Care Home: Shawe House Nursing Home Ltd

What the care home does well Staff were observed to be kind and attentive to the people living at the home. Positive comments were received from people spoken to during the visit. One visitor said `this is an excellent home and people get excellent care`. During the visit the home was clean and comfortable and the atmosphere was relaxed and friendly. One member of staff staff said that there is `a real family atmosphere in the home`. One visitor said `the staff really care and are very kind and patient with everybody`. People have an assessment of their needs before being admitted to the home to make sure that all of their needs can be met and people are encouraged to come and visit the home before making a decision to move in. The visitors spoken to said that they can visit whenever they like and were always made to feel very welcome. They also said staff were good at keeping them informed of anything to do with their relative. Staff spoken to also confirmed this. The visitors spoken to said they knew how to make a complaint and staff confirmed that people are encouraged to raise any concerns or complaints they have . What has improved since the last inspection? Since the last inspection visit a new manager and a clinical nurse lead have taken up post. We spoke to a professional from the Local Authority who had been undertaking weekly visits as part of a service improvement plan due to some concerns they had. They told us that since the new manager took up post they have seen big imrovements in all areas of the home management. During this visit the manager was very visable and one visitor told us `the manager is marvelous`. All care plans are in the process of being reviewed and new easier to use paperwork is being put into place. Staff and visitors spoken to said they have seen improvments since the new manager has started. Staff said that training has improved and so has the team moral and staff support. Visitors commented on how much cleaner the home was and they said they liked the new decor. Since the last inspection visit some of the improvements to the environment include new dining room tables and chairs, new lounge chairs, the corridors have been redecorated creating a much lighter and airy atmosphere. One of the lounge, dining rooms had been redecorted and the second was due for redecoration the evening this visit was undertaken. New furniture, soft furnishings and curtains have been bought for many of the bedrooms.To assist people with their orientation around the home the corridors have a colour theme and new name plaques have been fitted to bedroom doors. Also large plaques have been fitted to bathroom and toilet doors making them easier for people with a memory problem to identify. To try and make meal times a more relaxed, sociable event staff sit at the dining tables and eat their meals with the people living at the home. Staff spoken to said they were really enjoying doing this and it made meals less hurried and more enjoyable. What the care home could do better: No requirements made during this inspection visit. However some recommendations were made in relation to the need to improve the medicines record keeping to better support and evidence the safe administration of medication. Key inspection report Care homes for older people Name: Address: Shawe House Nursing Home Ltd Pennybridge Lane Flixton Manchester M41 5DX     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Geraldine Blow     Date: 0 4 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Shawe House Nursing Home Ltd Pennybridge Lane Flixton Manchester M41 5DX 01617487867 01617487920 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.shawehouse.co.uk Shawe House Nursing Home Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 33 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: A maximum of 33 older people requiring nursing care as a result of an organic mental illness can be accommodated. Service users shall not be subject to detention under the terms of the Mental Health Act 1983. Staffing levels as specified in the Section 13 Notice dated 30 December 2002 shall be maintained. Date of last inspection Brief description of the care home Shawe House is a nursing home providing care for 33 older people with dementia. It is a large Victorian house that has been appropriately converted and extended. The home is located in Flixton in an area that is close to Flixton golf course. There are good bus links to nearby towns. There are 27 rooms of which 6 are shared rooms; 12 bedrooms have en suite toilets. Care Homes for Older People Page 4 of 28 Over 65 33 0 3 1 0 7 2 0 0 9 Brief description of the care home The rooms are situated on the ground floor and first floor and a passenger lift is available for people to use. Shawe House has two lounge/dining rooms. There are 3 bathrooms with toilets, a shower room with toilet and 3 single toilets. There is a large and well-maintained garden that overlooks green open space and a large parking area at the front of the house. The last inspection report is available in the main reception area for people to access. Fees charged by the home were £630. 80 per week. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This report is based on information gathered by the Care Quality Commission (CQC) since the last inspection visit on 31 July 2009 and supporting information received in the Annual Quality Assurance Assessment (AQAA) submitted prior to this visit. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. This visit was unannounced, which means that the manager and staff were not told that we would be visiting. The visit took place on Tuesday 4 May 2010. This report is an overview of what we found during the visit. References to we or us in this report represent the CQC. As part of the visit we spent time examining relevant documents and files. We also spent time talking with some people living at the home, some visitors and several Care Homes for Older People Page 6 of 28 members of staff. We also walked round the home and looked at the communal areas and some bedrooms. Feedback was given to the manager during the course of the visit. