CARE HOME ADULTS 18-65
Sharpe House 1 West Road Wiveliscombe Somerset TA4 2JS Lead Inspector
Kathy McCluskey Announced 9 June 2005
th 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Sharpe House Address 1 West Road, Wiveliscombe, Somerset, TA4 2JS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01984 629220 Jedd International Ltd Mr Declan Joseph Howlett PC Care home only 10 Category(ies) of Learning Disability (10) registration, with number of places Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th January 2005 Brief Description of the Service: The home is located in the small town of Wiveliscombe and is situated a short walk from the local community and its facilities. Sharpe House is a large detached property arranged over two floors. The layout of the home would not be suitable for service users with a physical disability. All bedrooms are single and have hand wash basins. Some bedrooms are located on the ground floor. The home does not have a passenger lift to reach the first floor. The home has dining room, lounge, conservatory, and two bathrooms, domestic style kitchen, laundry room and well-presented garden. Sharpe House is registered with the Commission for Social Care Inspection to provide personal care for up to 10 service users, under the age of 65yrs, who have a learning disability. The home is not registered to provide nursing care. The home is owned by JEDD International Ltd. The registered provider is Mr Declan Howlett. Since the last inspection, the home has been successful in recruiting a manager. The application for Kath Hellings is currently being processed by the CSCI.
Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The home’s last inspection was unannounced and was conducted on the 20th January 2005. Five requirements and one recommendation were raised. Details of any outstanding requirements are detailed on the last page of this report. This announced inspection was conducted over one day (6.5hrs) by 2 inspectors, Kathy McCluskey and David Kidner. The manager designate was available throughout the inspection. A tour of the premises took place where all communal areas were seen. 10 service users were living at the home and the inspector was able to speak with 4 of them. 2 staff were spoken with. A period of time was spent unobtrusively observing interactions between staff and service users. Records relating to care, staffing and health and safety were examined. The inspectors would like to thank service users and staff for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well:
Service users live in a comfortable, homely environment and have easy access to local facilities. The home has produced a Statement of Purpose and Service user Guide which provides service users and prospective service users with information about the home and the services it offers. The home has clear and consistent care planning systems in place and the home seeks the advice and input of other relevant professionals where required. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 6 Service users are encouraged to be involved in all aspects of life at the home. Their views are encouraged and acted upon. Service users are involved in choosing colour schemes for areas which are to be decorated. Service users spoken with stated that they were happy with the level of input they had. The majority of service users benefit from meaningful activities outside of the home. The home has a good range of policies and procedures which are available to service users and staff. Some of these have been produced in symbol format for service users. As part of this announced inspection, CSCI comment cards were sent to all service users at the home. At the time of this report, 8 completed comment cards had been returned to the CSCI. Comment cards indicated the following: All service users felt safe and well cared for. All indicated that staff treated them well and that their privacy was respected. Five indicated that they were happy with the provision of activities. All indicated that they liked the food at the home and all indicated that they knew who to approach if they were unhappy with their care. What has improved since the last inspection? What they could do better:
Since the last inspection, the home has experienced changes within the staff team. This has resulted in the home now only having a team of 5 staff with the
Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 7 deputy manager due to leave within the next few weeks. Staff commented that they often worked long shifts. Since the last inspection, to aid recruitment, the home has recruited staff from overseas and it was noted that the some had no experience and others had limited experience in caring for people with a learning disability. Whilst the inspectors could see evidence that staff had received mandatory health and safety training, there was no evidence of training in aspects of caring for service users with a learning disability, managing challenging behaviour, or appropriate training in how to communicate with people with communication difficulties. This is concerning as the home cares for people with varied and complex needs. It has been required that appropriate action is taken to address this by 30/08/05. This will be followed up by the CSCI. Service users spoken with did comment on the kindness of staff. The home is not following the correct or robust staff recruitment procedures. A requirement has been raised and the registered person must take immediate action to address this. A requirement was also raised at the last inspection. During a tour of the premises the inspectors were able to see a selection of service user bedrooms. Some of these were noted to be below an acceptable standard of cleanliness and