Care Home: Shannon Court

Similar services:

• Chirnside House
• Keer Sands Residential Home
• Chirnside House
• Rosehill Residential Home
• Ruskin Lodge
• Ruskin Lodge

What the care home does well What has improved since the last inspection? The statement of purpose and service user`s guide had been reviewed so that anyone thinking of moving into the home had up to date information about the service and facilities offered. As recommended following the last inspection the manager amended the complaints procedure. Anyone making a complaint had clear information about how soon they could expect a response. Some areas of the home had been redecorated and refurbished. As recommended at the last inspection the manager had looked at how the environment could help people become more orientated. There were some discreet signs to assist people to find their way around. There had been some improvements in the records for newly appointed staff. However, there should be some further checks to ensure that people using the service are protected. What the care home could do better: The assessments of anyone thinking of moving into the home should contain enough detail to make sure that any staff reading them have a clear picture of the person`s strengths and needs. Some of the care plans should have more detailed information about what people using the service need and how staff should support them. This would make sure that new or temporary staff had written guidance to refer to and also that people using the service always receive the same standard of care. In order to reduce the risk of medication errors some improvements must be made to records of medicines. The staff should also keep closer checks to make sure that out of date medicines cannot be used. The manager should make sure that minor maintenance and repairs that could enhance the comfort of people using the service are carried out as soon as possible. CARE HOMES FOR OLDER PEOPLE Shannon Court 112 Radcliffe Road Bolton Lancashire BL2 1NY Lead Inspector Jane Craig Unannounced Inspection 12th March 2008 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 Shannon Court DS0000005699.V337492.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. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shannon Court Address 112 Radcliffe Road Bolton Lancashire BL2 1NY 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) 01204 396641 01204 384412 julie.morrison@shannoncourt.eu Mrs Christine Flood Mrs Julie Morrison Care Home 59 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (42), Mental disorder, excluding learning of places disability or dementia (1), Old age, not falling within any other category (14) Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 59 service users to include; Up to 42 service users in the category of DE(E) (Dementia over 65 years of age) Up to 14 service users in the category of OP (Older People) Up to 2 service users in the category of DE (Dementia under 65 years of age) 1 named service user in the category of MD (Mental disorder under 65 years of age) may be accommodated within the overall number of registered places. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 20th February 2007 2. Date of last inspection Brief Description of the Service: Shannon Court is a privately owned care home providing personal and nursing care for up to 59 older people, many of whom have dementia related care needs. The home is situated close to Bolton town centre, off the main Bolton to Bury road. It is within easy reach of bus routes and shops. Accommodation is on three floors with lift access. All bedrooms are single, many with en-suite facilities. The home does not have a garden, but there is a pleasant enclosed patio with garden furniture that is well used in fine weather. Fees range from £364.27 to £572.00. Information about the home, including the last inspection report, is available from the manager. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. A key unannounced inspection, which included a visit to the home, was conducted at Shannon Court on the 12th March 2008. There had been one additional inspection to the home on 16th November 2007. At the time of the visit there were 44 people using the service. The inspector met with some of them and where possible asked about their views and experiences of living at the home. Four people were case tracked. This meant that the inspector looked at their care plans and other records and talked to staff about their care needs. As part of the key inspection a number of surveys were sent out to people living at the home, their relatives and staff working at Shannon Court. None were returned by people using the service. Comments received on the other surveys were taken into account during the key inspection. During the visit discussions were held with the registered manager and deputy, six members of the staff team and several visitors to the home. The inspector looked round the home and viewed a number of documents and records. This report also includes information from the Annual Quality Assurance Assessment (AQAA), which is a self-assessment that the manager has to fill in and send to the Commission every year. What the service does well: People’s health care needs were met. A person living at the home said that she was well looked after. A number of relatives also said that the care was good. One relative said they would recommend the home. The principles of respecting privacy and dignity were put into practice. Staff spoke to people politely and with respect. Routines were flexible to meet the needs of the people living there. One resident said that he could get up when he wanted and there were no rules. Wherever possible people were encouraged to make their own choices and decisions about their daily lives. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 6 There was open visiting which meant that people could see their relatives and friends at times that suited everyone. There was a varied menu and people had plenty of choices at each mealtime. One person said, “I can’t complain about the food.” Relatives also said the food seemed to be very good. People living at the home and their relatives knew how to make a complaint if they were not happy about anything. One person said that he had no complaints but if he did he would tell the nurses. Most staff had received training to help them recognise and respond if they thought anyone living at the home was being mistreated. The home was clean and free from odours. New décor and furnishings were homely and of a good standard. One person living at the home described his room as “smart.” A number of relatives who returned surveys made positive comments about staff. One person described them as “warm and caring.” Another person said, “They treat people as people.” There were good opportunities for staff to attend training courses. As well as courses in health and safety topics they also had training in specialist subjects. This helped staff to understand and meet the needs of people living at the home. Over half of the care staff held a nationally recognised qualification in care. The home was well managed. Staff felt supported by the management. People living at the home and their families had opportunities to make their views about the home known and influence future developments. What has improved since the last inspection? The statement of purpose and service user’s guide had been reviewed so that anyone thinking of moving into the home had up to date information about the service and facilities offered. As recommended following the last inspection the manager amended the complaints procedure. Anyone making a complaint had clear information about how soon they could expect a response. Some areas of the home had been redecorated and refurbished. As recommended at the last inspection the manager had looked at how the environment could help people become more orientated. There were some discreet signs to assist people to find their way around. There had been some improvements in the records for newly appointed staff. However, there should be some further checks to ensure that people using the service are protected. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 7 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 summary of this inspection report can be made available in other formats on request. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 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 Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People thinking of moving into the home received sufficient information to help them to make a decision but staff did not always obtain enough information to help them to understand the person’s needs. EVIDENCE: The statement of purpose and service user’s guide had been reviewed and updated in 2008. They provided comprehensive information about the home and the services offered. There was a copy of both documents in the reception area. Relatives who completed surveys indicated that they were given enough information about the home. Anyone thinking of moving into the home had an assessment, which helped the manager to make a decision whether the service provided at Shannon Court could meet the person’s needs. Information included in the Annual Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 10 Quality Assurance Assessment (AQAA) indicated that the assessments had been upgraded since the last inspection. Some of the pre-admission assessments gave very detailed information about the person’s strengths and needs. However, some were very brief and did not include enough detail. This could result in staff not having enough information about the person to ensure a smooth admission to the home. Care staff said they were told all about new people when they came in and would usually read assessments or care plans later. However, one member of staff was unaware of an important piece of information about a recently admitted resident, which could have an impact on how care was provided. Standard 6 was not applicable. Intermediate care is not provided at Shannon Court. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Despite some shortfalls in care records, people’s health and personal care needs were usually met in accordance with their wishes. Practices for managing medication were not completely safe and could increase the risk of errors. EVIDENCE: Anyone admitted to the home had a baseline admission assessment. This information helped staff to formulate a care pan to meet the person’s individual needs. Four sets of care records were inspected as part of the case tracking process and others were viewed in less detail. The quality and detail of care plans varied. Some were very clear and gave staff explicit directions on how to provide support to meet individual needs and Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 12 preferences. However, some plans, including those to assist with specialist needs and behaviours, were not specific or individual enough. For example, one person whose behaviour was assessed as possibly causing harm to others had a care plan, which gave vague directions such as ‘give time and reassurance’. This lack of clear strategies could put people using the service and staff at risk. The care plans were reviewed monthly. There were some good evaluation notes, which showed the progress the person had made and any changes in their needs. However, this information was not always transferred to the care plan. For example, the plans to assist one person with their mobility were out of date. This meant that new or temporary staff would not have written information to refer to if they were unclear about what care to provide. Despite shortfalls in some of the written plans, staff spoken with said that they had a verbal handover every morning and were given sufficient information to provide the right care. Those who completed surveys also indicated they were always given up to date information about the people they cared for. People using the service and their relatives were able to read and input into care plans if they wished. Family members were also invited to attend review meetings. The manager was aware that some care plans were lacking in detail and she said that she intended to do some further training in writing care plans. The AQAA