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? Since the last inspection visit a new manager and a clinical nurse lead have taken up post. We spoke to a professional from the Local Authority who had been undertaking weekly visits as part of a service improvement plan due to some concerns they had. They told us that since the new manager took up post they have seen big imrovements in all areas of the home management. During this visit the manager was very visable and one visitor told us the manager is marvelous. All care plans are in the process of being reviewed and new easier to use paperwork is being put into place. Staff and visitors spoken to said they have seen improvments since the new manager has started. Staff said that training has improved and so has the team moral and staff support. Visitors commented on how much cleaner the home was and they said they liked the new decor. Since the last inspection visit some of the improvements to the environment include new dining room tables and chairs, new lounge chairs, the corridors have been redecorated creating a much lighter and airy atmosphere. One of the lounge, dining rooms had been redecorted and the second was due for redecoration the evening this visit was undertaken. New furniture, soft furnishings and curtains have been bought for many of the bedrooms. Care Homes for Older People Page 8 of 28 To assist people with their orientation around the home the corridors have a colour theme and new name plaques have been fitted to bedroom doors. Also large plaques have been fitted to bathroom and toilet doors making them easier for people with a memory problem to identify. To try and make meal times a more relaxed, sociable event staff sit at the dining tables and eat their meals with the people living at the home. Staff spoken to said they were really enjoying doing this and it made meals less hurried and more enjoyable. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 28 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had their needs assessed before they move into Shawe House to ensure that their care needs can be met. Evidence: The Statement of Purpose had been updated to reflect a new manager had taken up post. This means that people are given up to date information about Shawe House. Files looked at and information received in the completed AQAA identified that people have their needs assessed before moving into the home to ensure that their needs can be met. We were told that there have not been any new admission since the new manager has taken up post but it is her intention that the clinical nurse lead, who is a Registered Mental Nurse, will undertake the assessments. The assessments will include the person being assessed, their family or carers and where appropriate other relevant health care professionals will be involved. Care Homes for Older People Page 11 of 28 Evidence: There was a set pre admission assessment record in use. It was noted that this did not include peoples religious or cultural needs. However the manager said the record was under review and it was her intention to include this in the new document. The manager and the AQAA confirmed that people, where possible, are encouraged to visit the home, without an appointment as many times as they like, have look round and meet people. Care Homes for Older People Page 12 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, social and personal care needs of people are being met by staff that respected their privacy and dignity. Evidence: We looked at a selection of care plans to see if care needs were clearly identified and what support was needed to meet those needs and encourage Independence. The manager acknowledged that there were shortfalls in the existing care plans and due to this they were in the process of reviewing all of the care plans and implementing new documentation. The plans of care looked at were well organised and easy for staff to follow. Evidence was seen that relatives had been involved in the care planning process. The manager said people were encouraged to be involved so that personal, accurate information can be used as a basis for care delivery. The care plans looked at were much improved from the previous inspection visit and Care Homes for Older People Page 13 of 28 Evidence: on the whole contained details of peoples needs, personal choices and preferences. For example some care plans detailed exactly what specific help the individual person needed at meal times or help to mobilise. However some parts of the plans were a bit vague with particular reference to personal hygiene. For example the care plans did not identify if people preferred a bath or shower, what time of day they preferred it and there was no direction on how the person was to be supported when having a bath or shower. This was discussed with the manager who said that she was working with staff to improve the personal information included in the plans of care. The manager said it was her intention to implement a personal care record that will be completed by the care assistant detailing exactly what care had been given. Appropriate risk assessments had been undertaken and regularly reviewed to ensure that any identified risks are minimised. There was a relatives communication sheet, a record of GP and health care professional visits which enable at a glance to see what health care needs have been provided or need to be provided. The care plans include a spirituality assessment and a life history which provides staff with an insight into peoples past lives and history. Visitors spoken to during the visit were complimentary about the staff and the care received. One lady said staff are very good and very kind, nothing is too much trouble for them. Another visitor said that the staff treat people as an individual. Staff were seen to be kind and patient when helping people and they seemed to have good relationships and had a good knowledge of peoples needs and personalities. All the visitors spoken to said that they thought the staff respected peoples privacy and dignity. We looked at the way they manage peoples medication. We saw that medication was stored safely and appropriately. We were informed that the GPs original prescription comes to the home for checking before it is sent to the pharmacy for dispensing. We looked at the medication administration record (MAR) sheets. We saw that that there were photographs of each person to reduce the risk of giving a person the wrong medication. Care Homes for Older People Page 14 of 28 Evidence: When we examined the MARs we noted that there were some gaps in the recording of medication. We did a visual check of the blister pack in use and a tablet count of boxed medication. It appeared that the medication had been given but had not been signed for. This does have the potential to put people at risk and was discussed with the clinical nurse lead and the manager. We were told the shortfalls would be addressed with the specific nurses. It was noted that for some medication there was no specific instructions. For example cream was prescribed as apply as directed by doctor but there were no instructions where to apply the cream. Also instructions for eye drops were