Inspection on 17/01/06 for Sherwood Lodge

This inspection was carried out on 17th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sherwood Lodge 01/06/05

Sherwood Lodge 07/02/05

Sherwood Lodge 25/05/04

Sherwood Lodge 04/12/03

Sherwood Lodge 19/08/03

Sherwood Lodge 28/01/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sherwood Lodge 71 Atheldene Road Wandsworth London SW18 3BU Lead Inspector Louise Phillips Unannounced Inspection 17th January 2006 09:40a 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 Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sherwood Lodge Address 71 Atheldene Road Wandsworth London SW18 3BU 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) 020 8874-4251 020 8870 3815 Servite Houses Mrs Nelly Iweha Care Home 47 Category(ies) of Dementia - over 65 years of age (47), Old age, registration, with number not falling within any other category (47) of places Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st June 2006 Brief Description of the Service: Sherwood Lodge provides care and support for up to 47 residents who may also have dementia care needs. Accommodation at the home is provided over two floors, divided into the four living areas of Jasmine, Bluebell, Rosemary and Lavender. Each area has its own kitchen/ dining room, lounge, bathroom and toilet facilities. The home is situated in a quiet residential road and is close to transport links and public amenities. Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day with time spent talking to residents, staff, the manager and viewing paperwork. A tour of the premises was carried out, with care and staff records inspected. Seven staff and three residents were spoken during the inspection. What the service does well: 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 contacting your local CSCI office. Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 6 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 Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The new care planning system needs to be simplified. Good improvements have been made to ensure that residents are given their medication correctly. EVIDENCE: The previous inspection of Sherwood Lodge raised concerns about the new format of care planning that was due to be implemented at the home. A requirement was made for this to be more simplified so that it would be easier to understand for the staff and residents at the home. Following a discussion between two area managers of Servite Houses and the CSCI in October 2005 it was agreed that this care plan format could be implemented on a ‘pilot’ basis for a period of six months, where the use of this would then be reviewed and changes made where necessary. At the time of this inspection the new care plan format was being implemented at the home. A number of staff were spoken to about how they found using the new care plan format. The responses were: Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 9 “…it is fine…” “…I find it very confusing…” “…there are so many bits of paper – I don’t see the point of a lot of it…” In addition, the manager discussed the particular problems that some staff with poor literacy skills are having trying to complete the care plans, where she said that senior staff are having to write the plans for them. The content of information in the care plans is good and the staff have taken care to write in areas only where a need has been identified for the resident. In addition, the writing in the daily care notes have improved a lot to provide a much more detailed picture of what the resident has done, and the care provided throughout the day. Due the responses from staff and the need to decrease the amount of paperwork the requirement has been restated to ensure the care planning system is more simplified and accessible. Good improvements have been made to checking that residents are given the right medication. Spot checks are carried out monthly on the medication records and actions taken to address any discrepancies, whether it be reminding staff or contacting the pharmacy where discrepancies have been found. Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Activities are provided for the enjoyment of residents, though not specific to the needs of residents with dementia. Residents have good food served in a respectful manner. EVIDENCE: The manager described that one care worker is nominated to carry out and plan activities for the residents. The care worker does this once they have assisted residents with their personal care needs in the morning. The carer has received no formalised training in providing activities for older people, or for people with dementia and it is required that they receive this training. The home offers a variety of activities throughout the week, such as snooker, baking and group exercises. Photos around the home also show the AfroCaribbean party that was held at the home in August last year. Last summer the home sent questionnaires to each resident to gain their feedback on the activities provided. The manager stated that the responses and suggestions for different activities were used to develop the weekly timetable of activities offered at the home. Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 11 One of the residents spoken to said that they did not join in the activities, but commented that “…I get my fags, paper and food, I’m happy…” Lunch was seen being served, where the main meal was mashed potato, sausage and onion gravy and broad beans; or an alternative if residents preferred. The food looked appetising and good portion sizes given. Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The manager is proactive in addressing concerns raised about the home. EVIDENCE: The manager described a complaint that had recently been received at the home. She discussed that she had encouraged the complainant to put their concerns in writing to enable a thorough investigation to be carried out. The records detailed that the investigation was well managed and an appropriate outcome received. Staff records indicate that they had received recent training in abuse awareness. Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26 Good improvements have been made to the décor in the home, though further work is needed to make it more homely and comfortable for the residents. EVIDENCE: Since the last inspection the home has addressed a number areas that required redecorating. The most noticeable improvements were the complete refurbishment of the bathroom in the annexe area, the new floor surface in Bedroom 30 and the replacement of the televisions on each unit around the home. At the time of the inspection the bathroom on Jasmine unit was being redecorated by the new ‘handyman’ employed by the home. There are some areas that still need attention, particularly the refurbishment of the sluice room on Bluebell unit, repairing of the skirting board in the female toilet on Jasmine unit and the redecoration of all communal areas throughout the home. Requirements have been restated to address these issues. Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 14 Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 Staff receive some appropriate training for their role, though no training specifically for the care of people with dementia. EVIDENCE: Following the last inspection, the manager stated that the home is currently recruiting for night and senior carers to enable three staff to be on waking duty throughout each night. The staff training records for the past year reflects that courses have been undertaken in abuse awareness, medication awareness and induction for new staff. The records indicate that staff receive training in ‘dementia awareness’. For a home registered to provide care for up to 47 people with dementia the training of staff should be at a more than just an awareness level, and it is required that all staff undertake formalised training in dementia care. Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 Residents benefit from the experience and commitment of the manager at Sherwood Lodge because the home is run in the best interests of the residents. EVIDENCE: “…manager and her assistant are lovely, lovely, I couldn’t fault them…” This comment was received from a resident at the home, and echoes the responses of residents about how they feel the home is managed. The manager of Sherwood Lodge demonstrates a good sound knowledge of her responsibilities and the importance of balancing these with the needs of the residents at the home. The manager also has a good awareness of the areas of improvement needed to develop the service further. She is currently working towards obtaining the NVQ level 4 in Management. Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 17 The home has taken positive steps to ensure the safe storage of cleaning products on the units around the home. Monthly checks are also carried out on first aid boxes around the home. Further improvements since the last inspection have been the continuation and appropriate recording of one-to-one supervision sessions with staff. In addition, regular staff meetings, residents meetings and twice yearly meetings with relatives of people living at the home. Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X X 3 X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1)(2) Requirement The Registered Persons must ensure that the care plans at the home are in a format that is easily understandable and accessible to the staff and residents. (Previous timescale not met) The Registered Persons must ensure that staff who provide activities receive specific training in providing appropriate activities for residents with dementia. (Previous timescale not met) The Registered Persons must ensure that the following maintenance/ hygiene issues are addressed: - the bathroom on Jasmine unit is redecorated - the skirting board in the female toilet on Jasmine unit is repaired - the communal areas throughout the home are redecorated. (Previous timescale not met) The Registered Persons must ensure that the sluice area on Bluebell unit is refurbished DS0000010223.V281931.R01.S.doc Timescale for action 30/03/06 2 OP12 16(2)(n), 18(1) 30/03/06 3 OP19OP21 23(2) 30/03/06 4 OP26 23(2)(b) 30/03/06 Sherwood Lodge Version 5.1 Page 20 5 OP30 18(1) throughout. (Previous timescale not met) The Registered Persons must ensure that all care staff receive up-to-date and formalised training in dementia care. (Previous timescale not met) 30/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP27 Good Practice Recommendations The Registered Persons should ensure that the home have three waking staff (including one waking senior) on duty during each night shift. Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sherwood Lodge DS0000010223.V281931.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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