indicated that she plans to continue to refine and up date the care plan format Care plans included risk assessments for moving and handling, nutrition, risk of falls and pressure sore risk. There were usually corresponding plans to minimise identified risks but not in all cases. For example one person was assessed as being at high risk of developing pressure sores but there was no strategy in place. However, staff were able to talk about what care they gave to ensure that the risk was controlled. Ongoing health care needs were monitored and people were referred to outside agencies as necessary. Advice from other professionals was added to the relevant care plan so that it became part of everyday care. People using the service said that they were well looked after. Relatives and friends who completed surveys indicated that the service gave the care that was expected and that their relatives care needs were met. One relative said the care was, “excellent.” Another commented, “You can’t fault the care.” Staff received training in core care values such as promoting privacy and dignity. Care plans made reference to respecting privacy, dignity and choice when assisting with personal care. During the course of the inspection staff Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 13 were observed speaking to people politely and with respect. Care staff discussed how they ensured that people’s right to privacy was upheld. One member of staff also talked about the importance of offering choice and encouraging independence in order to maintain people’s dignity. Discussions took place with the manager with regard to ensuring that any health related activities were always carried out in private. According to information received on the AQAA, the policies and procedures for managing medication had been reviewed since the last inspection. There were complete records of medication received and disposed of. Most Medication Administration Record (MAR) charts were complete and reasons for not giving medication were usually explained. There were some handwritten additions to MAR charts that were not always signed and witnessed. This could increase the risk of transcribing errors. Nursing staff had altered the dosage and frequency instructions on some MAR charts. There was often no reason stated and no evidence of authorisation for the change in prescription. One person was having dressings applied but there was no record of them being prescribed. Random checks of other medication showed that the records tallied with the amount of stock left which indicated that people were generally receiving their medication as it was prescribed. Storage areas were clean, tidy and secure. Not all products with a short shelf life, such as eye drops and insulin, were dated on opening. This could result in them being used after the recommended period of time. Controlled drugs were stored, recorded and administered in accordance with agreed protocols. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily routines and meals suited people living at the home and most people were assisted to meet their social and recreational needs. EVIDENCE: Information about preferred daily routines, interests and religious needs was usually recorded on admission assessments. This information was of particular importance when people were unable to make their own choices and decisions. However, although the assessments were available to staff, the information was not always transferred to care plans which may reduce the chance of it being incorporated into daily practice. For example, the assessment for one person indicated that they preferred a shower to a bath. The care plan indicated that the opposite was true. Relatives who returned surveys acknowledged that, wherever possible, staff tried to support people to live the life they chose. At the time of the visit a resident said that he was, “never told not to do anything.” Staff confirmed Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 15 that routines in the home were flexible to meet the needs of people living there. One said, “No-one has to be in bed for a certain time.” There was a policy of open visiting. Two visitors said they were always made to feel welcome and another said they were always offered a drink. People who were visiting at lunchtime were offered a meal. Relatives who completed surveys indicated that they were kept up to date with important issues. There were mixed views about the level of activities in the home. It was the perception of some relatives that there were no social and leisure activities going on. The activities room had been moved to the basement which could account for some of the lack of visibility. Everyone had a plan to support their social care needs. Some were not always specific enough. For example, they directed staff to provide activities that suit the person but did not give an indication of the person’s current interests and abilities. It was evident from talking to one of the activity staff that they took time to get to know people’s social histories. There were two activity co-ordinators and a part time therapist employed at the home. There was a programme of planned activities that included games, crafts and music groups. The activity staff said that these were very flexible to suit day to day changes. There were small group outings to local places of interest and one to one outings, for example, to do shopping and have lunch. One resident said he had a newspaper every day and also liked to play dominoes sometimes. Records showed that some people participated in a varied programme of activities but others showed very little engagement. Care staff said they also carried out one to one activities and discussions with people when they were able but there were no records of these. Most care plans indicated that people were offered weekly therapy, for example, massages from a qualified person. The AQAA indicated that the manager plans to continue to develop these therapeutic activities. On the day of the visit the meals looked appetising and people appeared to enjoy their food. One person said the meals were “great” and another said, “I can’t complain about the food.” Relatives also said the food seemed to be good. One person said their relative was on a soft diet but it was served nicely and not all mushed together. There was a varied menu and people had choices at each mealtime. The kitchen staff kept a list of people’s preferences to ensure that people were not served with meals they did not like. There were plenty of fresh vegetables and homemade cooking. Fresh fruit was offered as an alternative to biscuits and sweet snacks every afternoon. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 16 There were two sittings at each mealtime. This ensured that there was sufficient space in the dining room and mealtimes were seen as a social occasion and not rushed. It also meant that there were enough staff to assist people who needed encouragement or physical help. Equipment, such as deep plates, was available to assist people to remain independent. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 17 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. People were confident that their concerns would be listened to and acted upon. Staff training was in place to ensure that people were safeguarded. EVIDENCE: The complaints procedure had been amended as recommended following the last inspection. It included the timescales for acknowledging a complaint. There was a copy of the procedure in the reception area. Relatives who returned surveys showed that they knew how to make a complaint. Most also indicated that the manager and staff had responded appropriately to any concerns they had raised. At the time of the visit a resident said they had no complaints but could tell the nurses if they did. Staff surveys indicated that they knew how to respond if a resident or relative expressed any concerns. There had been three complaints about the service in the past year. Records showed that they were investigated and responded to within the agreed timescales. Two were found to be unsubstantiated and one was still ongoing. Most staff had received training in safeguarding adults. Further training was planned. Staff spoken with said they would be able to recognise abuse and Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 18 they knew to report to senior staff. The manager was trying to source training specifically for senior staff to help them in their role. There was a copy of the social services safeguarding policy for staff to refer to. Discussions took place with the manager about having a clear procedure for staff to follow in the event of suspected abuse, which included contact numbers and clear guidance. The manager and deputy were aware of how the Mental Capacity Act could impact on some of the people using their service and what staff roles may be. There were in the process of trying to source further training. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and well maintained and provided people with a safe, comfortable and homely place to live. EVIDENCE: There had been one additional visit to the home following concerns about the environment. No requirements or recommendations were made as a result of this inspection. A tour of the environment showed that most areas of the home were in a good state of repair. There was some building work going on in the area which usually accommodated people requiring nursing care. There was minimal disruption and people still had a choice of seating areas. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 20 There had been some redecoration and refurbishment already in communal areas. For example, new carpets and large flat screen TVs in lounges, which were more accessible and safer for people using the service. Information included on the AQQA showed that the manager was continuing to work on recommendations to improve the environment to aid people with dementia. There was a planned refurbishment of bedrooms. However, a tour of the premises showed that there were some areas that needed more immediate attention, for example a noisy fan and a bedroom window that did not shut completely. There was a new laundry that had been finished to a high standard. On the day of the visit it was clean, tidy and well organised. A relative commented that her mother’s clothes were well kept. The home was clean and tidy. There were no unpleasant odours. All staff, including ancillary staff, had received infection control training. There were ample hand-washing facilities. Infection control information and posters were on display in staff areas to remind them of universal precautions. Protective clothing was available. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 21 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, 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. People living at the home were supported by staff who received regular training and supervision. This helped to ensure their needs were understood and met. Recruitment practices did not provide complete safeguards. EVIDENCE: There were some mixed views about staffing levels. One relative wrote that the home has a shortage of staff which makes it difficult to run smoothly. Another commented that staff could not sit with residents because they had too much to do. Most staff said that providing everyone turned in there were enough to meet the needs of people living at the home. During the course of the visit there were periods of time when the lounge was left without supervision. This meant that strategies to protect people who were at risk of falls or vulnerable to harm from others, could not be employed. A member of staff confirmed that the lounge was left without staff when they were busy. A relative also commented that it was a regular occurrence that there were no staff around, especially after lunch. Most of the relatives who returned surveys made positive comments about the staff. One person described them as “warm and caring” another said that staff Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 22 “treat people as people.” Two of the people living at the home also said the staff were very good. The files of two new staff were inspected. As previously recommended all documents were dated and it was evident that