropriate supervision, appraisal and support of staff, good practice is being promoted and the welfare and best interests of residents is being protected. Records are generally being well maintained. However, some key policies and procedures require review and updating. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 29 Generally, the health, safety and welfare of residents and staff are being appropriately promoted and protected. EVIDENCE: The registered manager, Marian Drake, has been in post since January 2006. She has had extensive previous experience within residential care management, and is currently studying for the required NVQ level 4 and RMA qualifications. The management approach was evidenced as being open and enabling, and conducive to creating a positive and inclusive atmosphere in the home. Views expressed by residents and one visiting relative were very favourable, with individuals indicating that the home is being run in their best interests. The home has developed quality assurance systems to assist in measuring the success of the home in meeting the aims and objectives set out in the home’s Statement of Purpose. A quarterly audit with which to monitor the quality of the service is completed by the manager, with outcomes and required actions being assessed by the providing organisation. Questionnaires called ‘satisfaction surveys’ are distributed annually to both residents and relatives, to ascertain their views of the home. The manager advised that the findings are published in a report, with a copy being placed on each of the home’s two notice boards. Feedback from the 2006-07 surveys indicates that there is a generally high level of satisfaction with the home among both residents and their relatives. The home is presently holding joint residents and relatives meetings on a 3 monthly basis. These are, however, presently being held 3 monthly rather than 2 monthly, and are including relatives in the discussions. Given the need for proper consultation and the respect for residents’ rights, residents must have ownership of their meetings where they can, in confidence, freely discuss issues and express their own views, wishes and preferences regarding their day-to-day lives. These meetings must not, therefore, include relatives, friends, representatives, or any other stakeholders, and must be held on a regular 2 monthly basis. A requirement applies. The inspector nonetheless appreciates the value of feedback from residents’ relatives and representatives, and understands that the home has previously held separate meetings to consult with relatives and obtain their views. The The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 30 manager advised that the providing organisation is looking to arrange a separate relatives forum to include all their homes. The home has systems in place for safeguarding residents’ monies. Full records and receipts are kept for any transactions that are made for residents 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 home’s administrator has a banking background, and outlined the process that she administers for protecting the monies of those residents who are unable to manage these for themselves. The home does not act as an appointee for any residents, with either a relative or solicitor fulfilling this role where the person is unable to manage their own monies. The home maintains a record of residents’ monies that have been deposited with the home for personal expenditure, with financial record sheets for each resident being maintained. These evidence details of any items of expenditure that have been made on behalf of residents, with authorised signatures and running balances being recorded. The administrator completes monthly checks on residents’ monies to ensure that the balances have been accurately recorded. The home operates a comprehensive supervision programme for staff, with sessions being held approximately once every two months. The inspector was, however, unable to evidence some recent supervision records on staff files, these records presently being stored on computer files. Hard copies of supervision records must, however, be evidenced on staff files for the purpose of both monitoring and inspection; the inspector has decided not to apply a requirement on this occasion. Record keeping was observed to be good, with staff and service user records being generally well maintained. The inspector identified the need for some key policies and procedures to be reviewed. This included those for the privacy, dignity and rights of residents, vulnerable adults protection and whistle blowing, none of which have been reviewed since 1999. Review of these and other key policies should be prioritised and then undertaken on an annual basis so as to ensure that they are up to date and consistent with current guidelines, legislation, and good practice. The inspector was satisfied that the health, safety and welfare of residents and staff are being appropriately protected. The home’s Health and Safety assessment was last reviewed in March 2007, and the Fire Risk assessment, in February 2007, with fire risk action plans having been put in place. This followed an assessment by fire safety consultants. Fire alarm and emergency lighting tests are being completed on a 3 monthly basis, most recently on 21 August 2007. A fire inspection took place on 13 April 2007, and a revised fire evacuation strategy, taking account of the new dementia unit, was The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 31 subsequently implemented. Fire drills are being held on a two monthly basis, including one drill during the night within the last 12 months. All health and safety checks, including the inspection of the home’s portable electrical appliances, gas supply, fire equipment and alarms, emergency lighting and call system, have been completed within the last 12 months. Hot water temperature, fridge/freezer and oven temperature checks are all being completed on a regular basis. The home’s lift is being serviced on a monthly basis, the date of the previous service having taken place on 10 October 2007. The home’s bath hoists were last serviced on 22 February 2007. The inspector identified the need for an electrical installation inspection. This should be renewed once every 3 years and, having last been completed on 23 May 2007, this is overdue and needs to be urgently updated. A requirement applies. The home needs to arrange for an Environmental Health inspection, the previous inspection having last taken place on 2 August 2004. This replaces a previous requirement. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 32 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 2 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 2 3 The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 33 Are there any outstanding requirements from the last inspection? Yes (1) STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(2)(a) &(b) Requirement Assessment of needs. The diagnosis of a resident must be double-checked, and professional advice sought, regarding the appropriateness of her being placed on the dementia unit. Unless there is clear evidence of dementia, and/or disorientation, transfer to the older persons’ unit on the ground floor should, in consultation with the resident and her relatives, be arranged. 2 OP10 12(1)(a)& (b) & 12(4) Privacy and dignity. The home’s policy and procedures for maintaining the privacy, dignity and rights of residents must be reviewed and updated. This should include reference to the needs of older persons with dementia. Copies of the updated policy and procedures must be distributed to all staff that work in the home. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 34 Timescale for action 31/12/07 31/03/08 Staff should sign to indicate that they have read and understood the updated policy and procedures. 3 OP14 12(3)(4)& (5) Choice and control. To provide the opportunity for full and proper consultation with residents, there must be separate residents’ meetings, with these being held on a regular two monthly basis. 4 OP18 13(6) Protection of service users. The policies and procedures for the protection of vulnerable adults, and whistle blowing, must be reviewed and updated so as to be consistent with current statutory guidelines and procedures. Copies of the updated policies and procedures must be distributed to all staff that work in the home. Staff should sign to indicate that they have read and understood these. 5 OP27 18(1)(a) Staffing. Given the increased level of vulnerability presented by residents with dementia, on the dementia unit, a third waking night worker is required for the home. 6 OP30 18(1)(c) Staff training. All care staff who work on the dementia unit must undertake training in challenging behaviour. The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 35 31/12/07 31/03/08 30/11/07 31/03/08 There should be an emphasis in the training on the behaviours that may be exhibited by people with dementia, and the types of strategies that can assist in managing difficult situations. 7 OP38 13(4)(a) & (c) Health and safety. The three-yearly inspection of the home’s electrical installation is overdue and must be completed as a priority. 8 OP38 13(4)(a) & (c) Health and safety. The home must arrange for an Environmental Health inspection, the previous inspection having last taken place on 2 August 2004. (This replaces a previous requirement). 31/03/08 31/12/07 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 OP2 Good Practice Recommendations The home’s statement of terms and conditions (Licence Agreement) would benefit from being reviewed and produced in a clearer and more user-friendly format. Individual mobility risk plans could be written in a more understandable format. More details are needed so that staff have full information on supporting a resident as it was not always clear what support they require with any mobility needs or preventing the risk of a fall. The inspector recommends that two staff members (one administering and one observing) should be involved in DS0000025855.V350291.R01.S.doc Version 5.2 Page 36 2 OP7 3 OP9 The Shaw the dispensation of medication to residents. This is in line with good practice, and is designed to ensure that medication is being administered safely and that error does not occur. Both the staff member who is administering medication, and the staff member who is observing, should sign to verify that the correct medication and dosage has been administered. The observer’s signature should be recorded on a separate medication record sheet. 4 OP12 The inspector would like to see the opportunity being provided for cards and board games for those residents who would enjoy this type of activity. The inspector recommends that brief details of any concerns should be logged in a concerns log. This would assist the manager to readily identify any recurring problems or concerns that may be affecting residents or particular individuals, and to identify any appropriate actions that may be required to effectively address these. The inspector recommends that a small core of staff, with relevant skills and understanding of dementia, (including perhaps 2 or 3 senior care workers), should be working solely or predominantly on the dementia unit. This would assist in developing specialised knowledge and expertise, and an increased understanding of individuals’ behaviours and needs, and would provide a basis for more clearly focussed support and consistency of care. 5 OP16 6 OP28 The Shaw DS0000025855.V350291.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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