Care Home: Shenstone Hall Nursing Home

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What the care home does well The home provides good sources of information to enable people to make choices about living at the home. "They convinced me of the merits of the home by doing unannounced visits and their personal information about the home". People`s needs are assessed in full prior to admission this gives assurances to both the residents and the home that needs will be met. Personal and healthcare needs will be met. There are good care planning systems in place and people have access to medical services, as they requirethem. There are good systems in place to manage medication and safeguard residents well being. "The home provides excellent care". The home provides good choices for meals and people told us that the quality of the food is very good. They said "I love the food, there`s always plenty to choose from". Complaints are taken seriously and always acted upon. Staff received regular training in Safeguarding and people should feel reassured they will be safe from harm in this home. The home is a pleasant and homely place to live. People told us they were happy and enjoyed living there. The home has beautiful views and is a Grade 11 listed building. The are sufficient staff on duty to meet the needs of the people who live there. They told us "you hardly ever have to wait for help", "the night staff are sweeties". What has improved since the last inspection? The home has met the outstanding requirement from the last inspection. All staff now have a Protection of Vulnerable Adults (PoVA) check before commencing employment. What the care home could do better: The home could build on the care planning system by making it more person centred and individual to people`s needs. The manager must address the risk to health and safety of residents by not using footplates on wheelchairs. The home must improve the way it records hot water temperatures in the home. this will ensure that residents have hot water on demand and any problems can be addressed promptly. The quality assurance system needs to be improved and kept up to date. CARE HOMES FOR OLDER PEOPLE Shenstone Hall Nursing Home 13 Birmingham Road Shenstone Nr Lichfield Staffordshire WS14 0JS Lead Inspector Mandy Beck Key Unannounced Inspection 11th April 2008 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 Shenstone Hall Nursing Home DS0000022373.V361941.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. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shenstone Hall Nursing Home Address 13 Birmingham Road Shenstone Nr Lichfield Staffordshire WS14 0JS 01543 480222 01543 480222 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) Dr Dhiraj Mahanta Mrs Deborah Mahanta Claire Annette Broadway Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (3), Physical disability (42), Physical disability of places over 65 years of age (42), Terminally ill (4) Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. PD Minimum age 60 years TI - Minimum age 60 years. Date of last inspection 3rd May 2006 Brief Description of the Service: Shenstone Hall is a Grade II (star) listed building originating in parts to the seventeenth century. The home was first registered in 1987. It has been sympathetically extended and currently provides nursing care for up to fortytwo elderly persons. Care is also provided on a respite basis to enable carers to have a break from time to time. The home is situated in a rural area of Staffordshire and enjoys extensive views over open countryside. Good road networks ensure easy access to local amenities provided in nearby Lichfield. Accommodation is provided on two floors. The home has both single bedrooms and shared rooms. Eight of the thirty-two rooms have an en-suite facility consisting of toilet and wash hand basin; all other bedrooms have handwashing facilities. The home has four communal dining and lounge situated on two floors accessible by a passenger lift. There are suitably adapted bathing and toilet facilities throughout the home and a central kitchen and laundry. There is car parking space and garden area for the residents to enjoy. The information on fees was not available in the Service User Guide. People will need to contact the home for these details. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We looked at all the information that we have received, or asked for, since the last key inspection. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. 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. • Surveys returned to us by people using the service and from other people with an interest in the service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. • Relevant information from other organisations. • What other people have told us about the service. • We also looked in depth at the care of three people who live at the home as part of our case tracking process. This enables us to make judgements about the home’s ability to meet people’s needs. • We spent time talking to the staff and the people who live in the home. This helped us understand what life is like living at Shenstone Hall. The quality rating for this service is 2 star. This means that people who use this service experience good quality outcomes. What the service does well: The home provides good sources of information to enable people to make choices about living at the home. “They convinced me of the merits of the home by doing unannounced visits and their personal information about the home”. People’s needs are assessed in full prior to admission this gives assurances to both the residents and the home that needs will be met. Personal and healthcare needs will be met. There are good care planning systems in place and people have access to medical services, as they require Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 6 them. There are good systems in place to manage medication and safeguard residents well being. “The home provides excellent care”. The home provides good choices for meals and people told us that the quality of the food is very good. They said “I love the food, there’s always plenty to choose from”. Complaints are taken seriously and always acted upon. Staff received regular training in Safeguarding and people should feel reassured they will be safe from harm in this home. The home is a pleasant and homely place to live. People told us they were happy and enjoyed living there. The home has beautiful views and is a Grade 11 listed building. The are sufficient staff on duty to meet the needs of the people who live there. They told us “you hardly ever have to wait for help”, “the night staff are sweeties”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shenstone Hall Nursing Home DS0000022373.V361941.