staff did not start work without references and a POVA first or CRB check. However, there were still some shortfalls. For example, the application form for one person showed they had gaps in their employment history. This had not been identified or explored. Nor were there any records to show that the potential risks of employing someone with previous convictions had been assessed and controlled. New staff had an initial induction which included an introduction to the organisation, orientation of the building and emergency procedures. Staff without qualifications then went through an induction programme that met the common induction standards. There were good records of training outcomes competency assessments. The manager also carried out regular interviews with new staff to check on progress and give feedback. The manager advised that all staff had received training in topics associated with health and safety. For example, moving and handling, first aid and infection control. There was no training matrix so not all training records were seen. Staff also had access to other training relevant to their role. For example dementia care training, tissue viability and palliative care. There was also a training aspect to staff supervision, which one member of staff said was useful. The AQAA showed that over 50 of care staff held an NVQ level 2 or above. The manager planned to continue to increase those numbers. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 23 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, 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. Residents and staff benefited from a safe and well managed home. There was a good level of consultation, which meant that people were able to contribute to service development. EVIDENCE: The registered manager is a first level nurse. She also holds a relevant management qualification. The manager said she continued to keep her clinical and management skills up to date by attending courses and through self-directed study. She was supported by the deputy manager and the registered provider. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 24 Staff who completed surveys indicated that they received regular support from the manager and one commented that they could approach her at any time. The AQAA showed that the manager had a number of plans in place for developing and improving the service. The service held the Investors in People award. There were also internal systems for monitoring the quality of the service. Anonymous questionnaires were sent out to people using the service, family carers, staff and other stakeholders every year. Results of the surveys were published in the quarterly newsletter. People were also encouraged to give their views of the service and make suggestions for change during resident and relative meetings. The AQAA outlined a number of improvements made following suggestions. For example, the large screen televisions and the therapy suite. The owners of the home carried out regular visits to ensure that the standards of the home were being maintained. The manager did not act as appointee or agent for anyone living at the home. A number of people had small amounts of money they gave over for safekeeping. Each person had a separate account sheet which showed income, expenditure and balance. Receipts were retained for proof of purchases. Fire safety training had been arranged to coincide with the completion of building work to ensure that staff had access to all parts of the home during their practise drills. Maintenance and servicing of the fire alarm system and other fire safety equipment was up to date. The AQAA showed that servicing of other installations and appliances was up to date. Certificates and service documents were seen for the gas appliances and portable appliance tests. There were environmental risk assessments and potentially hazardous items were stored safely. Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X 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 X X X X X X 3 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP9 Regulation 13(2) Requirement In order to ensure that people receive medication as instructed by the prescriber, handwritten entries on MAR charts must accurately reflect the information on the prescription. Prescriptions must not be changed without authorisation from the prescriber. Timescale for action 31/03/08 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 OP3 Good Practice Recommendations The registered person should ensure that assessments of residents are completed in full and in line with the National Minimum Standards. Assessments should be maintained in a uniform standard to ensure an audit trail. Care plans should be specific enough to ensure that new or temporary staff have sufficient directions to provide DS0000005699.V337492.R01.S.doc Version 5.2 Page 27 2. OP7 Shannon Court consistent care in the way the person prefers. 3. OP7 In order to ensure that staff have access to up to date information, care plans should be amended as and when the person’s needs, or directions for care, change. Handwritten additions to MAR charts should be double signed to reduce the risk of transcribing errors. Opening dates should be recorded on all products with a short shelf life to ensure that they are not used after the recommended period of time. The service should have a clear procedure for staff to follow in case of suspected or actual abuse. In order to enhance the comfort of people using the service, the registered person should ensure that maintenance and repairs fixtures and fittings in bedrooms are carried out ahead of the planned refurbishment. In order to protect people living at the home, a risk assessment should be carried out if an employee has previous criminal convictions on their CRB disclosure. 4. 5. OP9 OP9 6. 7. OP18 OP19 8. OP29 Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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. Extracts may not be used or reproduced without the express permission of CSCI Shannon Court DS0000005699.V337492.R01.S.doc Version 5.2 Page 29 - 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!