Care Home: Shaftesbury Court

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What the care home does well This home provides good outcomes for residents. Prospective residents were able to visit the home and received written information about the facilities provided. Once in the home, most residents settled quickly and said they were pleased they had chosen Shaftesbury Court. A number of residents referred to the home as "a first class hotel" and one other resident said, "This home is an extremely happy place to live in". Residents had an individual plan of care that was known and followed by staff. Staff worked in partnership with other care professionals to ensure that resident`s healthcare needs were met. Meals were carefully prepared and well presented. The cook spent time with residents to ensure that they received food that they had chosen and liked. The home had not received any complaints. Residents were aware of the homes complaints procedure, knew who to speak to if they had any concerns and were able to make suggestions and voice their opinions during resident meetings. There was a warm and welcoming atmosphere in the home. All of the communal areas were clean and comfortable. The layout of the home ensured that residents had adequate personal space and privacy and allowed residents to continue to care for some of their own needs where possible.The home has a stable team of competent and committed staff. Staff spent time talking with residents and took an interest in their health and personal circumstances. Equipment was serviced at regular intervals and fire precautions were good. This home was well managed. The atmosphere in the home was open and supportive, which made residents feel comfortable and safe. What has improved since the last inspection? Although the home had undergone a number of significant changes since the last inspection there was no indication that there had been any interruption to the service. The quality of care provided in the home was very good. The missing tiles in the laundry room had been replaced, new equipment had been purchased and plans were in place to redecorate parts of the home. Action had been taken to improve medication records. Management and staff had worked hard to ensure that they were able to account for all medication that was received and administered in the home. What the care home could do better: Action was taken by staff to prevent cross infection but some lapses were noted in the main kitchen. One bathroom did not have adequate hand washing facilities. There was a monthly entertainment programme and staff arranged bingo sessions twice a week. The activities programme did not meet resident`s expectations and needs. Some residents said there was not enough to do during the day and said they sometimes felt bored. Although the complaints procedure was displayed, some relatives had not seen it and were unsure what they should do if they had concerns about the service. The building was well maintained overall but some issues identified in the previous report had not been addressed. This included a broken window blind and uncovered radiator. Although staff took great care to protect residents from harm some of the routes into the home may present some risks to residents. Staff must reassess the security of the building without compromising resident`s freedom. Induction training for new staff was good but there was some delay in covering some of the topics in the induction workbook. CARE HOMES FOR OLDER PEOPLE Shaftesbury Court Selkirk Drive Erith Kent DA8 3QP Lead Inspector Maria Kinson Key Unannounced Inspection 18th July 2006 08:30 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 Shaftesbury Court DS0000067482.V294031.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. Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shaftesbury Court Address Selkirk Drive Erith Kent DA8 3QP 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) 01322 331 985 01322 333 931 www.sanctuary-care.co.uk Sanctuary Care Ltd Mrs Barbara Sweeting Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The following flats are registered: - 2, 4, 5, 9-15, 17, 20-23, 25-26, 28-35, 37, 39-43 Not applicable. Date of last inspection Brief Description of the Service: Shaftesbury Court is located in Erith within walking distance of local bus routes, but some distance from shops and other amenities. The Sheltered Plus Unit of Shaftesbury Court consists of 31 flat lets or bed-sits on two floors. Some of the suites have kitchen facilities and a balcony or patio area. All of the rooms are single occupancy and have en-suite facilities. Communal space consists of a large dining / sitting room on the ground floor and two other separate lounges. The tenants living in the sheltered flats can also use these facilities. The unit also includes two assisted bathrooms, one shower room, three additional toilets, a laundry, office space, kitchen and staff changing / rest facilities. A passenger lift serves both floors of the home. The Registered Manager is responsible for both the residential and sheltered units. The fees charged by the home range from £439.21 - £471.24 per week. This does not include additional charges such as chiropody, hairdressing, entertainment and newspapers. This information was supplied to the commission on 18.05.06. Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the ownership and registration of this home was transferred from Ashley Homes to Sanctuary Care Limited. This is the first inspection of this home since the new owners took over. This inspection took place on 18th and 20th July 2006 and was unannounced. The findings were informed by comments received from residents, relatives and staff, examination of records, observation of care practices and a tour of the home. The commission obtained written feedback about the service from five General Practitioners, fourteen relatives, eighteen residents and one Care Manager. Since the last inspection the commission had agreed to increase the number of registered beds from 27 to 31. What the service does well: This home provides good outcomes for residents. Prospective residents were able to visit the home and received written information about the facilities provided. Once in the home, most residents settled quickly and said they were pleased they had chosen Shaftesbury Court. A number of residents referred to the home as “a first class hotel” and one other resident said, “This home is an extremely happy place to live in”. Residents had an individual plan of care that was known and followed by staff. Staff worked in partnership with other care professionals to ensure that resident’s healthcare needs were met. Meals were carefully prepared and well presented. The cook spent time with residents to ensure that they received food that they had chosen and liked. The home had not received any complaints. Residents were aware of the homes complaints procedure, knew who to speak to if they had any concerns and were able to make suggestions and voice their opinions during resident meetings. There was a warm and welcoming atmosphere in the home. All of the communal areas were clean and comfortable. The layout of the home ensured that residents had adequate personal space and privacy and allowed residents to continue to care for some of their own needs where possible. Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 6 The home has a stable team of competent and committed staff. Staff spent time talking with residents and took an interest in their health and personal circumstances. Equipment was serviced at regular intervals and fire precautions were good. This home was well managed. The atmosphere in the home was open and supportive, which made residents feel comfortable and safe. What has improved since the last inspection? What they could do better: Action was taken by staff to prevent cross infection but some lapses were noted in the main kitchen. One bathroom did not have adequate hand washing facilities. There was a monthly entertainment programme and staff arranged bingo sessions twice a week. The activities programme did not meet resident’s expectations and needs. Some residents said there was not enough to do during the day and said they sometimes felt bored. Although the complaints procedure was displayed, some relatives had not seen it and were unsure what they should do if they had concerns about the service. The building was well maintained overall but some issues identified in the previous report had not been addressed. This included a broken window blind and uncovered radiator. Although staff took great care to protect residents from harm some of the routes into the home may present some risks to residents. Staff must reassess the security of the building without compromising resident’s freedom. Induction training for new staff was good but there was some delay in covering some of the topics in the induction workbook. Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 7 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. Shaftesbury Court DS0000067482.V294031.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 Shaftesbury Court DS0000067482.V294031.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): 2, 3 and 5. (Standard 6 does not apply to this home). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were admitted into the home once staff had undertaken a period of assessment and had confirmed that they were able to meet their needs. Residents received written information about the service and were given an opportunity to spend time in the home prior to making a decision to move in. EVIDENCE: Since the last inspection the number of registered beds had increased and the home had changed ownership. The Statement of Purpose was updated in April 2006 to reflect the changes that had occurred in the home. A local information booklet was also provided for residents. The arrangements for admitting new residents into the home were good. Staff visited prospective residents in their homes or invited them to spend time in the home so that staff could assess their needs. Where a more in depth assessment was required the resident was asked to spend a day and night in the home. Additional information about the resident’s medical history and social background was obtained from other professionals and relatives. Once Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 10 the assessment was complete the manager wrote to the resident to confirm if the home was suitable for meeting their needs. Staff advised residents to visit the home prior to making a decision about moving in. Most residents confirmed they had done this and said they were shown around the home and had an opportunity to meet staff and other residents. Residents received written information about the home before they moved in and were given a contract once the placement was made permanent. Shaftesbury Court DS0000067482.V294031.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, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff worked in partnership with other professionals to ensure that resident’s health care needs were met. Good systems were in place to ensure that medicines were stored and distributed in a safe manner. Residents were encouraged to manage their own medication where possible. Staff carried out their work in a manner that respected resident’s individuality and privacy. EVIDENCE: Three sets of care records were examined. All of the files seen included a full assessment of need, detailed information about resident’s personal preferences and usual routine, risk assessments and a care plan. Care plans outlined the action that staff should take to meet resident’s needs and were reviewed and updated regularly. One resident had recently had surgery and returned to the home. Staff had received training