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 Shenstone Hall Nursing Home DS0000022373.V361941.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): 1,3,6 Quality in this outcome area is good. People who may use this service will have good sources of information to make decisions about living there. They can also feel confident that their needs will be assessed prior to admission and that the home will be able to meet those needs once they move in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose and a Service User Guide both documents give people the information about the service the home provides and would enable them to make a choice about moving into this home. It is recommended that information on the range fees payable be included into the Service User Guide. One person told us “They convinced me of the merits of the home by doing unannounced visits and their personal information about the home”. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 10 Before people are admitted to the home Dr Mahanta (the provider) will visit each person to complete a pre admission assessment. This gives people to opportunity to ask about the home and also for both parties to be sure that the home can meet their needs. We looked at the assessments for two people who had been recently admitted to the home and saw that they were detailed and gave good sources of information about the person. This means that staff are able to plan good care with people because they have all the information they need to do it. This home does not provide any intermediate care service. Shenstone Hall Nursing Home DS0000022373.V361941.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): 7,8,9,10,11 Quality in this outcome area is good. People living in this home can feel confident that their health and person care needs will be met. Staff need to take more care to ensure that people’s privacy and dignity is met at all times. Medication systems within this home are good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of our case tracking process we looked at the care plans and risk assessments of three residents. It was pleasing to see that each person has care plans that reflect their individual needs. The person in charge explained that all care plans are reviewed on a monthly basis and/or more frequently if people’s needs changes. After every fourth review care plans are rewritten. The home does this to make sure that the care they are planning is still current and still reflects the needs of the people. We recommended that although care plans are of a good standard they could be further developed by making them more person centred in their approach. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 12 For instance, we saw that one person’s care plan said “needs hoist for transfers”, it would be more helpful to staff and resident if the type of hoist were included in the body of the care plan. Other examples included “make warm and comfortable” but there were no details of how to do this for the person. The home routinely completes risk assessments for all the residents. People are assessed for their risk of falls, moving and handling, pressure sore development and malnutrition. The risk assessments are kept under review the same as care plans. This means that people’s needs are being met by the home. The home has told us that they have training and information from a fall prevention specialist who will be returning to teach an appropriate method of tai chi for residents to promote balance and support. We saw that people are in contact with their doctors when they need them. People also have access to other health care professionals when their needs require it. We saw that people have visits from chiropody, dentistry and optical services on a regular basis. People told us “there’s been a lot of chest infections recently, we all seem to have had it but the staff and the doctors are wonderful and help us the very best they can”. “The home provides excellent care”. The home has good systems in place for the ordering, safe keeping and administration of medication. Trained nurses administer medication to residents. There are currently no residents that administer their own medication but we were told that the home would support people should they wish to do this. We looked at the systems in place for dealing with controlled medicines and found them to be satisfactory with accurate records kept of administration and receipt of controlled drugs. One health professional remarked “Medication is excellent and never had any bad reports only praise for the quality of care”. People told us they were treated with respect and dignity by staff most of the time. Some people said “at times I do feel rushed, I don’t think some of the staff understand that I like to take my time”, “we have seen the door left open on the toilet sometimes when someone is using it”. We saw on one occasion that staff had left the door of the toilet open whilst someone was using it and were talking above the resident. This was discussed with the person in charge who agreed that this was not good practice and would address it. This will ensure that people’s dignity and privacy is maintained whilst using the toilet. Other people said “they night staff are sweeties they really look after us, I don’t worry at all at night”. “They are compassionate and are caring, the home is clean and the residents are well dressed and respond to the buzzer quickly”. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15 Quality in this outcome area is good. People are supported to lead active lives and maintain their social contacts. Meals are of good quality with a variety of choice and needs catered for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home tries to support each resident to keep active. People said “they do try hard but you know you can’t please all the people all the time”. Some residents make use of the local village hall and luncheon clubs for a chance to meet with friends and socialise. The also tries to include people in the planning of activity by holding residents meetings, some of the minutes of some of the meeting were seen and it was pleasing to see that points raised by residents had been addressed by the home. The home has an open visiting policy. We had the opportunity to speak to some relatives during this inspection they told us “I have been visiting here for three years I wouldn’t want my relative cared for anywhere else”. “The care is very good both physical and emotional”. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 14 The home wants to support people so that they live as independent life as they can. The person in charge told us there has been some training recently that included the Mental Capacity Act 2005. It is recommended that all staff have some training in this area, this will help staff to understand their roles and responsibilities when supporting someone who may not have the capacity to make their own decisions. We sat with some of the residents for lunch. We saw that tables were laid and residents we enjoying a glass of wine with their meals in some cases. The meal was very tasty and well presented. We saw people being helped to eat their meals and staff did this in a sensitive and caring way. Residents said, “The meals are good”. “I love the meals”, “The food is very good and well prepared and varied”. Staff told us “the food is freshly prepared and there is always a choice for people to have”. The home has also been recently awarded a 4 star rating from the environmental health office for food hygiene. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 15 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): 16,18 Quality in this outcome area is good. People who live here can feel assured that their concerns will be listened to and acted upon. They will be protected from harm or abuse by appropriately trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear complaints policy that is on display throughout the home. The home told us “the ethos of the home is open and transparent, we welcome comments and suggestions and use them in a positive way to improve the service we provide”. The home has received no complaints in the last 12 months. We asked staff how they deal with concerns raised by residents they said “we always try to sort everything out as quickly as we can so that people don’t get too upset”. The home has appropriate policies in place for dealing with Safeguarding issues. Staff can also raise issues using the homes whistleblowing policy. Staff continue to have training in Safeguarding issues and the home has a rolling programme of training to make sure all staff do this. This will ensure that staff are aware of the signs of abuse and what to do if an allegation of abuse is disclosed to them. The home also makes sure that when recruiting staff it completes the required safety checks against the Protection of Vulnerable Adults list (PoVA) and Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 16 Criminal Records Bureau (CRB). These checks help to prevent unsuitable people working with vulnerable adults. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26 Quality in this outcome area is good. People live in well maintained and clean home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is welcoming and pleasantly decorated. Since our last inspection the home has told us that the following improvements have taken place. The kitchen, cellar and food storage areas have all been refurbished and redecorated. This enables the home to store more food and offer residents more choice. Some of the bedrooms have been re-carpeted along with the entrance hall, corridors and office. The lounges main staircase and landing have also been re-carpeted. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 18 The exterior woodwork has also been painted. Double glazing units have been replaced in the conservatory and the French windows have been refurbished. All of these improvements make the home a pleasant place to live. We spoke to some of the people who live there they said “I like my room, it’s smaller than I’d like but it has my possessions in it”, “sometimes it can take a while for things to get done, like the replacement of light bulbs which we need so that we can read”. “I have a lovely view from my room”. We were told by one resident that on occasion there is no hot water in their bedroom for them to wash with. We looked at the home’s records and found that they were not recording temperature in residents bedrooms. The person in charge told us “the person usually checks the bath temperature but we weren’t aware that we needed to monitor the bedrooms”. We have made a requirement that this is done. Residents must have access to hot water at any time of the day. The home must take action to ensure this happens. The registered provider, Dr Mahanta told us “ we have only just had the heating and water checked, we were not aware there was a problem no one has mentioned this to us. We will take action straight away to sort this out”. One person told us “They could improve by putting the footrests on the wheelchairs”. We also saw that staff were using wheelchairs without footplates, this can be dangerous practice given the risks to the person in the wheelchair. We discussed this with the person in charge who told us “some residents get nasty skin tears from the footplates so we have taken some of them off”. We have required the home to assess the risk to each person who uses a wheelchair in this way. Advice should be sought from wheelchair specialists about the best way to manage this risk to residents. The home has good systems in place to manage infection control. Staff have access to gloves and aprons, all communal toilets and bathrooms have liquid soap and paper towels. These measures will help reduce the spread of infection to residents. Staff are also having training in infection control this will help to keep their knowledge and practices up to date. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. There are sufficient numbers of staff on duty at all times to meet the needs of the people who live here. Staff are recruited safely and are given training to ensure they develop the skills they need to do the job. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels have not changed since our last visit they are as follows: One and two qualified nurses on duty on the early shift. There are usually two trained nurses on duty on the early shift for 5 shifts a week. For the rest of the 24 hours a day there is one qualified nurse on duty and additionally, on the: • • • Early shift (7.30 – 2.00) there are 6/7 care staff. (Some care staff start and finish at different times to ease the daily workload and this continues to be working well.) Late shift (2.00 – 9.30) there are 5 care staff Night shift (9.30 – 7.30) there are two care staff Two domestics clean the home in the morning and a further domestic is employed at night, all domestic staff also undertake laundry duties. The care manager reported that this system is working very well. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 20 We looked at the recruitment files for two new staff members; there were some shortfalls in the required information such as photographs, proof of identity and a full employment history. Dr Mahanta told us “staff files are kept upstairs in my office and I photocopy the CRB and application so that the manager can keep these in her office”. It was recommended that an audit of staff files be undertaken against the Care Homes Regulations 2001 to make sure that each file has the required information. It was also recommended that staff files be kept in one place to avoid duplication of information and confusion. The home has introduced a new induction programme for new staff based on the Skills for Care common induction standards. We were able to speak to new workers during the inspection about there experience and the support they felt they were being given. There were no “paper” copies of the induction records available at the time of inspection to examine. The person in charge was unable to locate them and the manager was not at work. It is recommended that copies of induction workbooks are kept with training records or in individual staff files so that they can be inspected when we visit. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. The home is run in the best interests of the people who live there. The manager is experienced and is fit to be in charge of this home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home has been in post for many years and has a lot of experience. People told us “she is very good, she will help with anything”. Staff said “she is always trying to do new things and keep on top of developments”, “I feel that I would be able to go to her if I was unhappy about something”, “we are supported by the manager”. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 22 The home has a good management team with the provider Dr Mahanta, Matron Mrs Broadway and the facilities manager all providing day to day care and attention to the home. Policies and procedures are updated to reflect changes in legislation and staff are aware of them. The home does have a Quality Assurance system. This system involves regular audits of the home environment, medication and care planning. The records we saw were slightly out of date and audits needed to be completed again. It was positive to see that residents and their families have been consulted about the care and service they receive from the home. There is also provision for meetings for residents, staff and relatives to take place but again this has not happened for a while. The home has good systems in place for dealing with residents money. We saw that there are locked facilities in the home for them to do this. If residents choose to keep their own money they do have a locked facility in their bedrooms. We checked the monies of three of the residents all were correct and the home keep good records of all outgoing and incoming transactions. The health and safety of residents is promoted throughout the home. There is regular staff training. The matron has produced a training matrix that showed that training is undertaken but there are gaps to be addressed. Fire records and training we up to date. Hoists and lifts have all recently been serviced. Accidents are reported properly and records kept. We have already mentioned the potential risk to residents by not using footplates on wheelchairs and this must be addressed. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 24 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 OP38 Regulation 13 (4)(c ) Requirement Timescale for action 30/05/08 2 OP25 23 (2) (j) The risk to people’s health and safety should be individually assessed and recorded when not using footplates on wheelchairs. This must be kept under review. Hot water temperature must be 30/05/08 monitored in people’s bedrooms. The home must record this and take appropriate action when the temperature is outside of recommended guidelines. 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 2 3 Refer to Standard OP1 OP7 OP10 Good Practice Recommendations Information on the range of fees payable should be included in the Service User Guide. The home should develop a more person centred approach to care planning so that individual preferences are reflected. Staff may benefit from more training in privacy and dignity to ensure that resident’s rights are not being DS0000022373.V361941.R01.S.doc Version 5.2 Page 25 Shenstone Hall Nursing Home 4 OP14 5 6 OP29 OP33 compromised. Staff should have training in Mental Capacity Act 2005 so they are aware of their roles and responsibilities when supporting someone who may not be able to make some decisions. The manager should audit all staff personal files to make sure that all required information is available. The manager must continue to develop the Quality Assurance system and produce an annual report on the findings. Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Shenstone Hall Nursing Home DS0000022373.V361941.R01.S.doc Version 5.2 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. 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