Care Home: The Shelbourne At Sway

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What the care home does well The service provides a luxurious environment with a wide range of facilities to enable people who use the service to have a good quality of life. The unit that provides support to people with dementia has been designed to make it easy for them to orientate themselves through the use of colour and personal objects of reference. People who use the service say they are encouraged to be independent, but are given the help they need when they need it. Comments made included: `I think this place is brilliant. Staff go out of their way to suit me.` `It`s very good here; they look after you very well. I have got better since I came.` `There is no where like your own home, but this place is the next best.` `Staff here are wonderful, I can`t speak highly enough of them.` People who use the service have a comprehensive assessment of need before moving in. This enables the registered managers to have a clear picture of what support the person will need in all aspects of their personal care and daily living routines. The service is developing good systems to monitor what is provided. Good communication between various departments ensures the smooth running of the service. Issues raised by people who use the service are listened to and acted upon. Staff have the opportunity to complete training and get qualifications that enable them to develop the skills they need to provide support to people who use the service. What has improved since the last inspection? N/A What the care home could do better: Staff felt they had a good induction, but the service needs to develop a formal system of monitoring, assessing and recording staff development during their induction period. The AQAA identified that the service plans to introduce a quality audit system to monitor all aspects of service provision and to help plan the future development. The responsible individual confirmed this will include an annual survey sent to people who use the service, their relatives and relevantprofessionals. Consideration needs to be given to how the views of people who use the Nostalgia Neighbourhood will be sought. Although the responsible individual visits the home several times a week, he now plans to introduce a monthly audit of the service. This is called a Regulation 26 visit and includes a written report that gives feedback to the registered managers about how well the service is being managed and any changes that need to be made. CARE HOMES FOR OLDER PEOPLE The Shelbourne At Sway Sway Place Church Lane Sway Hampshire SO41 6AD Lead Inspector Pat Trim Unannounced Inspection 25th November 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Shelbourne At Sway DS0000072160.V373064.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. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Shelbourne At Sway Address Sway Place Church Lane Sway Hampshire SO41 6AD 01590 681439 01590 681657 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) Shelbourne Senior Living Ltd Mrs Margaret Houston Tomlin Mrs Gina Anne Markham Care Home 68 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only – (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 2. Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 68 Date of last inspection Brief Description of the Service: Shelbourne at Sway is a purpose built residential care home catering for 68 older persons and people with dementia. The home is set in 6 acres of land and offers three distinct areas of service. The Assisted Living (for older persons) on the ground and first floor. The Nostalgia Neighbourhood (for people with dementia) on the second floor and separate cottages for sheltered accommodation, which are not subject to registration. The Assisted Living service is provided over the ground and first floor and provides a service for up to 43 people in the older persons category. There are 35 bedrooms, 27 are for single occupancy and 8 bedrooms, called bedroom suites, which includes a bedroom, en-suite, kitchenette and separate lounge. These rooms would be able to accommodate if requested, two people who wish to live together, for example a married couple. The Nostalgia Neighbourhood is situated on the second floor and is accessed through doors operated by keypad. The unit is well set out and promotes and encourages independence through enabling residents to move around and explore without hindrance or unnecessary restriction. There are 25 single rooms with en suite facilities. There is an extensive range of communal space including a large central atrium, furnished with armchairs, a tea palace, bar, cinema, fitness suite, The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 5 library with internet access, hairdressing salon, and private dining room. Each of the two units has a range of lounges, dining room and activities rooms. The range of fees given at the time of the visit was from £637.00 to £1200.00 per week. Services not included in the fee are hairdressing, physiotherapy, dentist, chiropodist and dry cleaning. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people who use this service experience good quality outcomes. The information used to write this report was obtained in the following ways. This was the first inspection visit made to the home since it was registered in June 2008, so there were no previous inspection reports to read, but information was taken from the registration report. We looked to see if we had received any complaints about the home and saw that we had not. We also looked at any information the home had given us about what might have happened since we visited and any information we might have received from other sources. We used some of the information the provider gave us about the home in a form called the Annual Quality Assurance Assessment (AQAA). This is a form the home has to fill out every year to tell us what they are doing to make sure the home gives the people who have used the service the care that they want. We also used information we received from surveys. We sent surveys to people who use the service to ask what they thought about it. We received four surveys back. We sent staff surveys to the home and asked them to give them to staff. We received 12 surveys back. We made a 7 hour visit was made to the home to carry out a key unannounced inspection. At the time of the visit 11 people were using the service. Time was spent talking with 4 of them to get their views about it. Time was also spent observing staff practice and the interactions between people who use the service and staff. There was also an opportunity to speak with 4 visitors to the home and to get the views of 2 members of staff who worked in the home. Time was also spent talking with the responsible individual and registered managers about their plans for the service. A partial tour of the environment was carried out and a random selection of documents was viewed. 4 people who use the service were case tracked. This means their records were looked at to see how the provider identified their needs and made sure they were met. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: Staff felt they had a good induction, but the service needs to develop a formal system of monitoring, assessing and recording staff development during their induction period. The AQAA identified that the service plans to introduce a quality audit system to monitor all aspects of service provision and to help plan the future development. The responsible individual confirmed this will include an annual survey sent to people who use the service, their relatives and relevant The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 8 professionals. Consideration needs to be given to how the views of people who use the Nostalgia Neighbourhood will be sought. Although the responsible individual visits the home several times a week, he now plans to introduce a monthly audit of the service. This is called a Regulation 26 visit and includes a written report that gives feedback to the registered managers about how well the service is being managed and any changes that need to be made. 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. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information they need to enable them to choose whether to move in. Detailed pre admission assessments ensure that people are only offered a place in the home if the service can meet their needs. EVIDENCE: The statement of purpose is available in a range of formats to enable everyone to have the information they need about the service. It informs people that wish to use the service an assessment of need will be completed before they are offered a place. It also asks people to visit the home prior to admission. Feedback from 4 surveys, completed by people who use the service, and from conversations with people living in the home, showed they felt they had sufficient information to enable them to make their decision. Comments The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 11 included: I made lots of visits before I moved in and we came and looked round. The AQAA recorded that everyone was required to have an assessment of need completed by one of the registered managers before moving into the home. The assessments for 4 people who use the service were viewed. These were very detailed, giving information about abilities and needs, personal preferences and daily routines. For example, the registered manager assessed abilities and needs in relation to mobility, health care, social/emotional support, nutrition, personal care, sleeping and daily life. People who use the service were asked to complete a life story, which included interests past and present, as well as information about family and occupational history. Risk assessments were completed to identify any areas of risk. These looked at the level of risk, contributing factors and strengths and gave staff guidance on how the risk should be managed. For example, the assessment showed one person was considered at low risk of falling, but contributing factors were that the person attempted to move unaided and had dementia. The strengths were that the person had no falls for the past 3 months and did not wander. Staff were therefore required to monitor the persons mobility and report any changes. They also had to make sure the person had their walking aid next to them and could reach the call bell. Some risk assessments seen had not been fully completed. This was discussed with Margaret Tomlin, one of the registered managers, who agreed to review them to make sure they were full completed. There was evidence that assessments were being reviewed. One person had moved from Assisted Living to the Nostalgia Neighbourhood and had their assessment reviewed and care plan amended. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 12 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. Care plans based on the persons abilities and needs make sure people who use the service receive personal care in a way that respects their dignity, privacy and choice. People who use the service have their health care needs monitored, which makes sure they are referred to health care professionals when they need to be. Staff receive the training and guidance they need to support people who use the service to manage their medication safely. EVIDENCE: Each person has a care plan which identifies what they can do for themselves and what help they need. For example, one person liked to put on her own makeup but sometimes got upset when she could not remember where she had put it. The care plan instructed staff to remind her where it was as often as she needed and not to rush her when giving help. Plans give very detailed guidance on individual personal care such as whether someone needs help with hair spray, uses soap on their face, likes nail varnish or uses perfume or aftershave. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 13 The AQAA recorded that, wherever possible, people who use the service were involved in planning their care. Some information was recorded in the first person and people who use the service had been asked to sign the paper record to show they had been involved in their assessment and care plan. The registered managers said families were involved in supporting people who lived in the Nostalgia Neighbourhood in the care planning process. Feedback from people who use the service showed they felt staff knew what help they needed and gave the care in the way they wanted it. Comments included: The staff are very good here; they look after you well You get constant attention. Just as good at night The staff are wonderful, always come when you need them. As the service is new, people who use it have not lived there for long yet and so the majority have not had a review. A discussion took place about the need for a system of review to be introduced, which showed why care plans were amended or remained unchanged. The registered managers said this was being developed. People who use the service thought their health care needs were monitored and met. One person said My doctor visits me regularly and I can see him when I want. Another person commented on how well the staff had worked with health care professionals to meet the needs of their partner. Daily records showed that people were able to see a range of health care professionals such as dentists, district nurses, community psychiatric nurses and chiropodists. Assessments identified whether referrals were required and records showed appointments were made. Medication is ordered on a monthly basis and supplied by a pharmacy in a monitored dosage system. Records showed there was a system for checking medication in and returning unused supplies to the pharmacist for disposal. The pharmacy also offers training for staff and a regular audit of the homes medication procedures and storage. Medication is stored appropriately on both units, with lockable facilities available for people who self medicate. Staff were observed following good practice guidance when giving people their medication. A sample of medication administration records checked had been completed correctly. The medication procedure states that only staff who have received training are permitted to give medication. The member of staff giving medication to people living in the Nostalgia Neighbourhood said she had completed training and a copy of her certificate was seen. However, there was no record that the registered managers had observed staff giving medication to assess their competence and it was suggested that this should be implemented. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 14 The registered managers completed a medication risk assessment before people moved into the service. This showed whether they wished and were able to manage their own medication safely. Comments received from feedback surveys showed people thought staff gave them the assistance they needed with their medication. People who use the service thought staff treated them with dignity and respect at all times. Staff were observed knocking on doors and waiting for permission to enter. They were also seen giving unopened post to people who use the service. The assessment records a persons preferred form of address and staff were heard using these titles. There is a treatment room in the basement where people may see health care professionals if they do not wish to see them in their rooms. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 15 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. People who use the service are able to make choices about how they spend their time. They are able to join in a range of activities that provide mental stimulation and that they enjoy. People who use the service are able to choose what they eat from a range of nutritious meals that they enjoy. EVIDENCE: Care plans included detailed information about peoples daily routines, such as whether they like to get up and have breakfast, or preferred to have it in their rooms. At 9 a.m. some people were up, whilst others were still in their rooms. People who stay in Assisted Living are able to move freely round the communal areas on the ground and first floors. The main entrance opens into a large communal area, called the atrium, which has a tea/coffee bar called the Tea Palace, drinks bar and lots of comfy armchairs. People were seen coming to order drinks and sitting reading or chatting to each other and to visitors. There is also a private dining room that can be hired for family occasions. Visitors to the home said they were made very welcome and able to have drinks or meals. One person said she often had breakfast with her relative. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 16 The service has a library, which has a range of books, some in large print and is visited by Hampshires mobile library scheme. There is also a computer with internet access. Gina Markham said people wishing to develop their computer skills can access a training course, or staff are available to assist. A fitness suite is to be added soon and there is a cinema, activities room and hairdressing salon. A freelance hairdresser visits the service every week. On the first floor there is a television lounge and a quiet lounge so people have choice about where they spend their time. People who live in the Nostalgia Neighbourhood are able to move freely around the unit and can choose to spend time in their rooms or in any of the communal areas on the second floor. They are also able to access all the facilities referred to above, when accompanied by a member of staff. The detailed care plans record past and present hobbies and the registered managers said this information is being used to plan activities. For example, one person