Inspection on 20/01/09 for Sherbourne Grange

This inspection was carried out on 20th January 2009.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sherbourne Grange 30/01/07

Sherbourne Grange 28/02/06

Sherbourne Grange 04/10/05

Sherbourne Grange 14/12/04

Sherbourne Grange 22/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOME ADULTS 18-65 Sherbourne Grange 18-20 Sherbourne Road Acocks Green Birmingham West Midlands B27 6AE Lead Inspector Kerry Coulter Unannounced Inspection 20th January 2009 09:30 Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 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 Sherbourne Grange DS0000050474.V373929.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 Adults 18-65. 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. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sherbourne Grange Address 18-20 Sherbourne Road Acocks Green Birmingham West Midlands B27 6AE 0121 706 4411 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) ferndale.care@btconnect.com Ferndale Care Services Ltd Bernadette Carol Whatmore Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2007 Brief Description of the Service: The home is located in the Acocks Green area of Birmingham, in a residential area. It is within walking distance to Acocks Green shopping centre and there is a range of leisure facilities in the area. Off road parking is available to the front of the home. The home consists of two Victorian three-storey houses. The home is split into two clusters; each can be accessed by their own front door and have their own lounges, dining areas and bathrooms. There is a shared laundry, kitchen and garden. All bedrooms have ensuite facilities and there is a large bathroom suitable for assisted bathing on the first floor of one of the houses. One of the houses also benefits from the facility of having a passenger lift so that people with mobility difficulties can access the first floor. The home provides a service to people with a learning disability from the age of 18 years to 65 years. Inspection reports were available in the Home. The fees to live at the home were not recorded in the service user guide. For fee information it is advised to contact the home manager. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection was carried out over one day; the home did not know we were going to visit. This was the homes key inspection for the inspection year 2008 to 2009. The focus of inspections we, the commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and the Annual Quality Assurance Assessment (AQAA) completed by the manager. This provides information about the home and how they think it meets the needs of the people living there. Surveys were received from twelve people who live at the home, one advocate and ten members of staff. Three of the people living in the home were case tracked. This involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. A partial tour of the premises took place. A sample of care, staff and health and safety records were looked at. The people living there were spoken to and asked their views on living in the home. The manager and staff on duty at the time were spoken with. Following our visit to the home we also spoke with one health professional regarding the care the home was providing to one person who has sore skin. What the service does well: Information about the home includes pictures so it is easier for people to understand. Each person has a care plan so that staff know how to support them to meet their needs. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 6 People are offered a range of activities that they enjoy and help them to lead the lifestyle they choose. People are supported to maintain and develop relationships with friends and family so that they have a good lifestyle. People are offered an opportunity to go on holiday each year so they can see different places and experience new things. Staff make sure that people get the medicines that each person needs so they can keep well. Different healthcare professionals support the people living there and staff make sure they follow the advice given so that people can be well. The people living there were well dressed. Staff at all times treated people with respect and maintained their privacy and dignity so ensuring individuals well being. Each person has their own bedroom and they all contain things that are important to them. The staff were seen to have excellent relationships with the people living there and spoke to them naturally, with empathy and supporting them as they wish. This gives people a sense of wellbeing. The home has in place a quality monitoring system based on seeking the views of the people living there so they decide how improvements are made. People told us: ‘ my social worker showed me round, was only going to stay for a short while but liked it so decided to stay’. ‘I am happy living at Sherbourne, I have met new friends and enrolled at college and go on holidays’. ‘I have a membership pass to Dudley Zoo and go often, go to night school to do needlework, go to the library. ‘Food is good’. What has improved since the last inspection? A new admission criteria has been produced, this is provided to people thinking of moving to the home to help them decide if the home can meet their needs. Photographs of the home are now given to people thinking of moving to the home so they can get an idea of what the home looks like. Menus are in a format that the people living there can understand so they can be more involved in choosing what they eat. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 7 A new training package has been purchased for challenging behaviour and prevention of abuse so that staff will have more training and be able to keep people safe from abuse. A new system is in place to consult people at the home regarding the recruitment of new staff to help ensure people are supported by staff that they like. A new and more efficient boiler has been purchased, new carpets have been fitted in some bedrooms and hallways and a ramp has been purchased to improve wheelchair access to the garden so that the premises meets peoples needs. Fire training for people who live at the home has been undertaken by the West Midlands Fire Service to help people know what to do if a fire occurs and help them to stay safe. 