in order to meet the resident’s needs and the district nursing team were providing support. Records showed that staff had spent time with resident’s discussing whether they wanted to manage their own medication, required a key to the home and if they wanted to be Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 12 checked during the night. Daily records included information about the care provided and significant changes in the resident’s health or wellbeing. Staff completed a risk assessment where it was identified that residents may be at risk of harming themselves or others. Risk assessments were seen for residents that smoked, prepared hot drinks and had frequent falls. Residents said that they always or usually received the care and support they required, that staff listened to what they had to say and were always or usually available when they needed them. Residents and relatives that completed comment cards or spoke to the inspector said that staff were “hard working and always ready to help”, “I know I can always call for help day or night”, “ I am very happy, all my needs are met”, I know that my relative “is really cared for in every sense of the word 24/7”. Residents were satisfied with the arrangements for obtaining medical advice and some residents commented that care staff were very observant, noticing things such as rashes that they did not notice themselves. One resident said that she had chosen to continue to visit her family GP and make her own appointments but added “staff would arrange this for me if necessary”. Written feedback about the service was obtained from five GP’s and one Care Manager. All of the respondents said that staff communicated effectively and were satisfied that residents living in the home received good care. The management of medication was good. Records of medication received into the home, administered to residents and returned to the pharmacy were excellent. Three medication charts were examined; there were no gaps on the records seen and staff had entered a code to explain why medication was not given. Medication was stored securely and staff had recorded the date that they opened medicines with a limited shelf life such as eye drops. Two staff were observed administering medication from a trolley in the lounge. Staff addressed residents personally, medication was administered into clean medicine pots and fresh drinking water was provided. Staff allowed adequate time for residents to take their medication and provided support and assistance where necessary. One staff member signed the administration record prior to the resident accepting and taking their medicines. See recommendation 1. Staff were observed undertaking care procedures such as administering medication, assisting residents to their rooms, serving meals and talking with or reassuring residents. Care, management and kitchen staff were professional in their approach and showed great concern for residents health and wellbeing. Although some residents had a rather negative outlook staff remained cheery and patient and did their best to promote independence and choice. One resident said that staff always asked her if she wanted them to put her washing away but she preferred to do this task for herself. Staff were seen knocking on resident’s door before entering and residents said that staff Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 13 usually knocked or called out before they came into their flat. Staff spent time listening and talking with residents and offered support or assistance where possible. Residents were informed about significant changes or personal issues such as hospital appointments. Staff treated resident’s personal property and home with respect. Clean clothing was neatly folded into laundry baskets and residents were given their own personal mug or cup and saucer at meal times. Staff knew which residents required a small lunch and who would like a second cup of tea but continued to ask and offer residents choices throughout the day. Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home arranged some activities but this did not meet resident’s needs and expectations. Residents were able to maintain contact with their family and develop new friendships in the home. Residents were encouraged and supported to maintain an independent lifestyle and make decisions and choices for themselves. This home provides a varied and appetising diet for residents. EVIDENCE: Residents were extremely positive about the care and attention that they received in the home. However some of the more dependent residents expressed concerns about the provision of activities. Residents told the inspector that there was little variation in activities, bingo twice a week and a monthly social event. Residents said “I need more things to do, it can be very boring”, “I would like light exercises to help my mobility”, care staff are supposed to do activities with us in the morning and afternoon but “haven’t got time to do anything else or other activities, as they are too busy”. Residents said that there were no outings because “staff were not insured” and the carer that used to organise bowls had left. A programme of monthly entertainment was planned for the year ahead and advertised on the notice board. The Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 15 programme included quizzes or musical entertainment that residents said was “very enjoyable”. Records of activities indicated that there had been no activities, other than one bingo session in the two weeks prior to this inspection. The inspector understood the recommendation to provide dedicated activity staff was under consideration. See requirement 1. Feedback from relatives was good. Relatives said they were kept informed about important matters affecting their relatives health and care, were able to visit their relative when they pleased and were satisfied with the overall