from the Nostalgia unit liked to garden and to spend time at the beach. The registered manager said there were plans to add a garden shed and beach hut to the enclosed garden area belonging to the unit. People who use the service felt enough activities were arranged and that they were able to make choices about how they spent their time. One person commented that there was always something to do if you wished but that you could also choose not to join in. Information about the various activities are displayed on a notice board on each unit. The print is small so it was recommended that larger print be used and possible alternative ways of giving information to people living on the Nostalgia Neighbourhood be considered. The service employs an activities co-ordinator, who arranges a wide range of activities and trips out. On the day of the visit, she was arranging for someone to come and play the piano each week. Recent trips out have included visits to Hythe and Burley and a walk round Sway. In house activities included quizzes, craft and social events. Maggie Tomlin, the registered manager of Nostalgia Neighbourhood said she was developing an activities programme for smaller groups or with 1 to 1 support to ensure people with dementia had a varied and stimulating activities programme. Staff had already completed activities training and were going to undertake further courses to help them develop skills to support people who use the service. Gina Markham, the registered manager of Assisted Living said the service wanted to develop and maintain links with the local community. There is a weekly coffee morning, attended by people from each unit, friends and relatives and people from the local community. People who use the service are also able to go to a weekly coffee morning at the local Church. A minister The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 17 visits the service every month to hold a communion service for those who wish to attend. Information given to people before they move in tells them they may bring personal possessions with them. Those spoken with during the visit confirmed they had been able to do this. Comments made by people who completed survey forms and by people spoken with during the visit showed they usually liked the meals provided and thought they had choice. One person had commented that meals sometimes took too long to be served, but said this had improved since they completed the questionnaire. People are able to give their views about the meals served at regular residents meetings. The service employs a chef and kitchen staff to provide all the meals, although people who stay in Assisted Living have a small area in their rooms where they are able to make hot drinks and snacks. The registered managers said people are not expected to pre order their meals. Instead, they choose what they want from the selection of main meals and puddings from the menu at the time of the meal. They may have a cooked meal at every mealtime and there was a choice of at least 3 main meals offered. Meals were well planned with a good selection of fresh fruit and vegetables. Staff who work with people living in the Nostalgia Neighbourhood said they establish what people like and dislike as part of the assessment and a record is kept in the serving area. Margaret Tomlin said staff closely monitor if the person appears to like what has been offered and an alternative choice is ordered if they do not. At present there is no-one living there who is not able to choose what they wish to eat, but plans are in hand to offer choice using methods of non verbal communication, such as the use of pictures or showing people plated meals. She is also introducing finger food to help people continue to be able to eat independently. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 18 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 who use the service have the information they need to be able to make complaints. The registered managers and staff have the training and information they need to enable them to follow the safeguarding procedure effectively and to minimise the risk to people who use the service. EVIDENCE: The AQAA recorded We have a complaints and feedback system in place to ensure all concerns are listened to and dealt with. The Statement of Purpose gives people information about the complaints procedure and feedback from people who use the service showed they felt they would be able to raise issues and have them resolved. No one who gave feedback had made a complaint. The AQAA stated that no complaints had been received and the commission had not received any either. Feedback from 12 staff survey forms confirmed they knew how to support people who use the service to raise issues. One staff member commented I know about the complaints/concerns/compliments procedure. It is clearly documented and explained during the induction session. Each resident is given documents in their move in pack. The service had a safeguarding policy and procedure in place. Feedback from staff evidenced they felt they had sufficient training and guidance in respect of safeguarding. Staff spoken with showed they knew what to do if someone made an allegation of abuse to them. The registered managers said staff were The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 19 able to attend safeguarding training and certificates of attendance were seen on the 3 staff files viewed. The training co-ordinator confirmed staff received training about working with challenging behaviour as part of their induction. Two new staff were having their training on the day of the visit. One registered manager recently had the opportunity to demonstrate her understanding of the safeguarding procedure by making a referral to Adult Services. Both managers are now aware when to use the procedure and have shown their willingness to work with Adult Services to safeguard people who use the service. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 20 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 excellent. This judgement has been made using available evidence including a visit to this service. People who use the service live in a clean, comfortable, safe environment that meets their needs and that they like. Staff have the training and guidance they need to protect people who use the service from the risk of infection. EVIDENCE: The service has been furnished to a high standard. The communal areas on the ground floor and first floor are well thought out and arranged so people who use the service have lots of different places to sit. There are extensive facilities, which provide a range of activities, already referred to in previous sections of this report. People who use the service thought the environment was very good and particularly liked the tea palace and atrium. The service has accommodation that may be booked for visitors who wish to stay overnight. The second floor has been designed to provide an environment that enables people with dementia to remain independent. There is a central corridor The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 21 around the atrium, which means people have plenty of space to walk. This area has been furnished with a range of objects that people can handle. For example, there is an old fashioned typewriter with paper, a hat stand with hats and a crib with a baby doll. Sensitive signing has been used to help people orientate themselves. Toilet doors are all painted the same colour and each bedroom has a designated space for an object of reference, such as a photograph or favourite picture to help people identify their room. There is a quiet room with sensory equipment. All corridors are wide and well lit, with handrails to help people with limited mobility. Each person has their own en suite facilities and there are also communal bathrooms with specialist baths for people who need help with bathing. There is a formal garden with seating areas and level access paths. The ground floor bedrooms have patio doors that open on to it, which can be linked to the alarm system. The first floor communal rooms have patio doors that open onto balconies. There is a separate enclosed garden that people who live in the Nostalgia Neighbourhood may use unaccompanied, although they do need a member of staff to help them get to it. The responsible individual stated that Environmental Health and Hampshire Fire and Rescue service visited to establish compliance with their regulations when the service opened. There were no requirements. The service employs a housekeeping team to carry out all the cleaning. There is a cleaning schedule and people who use the service said they were very satisfied with the level of cleanliness. One person said she liked to do her own dusting, but staff did the rest of her cleaning every day. The service employs a maintenance team to keep the environment well maintained. Heads of all sections give information to the head of maintenance about any work that is required in their specific areas. The laundry is situated in the basement and cannot be accessed by people who use the service. Industrial washing machines are fitted that have disinfection programmes. Housekeeping staff are responsible for doing all laundry tasks and have clear procedures for dealing with soiled linen. The AQAA recorded that all staff have recently completed infection control training and certificates were seen on 3 staff files. The service has a contract for the removal of clinical waste and for the disposal of sharps. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 22 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. A well-trained and supervised staff team in sufficient numbers to meet their diverse needs supports people who use the service. A robust employment procedure makes sure the risks to people who use the service are minimised. EVIDENCE: People who use the service said they felt well supported by staff, who responded quickly to requests for assistance. One person commented staff always come when they are needed. As the service is gradually filling up, staffing levels are being monitored and increased as required. The registered manager for the Nostalgia Neighbourhood said staffing levels would be flexibly arranged to reflect the needs of people who used the service, but the projected staffing level for this unit was a minimum of 1 staff to 4 people who use the service. This was reflected in the staffing level for the day. The staffing levels for Assisted Living will be dependent on how many people using the service require help, as some people will not need the services of care staff. The registered manager for this service also stated levels will be flexibly arranged to meet the needs of the people who use the service. Care staff are supported by housekeeping staff who undertake all cleaning and laundry tasks, and kitchen staff, who prepare and serve all the meals for the The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 23 Assisted Living dining room. Meals for the Nostalgia Neighbourhood are sent from the kitchen to the serving area on the unit, via a service lift. The service has a recruitment procedure that ensures all relevant checks are completed. 