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. The summary of this inspection report can be made available in other formats on request. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are fully assessed before moving in to make sure the home is able to meet their needs. People have most of the information they need so they can make a choice as to whether or not they want to live there. EVIDENCE: A service user guide is available to people, this tells people thinking of moving to the home most of the information they need to make a decision about moving there. The guide is in an easy read format that includes pictures, making it easier for people to understand. Information about the range of fees to live at the home were not included, this needs to be added so that people have clear information about how much it costs to live there. Discussion with the manager indicates that people who are considering moving to the home also receive a copy of the homes admissions criteria and photographs of the home. One new person has moved into the home since our last key inspection and we looked at the procedure followed. Records showed that the home had completed a full assessment of the persons needs before they moved in. Information had also been obtained from the persons last home and a care plan from their social worker. On admission a checklist had been completed, this showed the person had been given a copy of the service user guide. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 10 We spoke with the newest person at the home and they told us they had visited the home before moving in. During our visit a potential new person was also visiting the home, the manager told us the person would also be visiting the home the following week where they would be having an overnight stay to see if they liked the home. Surveys from people at the home indicated that they all felt they had received enough information. Comments included: ‘had introductory visits’. ‘ my social worker showed me round, was only going to stay for a short while but liked it so decided to stay’. ‘felt a homely environment, came to visit a few times, was given information about the home and local area’. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have most of the information they need so they can support people in the way that the individual chooses so ensuring their well being. Some risk assessments required improvement so that the risks people face are well managed. EVIDENCE: We looked at the care files for three people. These included an individual care plan that stated how staff are to support the person to meet their needs and help them achieve their goals. These had been regularly reviewed. Records showed that people had been involved in their care plan. Plans were person centred and it is good that the home has plans called ‘me and my life’ that are in an easier to understand format for people. The annual quality assurance assessment completed by the home records that for one person the home intends to have their plan translated into Punjabi even though they do speak English, so respecting their culture. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 12 The people living there said and it was observed that they could make choices about what they do during the day, how they spend their time and what they eat and drink. Records show that people at the home have been consulted about the recruitment of new staff. Sometimes formal meetings are held with all the people living there. The minutes of these showed that people talked about menus, the environment, staffing, management arrangements and activities. Where people need support to make choices the home has made arrangements for advocacy involvement if it is needed. Records included individual risk assessments that stated how staff are to support individuals to take risks in their day -to-day lives. Assessments included manual handling, train journeys, use of massage chair, choking, use of walking frame, behaviour and seizures. Assessments had been regularly reviewed so that the control factors in place are still appropriate. Improvements were needed to some assessments. For example one person was assessed as needing regular checks during the night but the actual frequency of the checks needed was not specified. For one person there was not a risk assessment for pressure sores despite them being a wheelchair user. Two people who had rails fitted to their beds only had brief assessments in place that did not fully assess all areas of risk or consider the need to use bed rail covers. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that people living there experience a meaningful lifestyle that ensures their self-esteem and well being. People are offered a healthy diet and enjoy their meals. EVIDENCE: Care plans sampled stated the leisure and social activities that people enjoyed. One person who has communication difficulties has a photo planner of the activities they participates in. Some people go to day centres and some attend local colleges. One person told us that they have a voluntary job at a local charity shop. Discussions with staff indicate that one person has expressed a wish to have paid employment. Staff have been supporting them to apply for jobs and attend job interviews. The home also support people to participate in a wide range of activities, this includes shopping, progressive mobility, going to the Irish Centre, beauty Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 14 mornings, visits to the Temple, Phab club, coffee shops, the library and participating in domestic chores around the home. Records showed that they celebrate the cultural festivals relevant to the people living there. People told us they have the opportunity to go on holiday if they want to. One person had been on several holidays including one to ‘Gracelands’. Records sampled showed and people said they can keep in touch with their family and friends if they want to. This ensures that people can maintain relationships that are important to them. People were observed spending time talking to each other and to staff. One person has been supported to attend training re ‘safe relationships’. For one person who has expressed the wish to have a relationship the home has supported them to join the ‘Stars in the Sky’ dating agency. Where people’s relatives first language is not English the home has