Inspection on 08/05/06 for The Shelley

This inspection was carried out on 8th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Anchorstone Services Limited

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

CARE HOMES FOR OLDER PEOPLE The Shelley 54 Shelley Road Worthing West Sussex BN11 4BX Lead Inspector Mr E McLeod Unannounced Inspection 8th May 2006 09:15 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 Shelley DS0000065564.V290977.R02.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 Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Shelley Address 54 Shelley Road Worthing West Sussex BN11 4BX 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) 01903 859107 The Shelley Ltd Mrs Marlene Yvonne Sanders Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 32 service users to be admitted. No service users under the age of 65 to be admitted. Date of last inspection New service. Brief Description of the Service: The Shelley is registered as a care home for older persons (over the age of 65). It is situated in a residential area on the west side of Worthing, which has local bus and trains services. There are shops within a few hundred yards. The accommodation is provided on ground and first floor levels, and there is a passenger lift. All bedrooms have en-suite facilities, and a number of bedrooms also have kitchen facilities. The service is run by The Shelley Ltd, for whom the responsible individual is Mrs Marlene Sanders. The registered manager is also Mrs Marlene Sanders. The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was arranged to assess if key standards are being met by the home, which is a new service. The inspector was on the premises for five hours and 30 minutes. The inspector interviewed six residents, two care staff, and the registered manager Mrs Sanders. A partial tour of the premises was made. Policies and procedures, including those for the administration of medicines and the home’s complaints procedure were sampled. Care records including pre-admission assessments and individual plans of care were sampled. Staff recruitment and training records were also sampled. Outcomes for residents were assessed overall as excellent. The inspector would like to thank all staff and residents who contributed during the inspection visit. What the service does well: The home is well managed and has a commitment to resident’s choice and providing a high level of care and a good lifestyle for residents. Good arrangements for staff recruitment, training and supervision are in place. The communal and bedroom facilities are spacious and decorated and furnished to a very high standard. Fixtures and fittings are also of a high standard, and the premises are safe and well maintained. Residents have a good quality of life, and a sociable atmosphere in the home is encouraged. Residents are involved in choosing and arranging some of the activities provided. Meals are home cooked, presented well and taken in congenial surroundings. There is a “well person” clinic arranged once per month in the home, which is included on the activities programme, when an outside GP visits to see any resident who wishes advice – the doctor concerned will then link up the person’s own GP and local GPs have welcomed this innovation. The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 6 The health care needs of residents are being met. Good arrangements for the administration of medicines are in place. Good arrangements for pre admission assessments and trial stays are in place. Good information is provided for residents on the service they will receive in the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Good arrangements for pre admission assessments and trial stays are in place. Good information is provided for residents on the service to be provided. The outcomes for residents were found to be good. EVIDENCE: Copies of the statement of purpose and service user guide, which provide good information for residents and prospective residents on the service provided were sampled. Three sets of preadmission records were sampled, which included preadmission assessments, visits and trial stays. Mrs Sanders, registered manager, advised that the fees are between £385 and £520 per week. The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Care plans should be signed by the registered manager and the resident, and should include more on resident’s interests and established routines, and the action that will be taken to meet the care needs. The health care needs of residents are being met. Good arrangements for the administration of medicines are in place. The outcomes for residents were found to be good. EVIDENCE: Four sets of plans of individual care were sampled. Good information on residents’ needs are being provided, but sometimes the resident’s interests and established routines are not being recorded. Action that will be taken to meet the care needs of residents need to provide more specific guidance for staff. Some care plans seen had not been signed. Records indicate that monthly reviews of the care plans are taking place. Mrs Sanders said it was the intention to make the information in the The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 10 care plans more available by having a copy of the care plan in the resident’s bedroom where much of the personal care will be taking place. Health care appointments were being recorded in the care notes sampled, and residents interviewed said they arranged their own appointments with the local GP surgery and attended the surgery. There is a “well person” clinic arranged once per month in the home, which is included on the activities programme, when an outside GP visits to see any resident who wishes advice – the doctor concerned will then link up the person’s own GP said Mrs Sanders, who added that the local GPs have welcomed this innovation. Mrs Sanders said that staff attend hospital appointments with residents. A number of residents hold and take their own medication, and have lockable facilities in their bedrooms for this. Deliveries and returns for residents who self-medicate are recorded. Self medication risk assessments seen, and residents sign a form to formalise their consent to taking responsibility for their own medicines. Suitable lockable storage and arrangements for the administration of medicines are in place. The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 11 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): Residents have a good quality of life, and a sociable atmosphere in the home is encouraged. Residents are involved in choosing and arranging some of the activities provided. Meals are home cooked, presented well and taken in congenial surroundings. Outcomes for residents were found to be excellent. EVIDENCE: One resident said that with her poor sight the electronic reader in the library was useful. Two residents interviewed said they put on occasional programmes of music for other residents with the technical assistance of staff, one of whom said he takes part in the local recorded music society and attends concerts. The activities programme for the home indicates that there is something on every day, including scrabble, manicures, outings, tai chi, musical concerts and entertainers. Outings for shopping and coffee are also arranged. The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 12 Three residents were in the main lounge at 10.30 am, one playing piano, one reading a book, and one was reading a newspaper. Two residents seen in lounge/ diner around 10.45 am, having a chat. One had been reading a newspaper. Three of the residents continue to drive their own cars, and on the day of the inspection other residents were going out for walks or shopping. Residents interviewed gave examples of interests they continued to follow, and events in the