3 staff files seen showed this was consistently followed. Each file contained sufficient information, such as Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks, full employment history, references and interview notes, to enable the provider to be satisfied recruited staff did not present a risk to people who use the service. One person had a reference on the file that was addressed to whom it may concern. The person who dealt with staff applications said she normally sent for references, following receipt of the application. The need to ensure references were sought directly by the provider was discussed and it was agreed only solicited references would be accepted in future. Staff felt the employment procedure was thorough and fair. Comments included very thorough checks made, 10 year history, references, CRB etc and even though I had a current (CRB) from my previous employer I was asked to undergo another one before I started. The service employs a training co-ordinator, who monitors and arranges training. This includes the initial induction of staff. An induction checklist is completed to ensure staff have received the information they need on the first day of their training. In house training in respect of dementia care, working with challenging behaviour and fire safety, complements this. On the day of the visit, two staff were completing their initial induction. They were seen being introduced to people who use the service, having coffee with them and having the training referred to above. The training co-ordinator said after completing this part of their induction staff work alongside more experienced staff, as well as completing relevant training courses. Whilst it was evident from staff comments that this part of their training is completed, no written records are currently kept of this part of the induction, or of any assessment that staff are competent to work independently. This was discussed with the provider, registered managers and training coordinator, who agreed to look at ways of recording induction and competence and to refer to the Skills for Care guidance. Feedback from 12 staff surveys evidenced they felt they received good training and supervision, relevant to their role. One staff stated We liaise very closely with Brockenhurst College for mandatory training and are regularly kept up to date with all new developments in the training sphere. Staff records showed they had the opportunity to undertake mandatory training, such as moving and handling, infection control and food hygiene, as The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 24 well as service specific training, such as dementia care and working with challenging behaviour. The AQAA recorded that 61 of staff had completed their National Vocational Training (NVQ) 2. Feedback from staff and certificates seen on files confirmed staff were supported to complete qualifications. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 25 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. The service is well managed and systems are being put in place that enable people who use the service to give feedback about it. The service is regularly monitored to make sure people who use the service are protected against the risk of injury. EVIDENCE: The registered manager for the Assisted Living has extensive previous experience of managing care services. She has a National Vocational Qualification (NVQ) 4 and the Registered Managers Award. The registered manager for the Nostalgia Neighbourhood has extensive previous experience of managing residential services and working with dementia. She has a National Vocational Qualification (NVQ) 4 and the Registered Managers Award. Feedback from people who use the service, visitors to the service and staff The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 26 showed they felt the managers were approachable and had an open door policy. There is good communication between departments. Each aspect of the day to day running of the home has a different team, responsible to the head of that department. Every morning there is an informal meeting of the heads of departments to share information about the service and make sure the service operates smoothly. The AQAA recorded that the service plans to introduce a quality audit system. All aspects of the running of the home are being monitored and will be reviewed at the end of the first year. The responsible individual, Mr. Ken Waterhouse, is also the Managing Director of the company and said he was currently acting as the General Manager. This meant he was based at the community full time. He had not, therefore, introduced formal Regulation 26 visits. This was discussed and it was agreed these monthly visits would now be introduced as part of the quality audit system. The service returned the AQAA in good time and gave detailed information about what the service currently does to meet the Regulations and about future development. People who use the service said they were able to give feedback about the service at regular residents meetings. There was evidence the service responds to comments made by people who use the service. One person had commented in the survey form sent to the commission that meals took too long to serve. On the day of the visit the person said the time taken to serve meals in the dining room had greatly improved in the last few weeks. Another person had commented that the metal strips used to join carpets were dangerous, as people had tripped over them. They had all been replaced. The training co-ordinator had a matrix that enabled her to monitor staff training needs and to arrange refresher training when required. Staff were able to attend training courses in respect of health and safety such as food hygiene, moving and handling and infection control. They have fire safety training, including fire drills. A number of test and maintenance certificates were required to be submitted as part of the registration process. A random selection of certificates seen at the time of the visit demonstrated the service has arrangements for the regular maintenance of services and equipment. The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 27 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 “ ” 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 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection CSCI South East The Oast, Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 The Shelbourne At Sway DS0000072160.V373064.R01.S.doc Version 5.2 Page 30 - 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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