were shown to the manager at the time of the inspection. It was also noted that the kitchen required a deep clean. Some opened food items in the fridge had not been labelled with their open/expiry dates. A requirement has been raised that this is addressed. Improvements were noted in the home’s procedures for the management and administration of service user medication. The inspectors were able to see evidence that the requirement raised at the last inspection had been addressed. At this inspection it has been recommended that, to aid identification, the home should ensure that photographs of service users are attached to their individual medication records. It has also been recommended that any changes to prescribed medication is re-written and signed by two staff members. The home’s procedures for ensuring the health and safety of service users, staff and visitors are generally good though it has been required that the home maintains weekly in-house checks on the fire detection systems. This was also required at the last inspection. The home conducts regular fire drills for service users and staff though the registered person has been advised to ensure that a list those present, is maintained. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 8 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. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, and 3 Prospective service users are provided with the information they need to enable them to make an informed choice about moving to the home. The staff team do not have the collective skills or experience to fully meet the assessed needs of service users. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide which clearly identifies services offered by the home and ‘additional charges’. Additional charges are met by service users for toiletries, hairdressing, transport some activities and chiropody. The home has two cars and service users currently contribute 50 of their DLA mobility component towards the cost of transport. The homes fee range is between £298 and £565 per week. The CSCI have not been advised of any changes to the Statement of Purpose or Service user guide. At the time of this inspection, the home has full occupancy and the home has not had any admissions since 2002.
Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 11 Since the last inspection a number of staff have left employment and another is due to leave within the next week. On examination of records and discussion with staff, it appears that the remaining staff have very limited or no experience in caring for this client group and only the manager has training in Somerset Total Communication. It is recognised that other relevant professionals are involved with service users. Service users spoken with at this inspection informed the inspectors that the staff were kind and that they ‘helped them with things’. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 and 10 The home’s care planning system is clear and consistent. Service users are supported to take risks as part of their agreed plan of care EVIDENCE: Three care plans were examined at this inspection and each contained detailed information pertaining to the assessed needs of service users. Care plans had also been produced in symbol format for the benefit of service users. Care plans also contained 6 monthly reviews and copies of formal annual reviews. The inspectors were able to see evidence that service users had been involved in the review process. Service users are supported to take risks as part of their agreed plan of care. Appropriate risk assessments were seen in the care plans examined. Service users spoken with informed the inspectors that they were satisfied with the level of involvement they had with regard to decision making. Regular meetings are held for service users with meetings maintained. The inspectors were informed that, as some areas of the home are planned to be redecorated,
Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 13 at the next meeting service users will be encouraged to choose colour schemes. All records pertaining to service users are securely stored. Service users have access to their personal records in accordance with the Data Protection Act 1998. Service users and visitors have access to the home’s policies and procedures, some of which are available in symbol format. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16 and 17 The majority of service users benefit from meaningful activities outside of the home. Service users are offered varied and well balanced meals. EVIDENCE: Staff support and assist service users to maintain and develop personal and independent living skills in line with the individual’s agreed plan of care. At the time of this inspection, the majority of service users attend work or day placements. The home provides transport, for which service users contribute to the cost, and staff support service users to attend their placements where appropriate. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 15 The home encourages service users to access local leisure facilities and to pursue their own hobbies/interests. Local facilities currently utilised by service users include a sports centre, swimming pool, pub and church. A range of art materials, videos and bicycles are available at the home for service users though it was noted that at the time of this inspection, activities offered by the home were limited. The home currently only has a team of 5 staff including the manager and the deputy manager is due to leave. This will be followed up by the CSCI. The manager designate informed the inspectors that they were experiencing difficulties in occupying or providing meaningful activities for one service user due to their complex needs. It is recommended that the advice and input from appropriate professionals is sought. Care plans examined contained information relating to individuals preferences and social history. In line with the individual’s agreed plan of care and preferences of the service user, family links and friendships are encouraged. The home has an ‘open door’ approach to visitors. This was confirmed by service users spoken with. Service users chose where to spend their day and have access to all parts of the home. The only exception to this is the staff sleep-in room, and freezer room. Access to bedrooms is by invitation only. Service users who are able, have a key to their rooms and are able to lock the door. Staff can access bedrooms in the case of an emergency. Smoking is only permitted outside of the home. The home has a policy on alcohol and drugs. Given that some service users attend placements during the day, with the exception of weekends, a snack is offered lunch time with the main meal enjoyed at tea time. Meals are prepared by staff on duty. Service users spoken with informed the inspectors that they were happy with the food and choices available. Service users also confirmed that snacks and drinks were made available at any time. Fresh fruit was seen to be available for service users to help themselves. The inspectors were able to have lunch with three of the service users. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Service users have access to a range of appropriate healthcare professionals. Improvements have been made in the home’s procedures for the management and administration of service user medication, though further improvements are needed. EVIDENCE: In accordance with the individual’s agreed plan of care, and or request, staff support service users to meet personal care needs and to attend health care appointments. The inspector was informed that currently 7 of the 10 service users require some form of assistance to meet personal care needs which in the majority of cases were just staff prompts and supervision. All service users have an allocated key worker. All service users are registered with appropriate healthcare professionals and the advice and input of specialist professionals is sought where required. The home maintains detailed individual records relating to the health care needs of service users. The inspectors were able to meet with a psychiatrist during the inspection and were able to see evidence that relevant professionals were involved with individual’s care where appropriate
Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 17 The inspectors examined the home’s procedures for the management and administration of medication and were able to see evidence that the requirement of the last inspection had been addressed. Medicines received by the home are now being appropriately recorded on the MAR charts. As the home uses agency staff, it has been recommended at this inspection that photographs of service users are attached to MAR charts to aid identification. The manager designate was advised that any changes to a prescribed medicine should be re-written and confirmed with two signatures. At present staff are amending the current prescription. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has a satisfactory complaints system in place. EVIDENCE: The home has produced a complaints procedure which is clearly displayed in symbol format at the home. The inspectors were informed that the home has not received any complaints since the last inspection. No complaints have been received by the CSCI. An immediate requirement was issued at this inspection for the home’s recruitment procedures. (refer to Standard 34) Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30 Service users live in a homely environment where they are encouraged to personalise their bedrooms and to choose décor for communal areas. The home’s arrangement for reducing the risk of the spread of infection have improved though further improvements are needed. The home’s cleaning arrangements need reviewing to ensure all areas are maintained to an acceptable standard. EVIDENCE: All communal areas and six bedrooms were seen at this inspection. Sharpe House is a large detached property situated in the heart of the small town of Wiveliscombe. Local shops and bus routes are within a short walking distance of the home. Sharpe House promotes a homely atmosphere. Service users are involved in choosing décor for the home in line with the home’s planned maintenance and renewal programme. The registered provider had previously stated that there
Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 20 were draft plans in place to improve the environment. This will be followed up as the registered provider was not available for this inspection. On the day of the inspection, a new sofa was delivered to the home. Accommodation is provided over two floors and some of the ground floor bedrooms and communal areas are accessed by steps. The home would therefore not be suitable for service users with mobility difficulties. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 21 All service users are accommodated in single bedrooms, which are fitted with wash hand basins. No bedrooms are fitted with en-suite facilities. Bedrooms seen at this inspection were comfortably furnished and it was evident that service users are encouraged to personalise their rooms. The home has two bathrooms, one on each floor. Each are fitted with a shower attachment. Due to the risks to one service user, the tap heads on one bath and wash basin have been removed. At the last inspection it was recommended that this arrangement is reviewed and the inspector was informed that a spare tap head was kept in the bathroom for more able service users to use, though this was not evident at the time of the last inspection or at this inspection. The tap heads were seen to be located in a locked cupboard near the bathroom. Service users could therefore not access the tap heads without locating a staff member. It is again recommended that this arrangement is reviewed to ensure that more able service users can access the tap heads. The current arrangement of locking tap heads away infringes on the rights of other service users and has implications for satisfactory infection control measures. Service users at Sharpe House have access to a range of communal areas. The dining room has two tables, each seating six and a smaller table seating two. This room also has a sofa, armchair, T.V and video. There is also a lounge area with T.V and video. This room leads into a large conservatory area that is used for listening to music, relaxing or recreational activities. The kitchen & laundry area are domestic in style. Service users have access to a good sized garden. The home has a no smoking policy. Service users wishing to smoke are able to use the garden area. The home has suitable sleeping-in accommodation for staff. The home has appropriate signs and symbols located throughout the home to assist service users. The home is not registered to provide accommodation to service users which a physical disability. Cleaning is carried out by care staff and, where appropriate, service users are encouraged/supported to clean their own bedrooms. The standard of cleanliness in a number of bedrooms seen at this inspection were noted to be below an acceptable standard. The kitchen was in need of deep cleaning. These issues were brought to the attention of the manager at the time of the inspection. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34 and 35. The home’s recruitment procedures are not robust and do not fully protect service users from the risk of harm or abuse. The staff team do not collectively have the skills or experience to meet the needs of service users. EVIDENCE: All staff are issued with a job description which clearly identifies roles, responsibility and lines of accountability. The home has experienced changes in the staff team since the last inspection. The manager and records indicated that the home currently only has a team of 5 staff and the deputy manager is due to leave her post on 17/06/05. The home employs a number of staff from overseas and a number of staff did not appear to have the experience or necessary skills to care for this client group. It appeared that only the manager was trained in the use of Somerset Total Communication. The inspectors viewed the home’s annual staff training and development plan which had been dated 21/03/05. This indicated that 2 staff had been booked to attend training in food hygiene, 2 have been booked to attend first aid training
Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 23 and 1 member of staff was due to attend training relating to ‘taking care of medicines’. The inspectors were unable to see evidence of any other training having been booked such as; the management of challenging behaviour, effective communication or control and restraint. The inspectors examined three staff recruitment files for staff employed since the last inspection and the findings were as follows: FILE 1 • No application form was available in the file. • A brief resume of employment history only identified employment history from ’02 to ’04 with no experience in care. • Two written references were available but the inspectors were unable to ascertain whether one was from the most recent employer. • No photo ID was available. • A POVAFirst result was available but no CRB was available. It was concerning to note that this member of staff was working unsupervised. Only a one day in-house induction had been signed. FILE 2 • Only page one of the application form had been completed. No employment history was available. No referees had been identified. • A CV was seen which identified the last employment in 2004. No care experience was identified. • Two references were available though there was no evidence that one of these was from the last employer. • A POVAFirst was available dated 06/04/05. This indicates that the employment commenced prior to the POVAFirst having been received. • An Enhanced CRB was seen dated 20/05/05. • The employee had not signed confirming that they had received induction training. FILE • • • 2 Employment history only identified employment from 2002 There was no evidence of either telephone or written references A POVAFirst was seen dated 20/04/05. This indicates that employment commenced prior to the POVAFirst having been received. • An enhanced CRB was seen dated 18/04/05 • The employee had not signed confirming that they had received induction training. It was concerning that on the day of the inspection from 1600hrs until 0700hrs the next day, the two staff on duty did not have enhanced CRB checks and they had only been employed for 2 and 3 weeks. At the time of the inspection, the manager designate, Kate Hellings was requested to take immediate and
Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 24 appropriate action to address this. This was done whilst the inspectors were still at the home. An immediate requirement was issued at the time of the inspection. This was also raised as a requirement at the last inspection. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 25 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40, 41, 42 and 43 The home’s procedures for the health and safety of service users, staff and visitors is generally good though further improvements are needed. EVIDENCE: As the manager designate has only been in post since December and the CSCI is currently processing her application to be registered manager, a number of standards were not assessed at this inspection and will be followed up at the next inspection. The home has a range of policies and procedures available to staff and service users. A number of these are available in symbol format for service users. The inspectors were able to see evidence that policies and procedures had been kept under regular review. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 26 Records pertaining to service users were seen to be appropriately stored. Service users have access to their personal files in accordance with the Data Protection Act 1998. Following a tour of the premises, the following records were examined relating to the health and safety of service users, staff and visitors to the home. FIRE SAFETY –Weekly checks on the home’s fire detection systems had not been recorded since 05/05/05. Monthly checks on emergency lighting were maintained. The last recorded check was carried out on 09/05/05. Fire detection systems and fire fighting equipment is serviced by an outside contractor on an annual basis. This was last carried out in August ‘04. The home carries out regular fire drills for staff and service users. This last took place on 21/05/05. Records indicate the date and time of the drill but does not identify who took part. This has been raised as a recommendation. ELECTRICAL SAFETY – The home’s portable appliances (PAT) are tested annually. This was last carried out on 21/06/05. The home has an up to date electrical hardwiring certificate which is valid until November 2005. GAS SAFETY – The home’s last annual gas safety check was conducted on 26/01/05. ACCIDENTS – The inspectors were informed that the home had no recorded accidents since the last inspection. Separate records are maintained for ‘untoward incidents’. Three had been recorded since the last inspection. The home had informed the CSCI where appropriate. FOOD SAFETY – The inspectors were informed that staff involved in the preparation of food have an appropriate food hygiene certificate. A number of food items stored in the fridge had not been dated. Foods had been appropriately covered. Up to date records were seen relating to fridge and freezer temperatures. A cleaning schedule was in place for the kitchen though, as previously mentioned in this report, the kitchen required a deep clean. CONTROL & STORAGE OF SUBSTANCES HAZOURDOUS TO HEALTH (COSHH) – At the time of this inspection, all cleaning substances were seen to be appropriately stored. The home maintains appropriate COSHH records which were last reviewed on 12/03/05. The home’s business and financial plans were not requested for this inspection. This home displays appropriate and up to date employers liability insurance which expires on 29/09/05 Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 27 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 2 x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 3 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 1 1 2 1 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Sharpe House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x 3 3 2 3 D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 28 YES 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. 1. Standard Regulation Requirement Timescale for action 30/08/05 YA3, 32, 33 18(1)(a) and 35 & (c) 2. YA30 23(2)(d) 3. YA34 19 and Schedule 2 The registered person must take appropriate action to ensure that all staff have the skills and training required to meet the needs of the client group. Staff must also be able to communicate with service users in their preferred mode of communication. The registered person must 15/07/05 review the homes cleaning procedures to ensure that all parts of the home are maintained to an acceptable standard. The kitchen requires a deep clean. 09/06/05 The registered person must ensure that the home follows robust recruitment procedures which meet with all requirements set out in Regulation 19 and schedule 2 of the Care Home Regulations 2001. Staff must not commence employment until receipt of 2 satisfactory written references and an enhanced CRB check In the exceptional circumstances where staff need to commence Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 29 employment pending a CRB, A satisfactory POVAFirst check must be otained and the staff member must not work unsupervised. An Immediate requirement was issued. 4. YA42 13(4) (timescale of 28/01/05 not met) The registered person must ensure that weekly in-house checks are maintained for the homes fire detection systems (Timescale of 28/01/05 not met) 04/07/05 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. 4. 5. Refer to Standard YA20 YA27 YA42 YA42 YA14 Good Practice Recommendations The registered person should ensure that photographs of service users are attached to individual medication administration records (MAR) to aid identification. The registered person should ensure that tap heads which have been removed, are accessible to service users. The registered person should ensure that a list is maintained of staff and service users who have attended the homes fire drills The registered person should ensure that foods stored in the fridge are clearly labelled with the open/expiry dates The registered person should take appropriate action to ensure that the identified service user benefits from meaningful activities. Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 30 Commission for Social Care Inspection Riverside Chambers Tangier Taunton TA1 4AL 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 Sharpe House D53 - D02 S46271 Sharpe House V225482 090605 Stage 4.doc Version 1.30 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