arranged for letters to be translated into their first language. People told us their rights are respected. For example one person told us that staff always knock on their bedroom door before entering and we saw staff doing this during our visit. One person told us that they like to have a beer at night and staff make sure they get one if they want one. Some people have drink-making facilities in their own bedroom, which supports people’s personal development and independence. The home has a four weekly menu that showed meals on offer are varied and nutritious. People at the home are involved in planning the menu. Since the last key inspection the home has developed a photographic menu book to assist people who have communication difficulties to choose what they would like to eat. On the day of our visit some people went food shopping with staff and returned with lots of fresh vegetable and fruit. We spent time with people whilst they had their evening meal. Choice was offered and where needed people had adapted cutlery and plates. People had a choice of yogurts or fresh fruit for dessert. Comments from people who live at the home included: ‘Staff ask me if I would like to go out’. ‘I am happy living at Sherbourne, I have met new friends and enrolled at college and go on holidays’. ‘I have a membership pass to Dudley Zoo and go often, go to night school to do needlework, go to the library. Food is alright, we get a choice. Tea was nice. ‘Food is good’. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the people living there are usually met so ensuring their well being. EVIDENCE: The people living there were well dressed in appropriate styles to their age, gender, cultural background and the activities they were doing. Attention had been paid to individuals personal care indicating that people had the support they needed so ensuring they felt good about themselves. Records and discussions with people show that people are supported to purchase their own individual toiletries. Account is taken of people’s cultural needs and preferences when supporting people to style their hair. We part sampled the health records for two people and looked in more detail at the health care records for two other people. Records sampled showed that other health professionals are involved in peoples care where needed. Records showed and staff said that they work with other professionals to ensure individuals well being. People attend health check ups with the dentist, optician and chiropodist to ensure their health needs are met. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 16 Health Action plans had been implemented. This is a personal plan about what a person needs to stay healthy and what healthcare services they need to access. The recordings of outcomes of appointments were generally satisfactory so that health needs and any follow up action required could be monitored and actioned. However some improvement to daily records were needed, for example where staff had recorded information when people had complained of toothache or staff had noticed a health concern. From records it was sometimes difficult to track what action staff had taken to make sure the person was well. Where people had specific health conditions, for example epilepsy, there was guidance in place so that staff knew what support the person needed to stay healthy. We spoke with two staff, both were aware of the people at the home who had epilepsy and the action that needed to be taken should they have a seizure. Staff training on epilepsy is scheduled in 2009 and this will help to ensure all staff have a good knowledge about epilepsy care. The monitoring of people’s weight is important for the early detection of other health problems or complications. People had been supported to monitor their weight regularly. Some people attend the weight clinic so that accurate monitoring can take place. One person at the home has a pressure sore, the responsible individual for the home told us that this has been an ongoing problem and that they have had the sore since admission to the home. District nurses are involved in the persons care and have completed risk assessments and care plans. Records show that the district nurses have recently sought advice from the tissue viability service due to lack of progress. Part of the advice received was for the person to sit with their feet up when in their chair to relieve pressure. During our visit we saw that staff were following this advice. We spoke with two staff about the pressure care that the person needed, both staff were aware of the persons care plan. Records and discussions with staff indicate that some progress has been made in that currently the sore area does not need a dressing to be applied. Following our visit to the home we spoke with one of the district nurses who visit the home. They told us that the sore was now only superficial and that the home was doing all that was being asked of them to help the sore heal. Medication is stored in a locked cabinet so that people are not at risk of taking medication that is not prescribed for them. Staff have received training on how to safely administer medication, staff who are not trained do not administer medication. At the front of each persons Medication Administration Record (MAR) there is a photo of the person so that unfamiliar staff would know who to give the medication to. MAR’s sampled had been signed when medication had been given indicating that medication had been given as prescribed. Copies of each person’s prescriptions are kept so that staff can ensure that what is provided by the pharmacist is what has been prescribed by the doctor. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 17 Medication reviews take place with the person’s consultant or the G.P to ensure that medication is still required. During our visit staff gave one person paracetamol after they said they had a headache. When the person later asked for another tablet it was good that staff were aware that the time gap was too soon and so explained why it could not be given. Information was available in people’s care files to show that the home had explored with them their wishes in the event of their death so that staff can handle this as the person would wish. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that the views of the people living there are listened to and acted on and they are protected from abuse so ensuring their well being. EVIDENCE: The complaints procedure stated how people could make a complaint if they are not happy with the service provided at the home. The procedure is in an easy read format that includes pictures making it easier for people to understand. Information from the surveys we received from people at the home indicates they are aware of the complaints procedure and know who to speak to if they are unhappy. The annual quality assurance assessment stated that no complaints had been made to the home. We have received no complaints about this home in the last twelve months. Records sampled and discussions with staff show that the majority of staff have received training in safeguarding people from abuse. We spoke with two staff about what they would do to keep people safe if an allegation of abuse was made. Staff were not very confident in their answers but the actions they described should keep people safe. Discussion with the home manger and responsible individual for the home indicates that further safeguarding training is planned this year along with training on how to manage challenging behaviour. The home has purchased a training pack and video to use for this training. This should help to increase staff confidence in responding to any safeguarding issues. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 19 The home has clear information available to staff regarding safeguarding people from abuse, this includes the homes own procedures and whistle blowing policy as well as Birmingham’s multi agency abuse guidelines. For one person who lives at the home there have been some safeguarding issues, these have not been safeguarding issues from within the home but from an external source. The home has responded appropriately to these issues, working with social services and other professionals to ensure the person is protected from abuse or harm. An advocate has also been used to make sure the person has been fully supported during this process. The manager and two staff are booked to attend training on the Mental Capacity Act. This legislation came into force in April 2007 and requires an assessment of a persons capacity to be done if there is any doubt that they may not have the capacity to make a decision. The finance records of two of the people living there were looked at to ensure that their money was being looked after appropriately and was safe. Individuals benefits are paid straight into their bank accounts. People received their personal allowance money regularly and signed to say they had received this. Receipts were kept of all purchases. People’s money is audited as part of the responsible persons visits to the home to make sure it is being looked after safely. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable, safe and clean environment that meets their assessed needs. EVIDENCE: The home is registered for fifteen peoples and consists of two houses next door to each other. Some areas are shared such as the kitchen and laundry but otherwise they are run as separate units. We looked at all communal areas during our visit and some bedrooms. The home was a comfortable temperature and homely in style. The home was clean and free from offensive odours throughout making it a pleasant place for people to live in. A maintenance and replacement programme is in place so that the home is well maintained for people’s comfort. In the last twelve months a new and more efficient boiler has been purchased, new carpets have been fitted in some bedrooms and hallways and a ramp has been purchased to improve Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 21 wheelchair access to the garden. The annual quality assurance assessment states that in the next twelve months the home intends to improve the garden for sensory use, re-carpet stairs and hallway to the 3rd floor, improve lighting in lounges and create a meeting room. People’s bedrooms were individual in style and had been personalised. People told us they were happy with their bedrooms, one person said they had the opportunity to choose which bedroom they had. Another person showed us some paint they had brought for their bedroom and said they had chosen the colour. People told us they had their own keys to their bedroom. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing, their support and development generally ensure that the needs of the people living there are met. The recruitment practices need improvement to help to ensure that the people living there are safeguarded from abuse. EVIDENCE: The annual quality assurance assessment stated that 75 of staff have achieved a National Vocational Qualification (NVQ) level 2 or above in care. Some staff are now undertaking an NVQ at level 3 whilst there are some staff who have already achieved this. This exceeds the standard that at least 50 of staff have this qualification. This means that staff should have the skills to meet the needs of the people living there. Surveys from people living at the home indicate that staff usually treat people well and listen to what they say. We saw that staff interacted positively with people at the home. One staff spent time talking with one person when they were upset. The staff was patient and gave the person time to say what they wanted. Throughout our visit there was a good atmosphere in the home with lots of laughter between staff and the people at the home. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 23 The rota indicated that between five and six staff are on duty across the working day. Discussions with staff and surveys from staff indicate that there are usually enough staff to meet people’s needs. One person who lives at the home told us ‘there is always enough staff’. There were enough staff on duty during our visit and we did not see people having to wait for staff support. We have found at previous inspections that recruitment practice in the home has been good. However for two staff employed since our last inspection recruitment practice has not been robust. Whilst most recruitment documentation was satisfactory new criminal bureau checks had not been obtained for the staff when they had initially started working at the home. However discussions with the manager and staff indicate that the members of staff had not worked unsupervised with people at the home or undertaken any personal care. Following our visit to the home discussion with the responsible individual indicates procedures have been reviewed to make sure recruitment procedure is improved. The annual quality assurance assessment stated and records sampled showed that staff complete an induction when they first start working there so they know how to meet individuals needs. Records did not show that all staff had fire training in the last twelve months. This should now be updated so that staff have updated knowledge on how to reduce the risks of there being a fire and what to do if there is a fire. Records sampled showed that staff have completed training in first aid, health and safety, abuse, medication, food hygiene, moving and handling. The home has a training plan in place for 2009 and this indicates that training in person centred care planning, challenging behaviour, makaton (a form of sign language) and epilepsy is arranged. Staff spoken with said they were happy with the training on offer at the home. Staff receive regular supervision from the manager. These are sessions when staff can sit and talk to the manager about their role and the work they do, any concerns they may have and training and development needs. Staff meetings are held every few months and minutes of these were seen and indicated that relevant matters promoting the development of the home are discussed. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 24 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements ensure that the home is safe and well run in the way that the people living there want. EVIDENCE: Since our last inspection of the home there has been a new registered manager in post who was previously the deputy for the home. They have the required qualifications to manage the home having completed the registered manager’s award. The previous manager has changed role and is now the responsible individual. The manager co operated throughout the visit and demonstrated she knew the people living there and how to support them. Staff spoken with felt that management arrangements at the home were good and that the manager was approachable. Staff said they would feel confident in raising any concerns. One staff told us that the manager had lots of new ideas about improving the home. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 25 The manager sent us the home’s annual quality assurance assessment when we asked for it. It had been completed to a good standard and shows that the home is identifying where future improvements can be made for the benefit of people living at the home. The responsible individual for the home completes a report every month from their visits to the home to make sure the home is being well run. People who live at the home and staff are consulted with as part of the visit. As recorded earlier in this report peoples views are also sought at regular ‘residents’ meetings. The views of people’s relatives are also sought via questionnaires. It is good that where relatives have made suggestions for improvements the manager has written them a response indicating the action the home intends to take in response. A number of health and safety records were looked at. The manager had also completed the annual quality assurance assessment to confirm dates of health and safety checks. The home has employed the services of a Health and Safety consultant who has undertaken a full audit and produced a report on the findings. A copy of the report and actions taken were provided and indicate a commitment by the provider to providing a safe environment. Fire safety records showed that the fire alarm system is tested and serviced as required so that it is kept in a safe working condition. Fire drills were being carried out every six months so that people and staff have the opportunity to practice safe evacuation in the event of an emergency. It is an area of good practice that the home had recently arranged for fire training for people who live at the home to be undertaken by the West Midlands Fire Service. Photographs of the training were available and showed people having a fun time trying on the fireman outfits. Records sampled showed that equipment in the home is regularly serviced and well maintained so it is safe to use. Records showed that the temperature of the water is tested weekly to make sure it is not too hot and a risk of scalding to people. However only one outlet is tested each week. It is recommended that the frequency of testing for the baths and showers is increased as the current system means it could be a couple of months between tests for these outlets. We hand tested the temperature of one of the baths during our visit and found it to be safe. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 26 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 Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 3 3 3 X X 3 X Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 27 No 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 YA9 Regulation 13(4) Requirement Timescale for action 28/02/09 2 YA34 19 Satisfactory risk assessments must be in place for all risks identified to individuals to ensure their safety. Recruitment procedures for staff 28/02/09 must be robust to help ensure ‘unsuitable’ staff are not employed by the home. 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 Refer to Standard YA1 YA19 YA35 YA42 Good Practice Recommendations Information about the range of fees for the home should be added to the service user guide so that people know how much it costs to live there. Recording of people’s health and well being in daily records should be improved so that staff can better track what action has been taken in response to ill health. Staff should have updated training in fire safety so that they have updated knowledge on how to reduce the risks of there being a fire and what to do if there is a fire. Increase the frequency of testing temperatures of the hot DS0000050474.V373929.R01.S.doc Version 5.2 Page 28 Sherbourne Grange water at baths and showers to make sure it is not too hot and people are not put at risk of scalding. Sherbourne Grange DS0000050474.V373929.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sherbourne Grange DS0000050474.V373929.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. 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!