apply to affected eye(s) but there was no details as to which eye the drops were to be administered to. To ensure people receive medication as intended by the GP there should be clearly documented instructions. The manager and the clinical nurse lead both confirmed that they were about to change to a new medication administration system. The system is called Bio Dose and all medication, including liquid medication, will come ready dispensed in single use pots. The only medication that will not be in the pot will be PRN medication. As detailed in the previous inspection report we saw information from a GP giving permission for staff to administer medication to people covertly. This means that it is given without the persons knowledge or agreement. Where decisions are made about the use of covert treatments appropriate multi-disciplinary assessments should be carried out to show the decision was made in the best interests of that individual. This is in accordance with the Mental Capacity Act 2005 - Deprivation of Liberty Safeguards. This was discussed with the manager and the clinical nurse lead, both of whom said that the medication was no longer being given covertly. It was recommended that the the situation be reviewed. The clinical nurse lead undertakes a monthly audit of medication, which is seen as good practice and they have just recently had a PCT pharmacy audit with no concerns raised. Care Homes for Older People Page 15 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were a range of activities on offer and people were offered a varied and balanced diet. Evidence: Since the last inspection visit there are now 2 activity coordinators employed by the home. In peoples files there were life history sheets that were mainly completed by peoples family which detailed what peoples hobbies, interests and religious beliefs to ensure that activities provided are what people want to do. A record is kept of all activities undertaken which included herb growing, reading, reminiscence groups, hand massage music. Since the last inspection visit a daily reminiscence newspaper is produced and staff and visitors go through the newspaper with people on a daily basis. This is seen as good practice. There was information available of local religious organisations and these can be accessed on request. There was also contact numbers of local support groups such as Age Concern if people wanted to access them. We saw pieces of multi-sensory equipment in both lounges to provide stimulation and Care Homes for Older People Page 16 of 28 Evidence: relaxation for people. Staff and visitors spoken to confirmed that visitors are made welcome and can visit whenever they like. Visitors spoken to all said that staff are very welcoming and they are good at keeping them informed of any issues relating to their relative. A copy of the menus was seen, although the manager said that the menus were currently under review. The meals were varied and nutritionally balanced. There was a choice available at each mealtime and an alternative to these choices were also available. Staff and and visitors spoken to confirmed there are always choices available. A menu was on display so that people can see what was available on a daily basis. The lunch time meal seen on the day of this visit looked and smelt appetising. Nutritional risk assessments had been undertake to ensure that people were not at risk of malnutrition and staff were seen encouraging and helping people to eat meals. Since the last inspection visit staff now sit and eat their meals with people. Staff confirmed that this new system has been a great success and meal times now are less hurried and more sociable for people. People spoken to were all complimentary about the size and quality of the meals provided. Care Homes for Older People Page 17 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place to safeguard people from harm and people are able to raise concerns and their views are listened to. Evidence: There was a copy of the complaint procedure in the main reception area that was clearly written. There was a record of complaints and concerns made which included a conclusion. The manager said she encourages people to raise and concerns or complaints they may have and she makes herself available for people to talk to. She also holds an open surgery once a week if people wish to see her. Staff spoken to confirmed this. Visitors spoken to all said they knew how to make a complaint and felt that any concerns they had would be listened to and action would be taken. We were given some examples of when this had happened. We saw that the Local Authority safeguarding policy and procedures were available for staff to access. We saw training records that demonstrated that the majority of staff had undertaken safeguarding training. This was also confirmed by staff spoken to. The requirement made at the last inspection visit that all safeguarding situations must be referred under the local authorities safeguarding procedures had been met. Care Homes for Older People Page 18 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A clean and comfortable environment is provided. Evidence: Shawe House is set within its own grounds and has a large well maintained secure garden. Outdoor seating was available in the garden area. A maintenance man is employed to carry out general repairs and ensure the building is well maintained. During this visit a tour of the building was undertaken which included the communal areas and peoples bedrooms. The home was clean and tidy and all the people spoken to said that the home was always kept clean. There were policies and procedures relating to infection control. Bedrooms and the communal toilets and bathrooms had wall mounted soap dispensers and paper towel holders in an attempt to reduce the risk of cross infection. In addition there was wall mounted sanitizers which also help reduce the risk of cross infection. The AQAA identified that since the last inspection visit there has been extensive refurbishment of the premises and replacement of equipment. This was confirmed during a tour of the building and by staff and visitors spoken to. We saw that the Care Homes for Older People Page 19 of 28 Evidence: home was clean and tidy and bedrooms had been personalised with peoples personal effects which individualised their rooms. One visitor said that recently the home is a lot cleaner and it never smells unpleasant. Many areas of the home had been redecorated, much of the communal and bedroom furniture had been replaced and new soft furnishings had been bought to improve the presentation of the home. Visitors and staff spoken to were were very pleased with the improvements