community they continue to attend. Not many residents keep to their rooms, except for naps, so there is a sociable atmosphere in the home are residents said they enjoy each other’s company. A resident’s meeting has been arranged for the week commencing 15th May 2006. Residents have choices at meal times, and menus are provided. A lunch was observed in the dining room, which was being taken at a leisurely pace with wine and sherry also being provided. The lunch was nutritious and home cooked, and was attractively presented. Residents said they enjoyed the lunch. A cooked breakfast was also being provided in the dining room when the inspector arrived. Menus indicate that three cooked meals are provided each day. Coffee and tea facilities are provided in the main sitting room, and some of the bedrooms also have coffee and tea facilities. The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 13 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): Arrangements for complaints to be recorded and responded to are in place. Appropriate training and procedures are provided to ensure the protection of vulnerable adults in the home. The outcomes for residents were found to be good. EVIDENCE: A complaints procedure is in place, and a comments book for residents and visitors is provided. Residents interviewed said they found manager Mrs Sanders approachable, and would happily take any concerns or complaints they had to her. Adult protection training is provided for staff, and staff receive a copy of the “Abuse Matters” booklet which includes a flow chart of action to be taken in the event of abuse being suspected or identified. Adult protection procedures in the home are provided. The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 14 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): The communal and bedroom facilities are spacious and decorated and furnished to a very high standard. Fixtures and fittings are also of a high standard, and the premises are safe and well maintained. The outcomes for residents were assessed as excellent. EVIDENCE: Furnishings and decoration in communal areas and individual bedrooms are all of a high standard. Residents have personalised their bedrooms by bringing their own furnishings or belongings. Bedrooms are spacious, and some have fridges and kitchenette facilities. Some ground floor bedrooms also open onto a personal patio area with good quality garden table and chairs. Good en suite facilities are provided The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 15 in bedrooms, and the en-suite areas are arranged to meet the needs and wishes of the individual resident. The main sitting room has good quality furnishings, carpets and decorations, and facilities include a piano, a television, a CD player and a kitchenette area which includes a coffee machine. Although large, the room is attractively laid out. The dining room is also attractively laid out, and has an additional sitting area. The laundry room is suitably equipped, well arranged, clean and tidy. The kitchen is also well ordered, clean and tidy, and suitably equipped. All areas of the home visited were clean and hygienic, and with good quality fixtures and fittings. Additional facilities include a library with an electronic reader for the poorsighted, and a fully equipped hairdressing room. The gardens and grounds are attractively laid out, well presented and are well maintained. It was noted that the flooring of the service stairs, while new, was not sticking properly in some places. Mrs Sanders said that this was being attended to. No other safety concerns were highlighted. The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 16 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): Good arrangements for staff recruitment, training and supervision are in place. Outcomes for residents were assessed as good. EVIDENCE: Care staff numbers on the day of the inspection were adequate to ensure residents’ needs were being met. Additional to care staff, a cook and cleaning staff. Arrangements are in place for staff training, and although the service has been operating for only three months or so a programme of staff supervision has been commenced. One member of staff said “I have been a carer for 12 years, but induction helped focus my thoughts, because “here we are much more client orientated. Residents have more say here – when they have baths, when they have meals, things are very flexible. Less regimented”. A new member of staff, whose CRB check had not yet been received back, said “I am supervised with everything I am doing. Never lifted anyone here, and The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 17 won’t be hoisting residents until I’ve trained in that. I don’t do medication”. She added that she helps wash residents with supervision. Staff recruitment records and training certificates were sampled for three staff, and were found to be in good order. One member of staff has been working for 3 weeks without a CRB check, but advised the inspector she has not been working unsupervised with residents, and does not take on tasks she has not yet been trained to do. Records for staff supervision meetings were sampled. new staff were also sampled. Induction records for The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 18 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): The home is well managed and geared towards providing a quality service for residents. Good systems for review of the service and health and safety are in place. The outcomes for residents were assessed as excellent. EVIDENCE: It was clear from discussion with staff and residents that the home has a commitment to resident’s choice and providing a high level of care and a good lifestyle for residents. That this has been achieved within the short space of time the service has been operating indicates that registered individual and manager Mrs Sanders has brought to the service a clear idea of the type of service she wishes to provide, and the kind of qualities she is looking for in her staff team. The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 19 Residents and staff said the home has a good atmosphere, and one resident said “I haven’t met anyone who isn’t happy here”. Procedures are in place for reviewing the quality of the service, and Mrs Sanders said she receives regular feedback from residents on the service provided. Comment cards filled out by residents who have been for short stay included comments such as “I enjoyed my stay very much, it gave me new life”, and “a most happy stay in your delightful ‘four star hotel’.” The home does not undertake to manage to financial affairs of residents. Some of the policies and procedures sampled for the home (such as medication procedures) had not been dated or signed by the registered manager. A number of health and safety records were sampled. Hot water temperature check records were seen, and in areas accessed by residents were within acceptable limits. Accident records were sampled. Certificates for recent fire alarm tests, control of waste arrangements, electrical installation and a service of the passenger lift. There are no outstanding requirements from the inspection carried out by the fire service. The Shelley DS0000065564.V290977.R02.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 3 3 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 X 4 4 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 X X 3 The Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? no 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. Standard Regulation Requirement Timescale for action 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 Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Shelley DS0000065564.V290977.R02.S.doc Version 5.1 Page 23 - 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!