standard of care provided in the home. Staff were seen promoting resident choice in all aspects of their work. Residents were consulted about how much support they wanted to receive and were encouraged to continue to pursue activities that they had undertaken prior to entering the home. Some residents managed their own finances, visited local shops, laundered some of their own clothing and cleaned their flat. One resident said she liked to read until 02:00am in the morning and added, “there are no restrictions”. Residents meetings were taking place regularly. The home had a four weekly rotating menu. Menus were developed by the cook, in response to feedback and suggestions from residents and staff. The cook was seen talking with residents about what they wanted to eat and requesting information about special needs and preferences. Resident’s said “we have a variety of home cooked dishes, fresh vegetables and fruit”, “the cooks are wonderful”, “the meals are very good and always served up with a smile and kind word”. Breakfast and lunch was served in the dining room. Residents were able to choose where they sat and what they ate. Staff provided support and assistance where necessary and residents were given adequate time to finish their meal in their own time. Food was hot, nicely presented and looked very appetising. Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 16 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were adequate procedures in place to respond to complaints and to protect residents from abuse. EVIDENCE: The home had not received any complaints since the last inspection. Residents said they knew how to make a complaint and said they would speak to their key worker or office staff if they had any concerns. One resident said, “If I have a problem I can go to the office, they are very good”. Four relatives were not clear about the procedure to follow if they had concerns about the home and did not know how to obtain a copy of the latest inspection report. Although the complaints procedure was displayed on a notice board in the office it was difficult to see amongst the other papers pinned to the board. The acting manager agreed to move the complaints procedure and the note advising relatives about access to inspection reports, to a more visible area. The home had not dealt with any adult protection issues or made any referrals to the POVA list since the last inspection. Discussions with staff indicated that they had a good awareness of adult protection issues and knew what to do if they witnessed abuse in the home. The acting manager had arranged a staff training session about safeguarding adults. Shaftesbury Court DS0000067482.V294031.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, 23 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides a clean and comfortable environment for residents. Infection control procedures were mostly good but some lapses were noted in the kitchen. EVIDENCE: The home employs a part time maintenance person/gardener. Although the building was maintained to a satisfactory standard some parts of the grounds such as the car park and area behind the laundry were overgrown and looked neglected. One relative and one resident spoke to the inspector about this issue. The previous recommendation to repair the blind in the bathroom and cover the radiator in the ground floor bathroom had not been addressed. The acting manager said that quotes had been obtained for this work. The Registered Person should ensure that all parts of the home and grounds are maintained to a satisfactory standard. See recommendation 2 and 3. A redecoration programme was planned. Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 18 Since the last inspection the home had purchased a new washing machine, fridge freezer and replaced some carpets. New vacuum cleaners and a new front door were on order. The provision and range of personal space provided for residents in this home exceeds the National Minimum Standards. Residents were offered a flat-let or bed-sit depending on their needs and availability. Some of the larger units had a separate lounge, kitchen, bathroom and bedroom. Others had a combined lounge and bedroom, area for making light meals and drinks and separate en suite facilities. All of the rooms were single occupancy. The home did not have any scales that were suitable for weighing people that could not stand up. As the dependency of the current residents increases this equipment is likely to be required. The acting manager should consider this issue when preparing the homes annual budget. All parts of the home were clean, tidy and odour free. The acting manager said there had been some long- term sickness amongst cleaning staff, which had resulted in few problems but these were being addressed. One of the bathrooms had a hand washbasin but there were no hand towels or soap. Care staff were seen entering and walking about in the kitchen without wearing an apron or overall. See requirement 2 and recommendation 4. Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home has a caring and competent team of staff that worked hard to ensure that residents had a good quality of life. The homes recruitment procedure provides good protection for residents. EVIDENCE: The inspector examined copies of the staffing roster for a two-week period. The roster indicated that there were at least three care staff and a senior carer on duty throughout the day and three care staff overnight. The team leaders and manager provide support on weekdays and can be contacted during the night when they are on call. Six members of staff had left since the last inspection but there was no evidence that this had affected continuity of care for residents. Domestic, care and kitchen staff were seen talking to residents and relatives. Staff spoke clearly and positioned themselves where the resident could easily see and hear them. Staff had a good understanding of resident’s needs and were able to advise the inspector about the best method of communication to use when speaking with residents. Residents were familiar with all of the staff team and addressed them personally. The atmosphere in the home was friendly and welcoming. Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 20 Twenty eight percent of care staff had attained an NVQ level 2 in care and two staff were currently undertaking this training. The home continues to actively work toward meeting this standard. Three staff recruitment files were assessed. All of the files included information and documents about the applicant’s identity, suitability and fitness for the role they were undertaking. Individual training files were maintained for each member of staff and training needs were identified during supervision and appraisal meetings. Since the last inspection some staff had attended mandatory health and safety training updates and other relevant sessions such as person centred planning, COSHH, stoma care, infection control, first aid and care procedures. The company has a dedicated training manager and provides a programme of training for staff. Staff were also able to access local authority and college training courses. The acting manager had identified that the staff required dementia, food hygiene and safeguarding adults training in 2006. Most of these sessions were booked. Induction training consisted of a one-day local induction in the home to discuss policies and procedures and health and safety issues and completion of a workbook. The inspector viewed one workbook. Although the staff member had been in post for four months, most of the induction standards were incomplete. See recommendation 5. Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements were in place to manage the home during the manager’s absence. Appropriate action was taken to safeguard resident’s personal money. Health and safety issues were well managed overall but some concerns were identified about security. EVIDENCE: The Registered Manager is currently on sick leave. The commission were notified about the arrangements for managing the home during the manager’s absence. Staff and residents said that the acting manager was approachable and helpful and informed them about significant issues during staff and resident meetings. There was no evidence to suggest that the temporary Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 22 change in management had affected the quality of care provided for residents or the support provided for staff. The home had systems in place for monitoring the quality of care provided in the home. The manager was required to provide information about complaints, accidents and staffing to head office each month and the nominated person visited the home regularly to talk with residents and staff. A health and safety audit was carried out in January 2006. A number of residents were able to manage their own finances or were assisted to do this by relatives or friends. Staff held personal money, for some residents. Records maintained by staff clearly showed the date that money was returned to residents or used to pay bills for services such as hairdressing and newspapers. Staff signed all entries and receipts were retained for shopping that staff had undertaken for residents. Health and safety and fire records were sampled. All of the records seen were satisfactory. Since the last inspection an intruder had been able to enter the home. It was not clear how this had occurred but residents, staff and relatives had been reminded to be vigilant when entering and leaving the home. This inspection took place on an extremely hot day. The patio doors in the dining room that led directly out to the road were left ajar. One staff member was seen entering the home by this route. Staff should risk assess all possible entrances and exits to the home and consider whether additional locks or restrictors are required to maintain residents safety. See requirement 3. Staff were starting to use Sanctuary Care paperwork and new policies and procedures were beginning to filter through. Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 23 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 4 X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 16 Requirement The Registered Person must ensure that residents have access to a regular and varied programme of activities. The Registered Person must ensure that all visitors to the kitchen wear appropriate protective clothing. (The previous timescale of 01/02/06 was not met) The Registered Person must risk assess all of the possible routes for entering and leaving the home. If significant risks are identified staff must introduce strategies to safeguard residents. Timescale for action 30/11/06 2. OP26 13 02/11/06 3. OP38 13 02/11/06 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 OP9 Good Practice Recommendations The Registered Person should ensure that staff sign the DS0000067482.V294031.R01.S.doc Version 5.1 Page 25 Shaftesbury Court 2. OP19 3. 4. 5. OP19 OP26 OP30 medication administration record after the resident has taken their medication. The Registered Person should ensure that all parts of the home and grounds are maintained to a satisfactory standard. The maintenance employee’s hours should be increased. The Registered Person should repair the blind in the bathroom and cover the radiator in the ground floor bathroom. The Registered Person should ensure that all bathrooms have adequate hand washing facilities. The Registered Person should ensure that new staff complete the induction workbook within the first eight weeks of their appointment. Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Shaftesbury Court DS0000067482.V294031.R01.S.doc Version 5.1 Page 27 - 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. 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