made. Desk areas have been provided in the lounges so that the level of staff supervision and interaction has increased. Care Homes for Older People Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Shawe House are support by a staff team who know them well. Evidence: On the day of this visit there were seven care staff, two Registered General Nurses (RGN), the manager (RGN) and the clinical nurse lead, who is a Registered Mental Nurse (RMN), on duty to meet the needs of the 28 people living at Shawe House. In addition there was a team of kitchen and ancillary staff on duty to ensure peoples needs were met. These numbers appeared sufficient to meet the needs of the people living at the home. The staff demonstrated a good awareness of peoples individual needs and were seen to interact with people in a respectful manner. Visitors spoken to made positive comments about the staff team. They told us the staff are amazingly kind and patient, you cant fault the staff here and the staff are very good and seem to really care about people. We looked at a sample of staff files. We saw that appropriate information had been obtained for newly recruited staff. This included two written references, completed application forms and evidence that appropriate Criminal Record Bureau disclosure checks had been carried out. It was recommended that photocopied documents such as proof of identity and address are signed and dated to evidence that the original Care Homes for Older People Page 21 of 28 Evidence: documents had been photocopied. The AQAA stated and the manager confirmed that 14 care staff were employed and 12 of those had successfully completed National Vocational Qualification (NVQ) Level 2 or above. Staff spoken to said that they were encouraged and supported to undertake the training. From talking to staff and a professional from the local authority staff training is much more of a priority. Since the last inspection visit a training and resource room has been made available to staff, friends and family of people living at Shawe House. There is a TV and DVD player available along with up to date articles, booklets, posters, books and training DVDs. This is seen as good practice. Each staff member has an individual training recored and there is also a training matrix that was seen during this visit. Evidence was seen of recent staff training and training sessions that have been booked. The manager confirmed that she has the Skills for Care common induction standards for all new starters to complete. In addition she has given existing staff a copy of the booklet and asked them to complete it so that any further training needs can be identified and then actioned. We were informed that all new staff initially work a supernumerary shift and then work with a senior member of staff until they feel confident and orientated to the home. This is seen as good practice. Care Homes for Older People Page 22 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed in the best interests of the people living there. Evidence: At the time of this visit the manager had been in post for just over two months and was in the process of applying to CQC for registration. We saw a copy of an action plan that the manager was in the process of implementing and given to the Local Authority and Trafford Safeguarding lead following some concerns raised. The plan was detailed and informative about the actions already taken and to be taken to improve the standards at the home. The manager demonstrated a commitment to improve the service delivered at Shawe House. The people living at Shawe House benefit from a committed staff team. The manager operates an open management style and encourages people and staff to make use of the open door policy. The staff we spoke to said that the manager was always available and was very supportive. They said she had made improvements to the staff Care Homes for Older People Page 23 of 28 Evidence: team and raised standards within the home. The visitors spoken to expressed satisfaction about the care received and the friendly, homely atmosphere at the home. Since the last inspection visit and as required in the last report all incidents and occurrences listed in regulation 37 of the Care Homes regulations 2001 have been reported to us without delay. We saw that they had a system in place for measuring the quality assurance of the service provided at Shawe House. This included a questionnaire survey being carried out on a three monthly basis. The manager confirmed that the results received are analysed and it is her intention to produce an annual report based on the results. The clinical nurse lead is to provide a weekly report to the home manger on all clinical issues and monthly audits have started to be undertaken to review the quality of the service provided. The home does not have the responsibility for managing peoples finances. However they did hold small amounts of money given to them for safe keeping from peoples relatives or advocates. There were systems in place for managing this money. Receipts were not routinely given if money or valuables were handed over to the home for safe keeping. There is a policy and procedure file that the manager has responsibility for reviewing and updating in line with current legislation and good practice advice. They told us in the Annual Quality Assurance Assessment (AQAA) that maintenance records were up to date. Fire safety checks and water temperature testing records were looked at and found to be up to date. This means that the home is safe for people to live in. Care Homes for Older People Page 24 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 To ensure all peoples needs, personal choices and preferences are met it is recommended that the care plans include all of those specific details. To ensure people receive medication as indented by the GP the GPs specific instruction should be clearly recorded. In accordance with the Mental Capacity Act 2005, Deprivation of Liberty Safeguards it is recommended that the use of covert medication is reviewed. To ensure people are receiving medication as prescribed by the GP there should be an accurate medication administration record. It is recommended that photocopied documents are signed and dated to evidence that they were taken from the original document. It is recommended that a receipt is given when any money or valuables is received by the home for safe keeping that it is signed by the member of staff receiving the money or valuables and the person handing over the money or valuables. Page 26 of 28 2 3 9 9 4 9 5 29 6 35 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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