Inspection on 28/02/06 for Sherbourne Grange

This inspection was carried out on 28th February 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sherbourne Grange 20/01/09

Sherbourne Grange 30/01/07

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 09/07/2008.

CARE HOME ADULTS 18-65 Sherbourne Grange 18-20 Sherbourne Road Acocks Green Birmingham West Midlands B27 6AE Lead Inspector Donna Ahern Unannounced Inspection 28th February 2006 12.30 Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 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.V285130.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 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.V285130.R01.S.doc Version 5.1 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 Caron Jordan Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home can provide care for twelve service users with learning disabilities Service Users will be aged 18-65 years of age Service user numbers may be extended to 13 at a later date to be agreed with the CSCI subject to all requirements being met 4th October 2005 Date of last inspection 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. 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. Cluster one has five bedrooms, one on the ground floor two on the first floor and two on the second floor. Cluster two has one bedroom on the ground floor five on the first floor and one on the second floor. At the time of the inspection the home was accommodating twelve people. Both clusters have sitting and dining rooms and there is a shared main kitchen and laundry room. All bedrooms have ensuite facilities and there is a large bathroom suitable for assisted bathing on the first floor of cluster two. The home provides a service to people with a learning disability from the age of 18years. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and undertaken by one inspector. This was the second of the statutory inspections for 2005/2006 and not all of the National Minimum standards were assessed. This report should be read in conjunction with the inspection report of 4th October 2005. The inspection included observation of care practice and interactions between residents and staff. A partial inspection of the physical standards was undertaken. Residents care plans and risk assessments were assessed. Some Health and Safety records were inspected. The inspector had the opportunity to talk to the manager, owner and two support staff. An expert by experience Stephen, and his support worker Dawn from Sandwell People First were involved in part of the inspection. As a service user Stephen has an expert opinion on what it is like to receive services for people who have a Learning Disability. Comments and observations of the expert by experience and CSCI inspectors are referred to in the report as the “inspection team”. What the service does well: What has improved since the last inspection? Action plans to previous inspection reports have been received within the required timescales. Four of the six previous requirements had been actioned in full and progress had been made on the other two requirements with some further development required. Risk assessments had been reviewed and there was evidence of ongoing development and review of care plans. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 6 Three of the residents have their own drink making facilities in their room so that they can make their own drinks when they want to. The adult protection procedure had been amended so that it included all the required information and the company’s commitment to protect residents from abuse. 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. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 7 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.V285130.R01.S.doc Version 5.1 Page 8 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 the following standard(s): EVIDENCE: Not assessed at this inspection the standards were assessed in full at the previous inspection 4th October 2005. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 6, 9 Comprehensive care plans have been developed and were under review so that they evidence that residents needs have been met. Residents must be involved in the care plan process. EVIDENCE: Detailed care plans have been developed for each resident. There was evidence of ongoing development and updating of the care plans. Some reviews have taken place and for some people this has been in conjunction with their day centre. A number of risk assessments were assessed. These included medication, communication, family contact, use of kitchen and managing anxiety. These had all been kept under review and guidelines had been implemented so that residents receive the appropriate support from staff with the identified risk. The inspection team spoke to some of the residents about their care plan. Two of the residents spoken to said that they did not know what a care plan was. The inspection team advised that care plans are accessible to residents and the person should be central to the care plan process. A sampled care plan had evidence of the resident signing their own care plan. The manager said she is Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 10 working on care plans that are more residents focused and will be working with the day centres on developing Person Centred Plans. Residents spoken to said they have their own accounts but staff fetch the money for them. The inspection team thought that residents could be more involved in their money management and could be supported to individually collect their money on specific days. The manager stated that residents who have individual bank accounts are supported by staff to go to the bank to collect their money. Birmingham City Council Accommodation Charges department manages some of the resident’s finances and the home has not been able to set up individual accounts for these people. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 11, 12, 13, 15, 16, 17 Residents are supported to maintain family and friend contact and to access a range of opportunities in the community. EVIDENCE: Some of the residents go to day centres and some attend local colleges. One of the residents said that they are starting a work placement soon and they were really looking forward to it. Another resident was hoping to do get a job doing some voluntary work with animals. The manager said that she was in the process of finding suitable day centres for two of the residents, who require a high level of support. Some of the residents said they have a bus pass and assess places in the community independently. One of the residents said they go to college in the evening to do sewing and another resident said they go to a disco on a Friday night. The inspection team felt that it was important that residents were supported to do more things. Residents told the inspection team that they go food shopping sometimes with the staff. There is a set menu on a weekly basis. Another resident told the Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 12 inspection team that “ Staff now have some idea of what we like to eat and they write the list”. Since the previous inspection three of the residents have their own drink making facilities in their room. One of the residents said that they don’t make drinks for themselves when they are downstairs but they make drinks when they are in their own room. Another resident said, “ They have money every day to choose their own food and they like to cook their own food”. The inspection team thought this was really positive that they were supported to develop these skills. The inspection team felt that the menu should be put into picture form so the people who cannot read the menu would be able to understand it and it would be more meaningful to them. They thought that more work could be done with involving residents when planning meals. The manager said that they are in the process of developing a menu, which will include pictures. One of the residents is involved in a healthy eating project at the day centre, which is promoted by the dietician service; the manager plans to incorporate this work within the home. The manager said that residents are encouraged to help out in the kitchen and that some residents choose not to Menus looked at offered two choices for each meal and a record of what each resident has eaten is kept. At the Residents meeting held in September 2005 the minutes indicated that menus were discussed. There was also a comment in the residents meetings reminding residents that they can cook and assist with food preparation but due to safety reasons one person at a time would be supported to cook. The inspection team felt that the residents should be more involved in cooking because they are more than capable and it would be positive to develop their skills. Residents said that they could go to bed when they choose and get up when they want to. This was observed at the time of the visit. The inspection team did not like it when one of the staff walked straight into a resident’s room without their permission and said, “I will give permission”. Other staff were observed being respectful and did ask for permission from the residents before entering their room. The manager stated that now the home is at full occupancy there have been moves to operate as two separate clusters some of the resident have found this difficulty and the manager said residents were being supported to adapt to the changes. One of the residents said that they phone their relatives regularly. Another resident said that they choose not to see one of their relatives but do see the relatives that they want to. Some of the resident’s family contact arrangements are complex. Sampled care plans had details of contact Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 13 arrangements and where applicable risk assessments and guidelines had been implemented. One of the residents has a befriender through the share scheme. A payphone has been installed in the hallway for residents use. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 14 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 the following standard(s): EVIDENCE: Not assessed at this inspection the standards were assessed in full at the previous inspection 4th October 2005. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 22, 23 The complaints procedure must be in an accessible format so that residents feel they are listened to and their views acted on. EVIDENCE: The manager had received no complaints about the home. Most residents would be able to express their views. The manager said that a lot of general issues are dealt with informally and promptly and are recorded in the resident’s daily records. It was discussed with the manager that maybe some of the issues raised by residents could be logged as a complaint. This would be viewed as a positive development and further evidence of the good practice that is already established in the home. The inspection team asked residents what they would do if they were unhappy or upset, residents said they would “talk to staff” or “talk to the manager in private”. The inspection team could not see an easy to understand complaints procedure displayed around the home. There was one in the office and the manager said that all residents received a copy when they moved into the home. The manager agreed to reissue the complaints procedure to residents and will also discuss it in the next residents meeting. The Adult Protection Policy was assessed at the previous inspection and required some further development so that it clearly states that Social Care and Health are the lead agency in all protection matters and it must make it explicit that the manager does not investigate until social Care and Health have advised on how the investigation should proceed. It also required the company’s commitment to invoke procedures in relation to staff employment to protect both residents and staff. This had been actioned. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 25 Action must be taken to ensure resident’s rooms are adequately heated. EVIDENCE: Not assessed in full at this inspection the standards were assessed at the previous inspection 4th October 2005. Three of the residents told the inspection team that their rooms are cold. Two of the bedrooms are exceptionally big and one of the residents uses her room as a bed-sit. The manager stated that the central heating is left on throughout the day however she agreed to take action in respect of this and additional heating would be provided in the large bedrooms. It was suggested that the manager monitors the heating in the bedrooms. The expert by experience felt that some parts of the home would benefit from decorating to brighten up the rooms. One of the residents told the inspection team that they had just picked some colours for their room and was really looking forward to having their room painted. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Staff training required updating so that staff had the required skills and knowledge to meet resident’s needs. The way some staff speak to residents must be addressed so that residents feel they are treated with respect. EVIDENCE: Four care staff are on duty across the working day. At night there continues to be one waking night staff on duty throughout the night and an additional night staff member on duty from 21.00hrs to 1.00am to support the specific needs of one resident. Staffing levels were adequate. The manager indicated that staffing levels would be kept under review. The manager stated that some updates were required on staff training including Manual Handling and Food Hygiene and that these were in hand. The support for waking night staff was discussed and the manager confirmed that night staff have the same opportunities to attend training and receive supervision. Two Staff files were assessed and contained all the required information including application form, references, proof of identification, CRB and induction programme. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 18 The inspection team spoke to residents about the support they get from staff. One resident said, “I Like them” the resident said, they were going to change their key worker. Another resident said they like the staff sometimes and other times they didn’t like the way that staff spoke to them and “they don’t speak to me nice”. This matter must be addressed. The manager agreed to raise this matter at the next staff meeting and address this through staff training and development and said that the way staff talk and interact with residents is monitored. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Resident’s benefit from a style of management that is open and inclusive. EVIDENCE: An experienced manager who has a number of years experience manages the home. She was open and welcoming to the inspection process. Action plans to previous inspection reports have been received within the required timescales. Four of the six previous requirements had been actioned in full and progress had been made on the other two requirements with some further development required. CSCI have received notification of incidents that have occurred in the home. Examination of these indicated that the manager had taken appropriate action to safeguard residents and where appropriate other professionals had been informed and their input requested. There was evidence from sampling policies and procedures that these are kept under review and amended to reflect changes in legislation and good practice. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 20 There was evidence that the manager and staff liaise with the friends and family of residents. The homes development plan was not assessed. Fire records and health and safety checks assessed were in good order. It was advised at the previous inspection that that the Workplace Fire Risk Assessment must be an active document with information added to the assessment when any fire measures are reviewed. The document had recently been reviewed. The manager stated that the evacuation plan was still under review and that she had sought advice from West Midland Fire Service who had undertaken an inspection of the premises on 6th February 2006. The manager said that the evacuation plan would also be produced in a format suitable for residents. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 21 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 X 25 2 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 3 X X 2 X Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 22 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 YA6 Regulation 15 (1)(2) Requirement Care plans required review. Progress made further work required. The complaints procedure must be reissued to residents. The heating in resident’s bedrooms must be reviewed and where required additional heating must be provided. Staff training updates in mandatory training must be actioned. Training must be provided on respect and attitudes. The Fire procedure required further development. Timescale for action 31/05/06 2. 3. YA22 YA25 22 (2) 23 (2)(p) 31/03/06 31/03/06 4. YA32YA35 18 (1)(c) 31/05/06 5. YA42 23(4)(c)iii 30/04/06 Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 23 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 Refer to Standard YA11 YA17 Good Practice Recommendations Further opportunities for residents to develop their independence skills must be explored. The menu should be provided in a format that benefits all residents. Sherbourne Grange DS0000050474.V285130.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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