Inspection on 30/01/07 for Sherbourne Grange

This inspection was carried out on 30th January 2007.

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 no outstanding requirements from the previous inspection report, but made 5 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 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 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 Key Unannounced Inspection 30th January 2007 11.00 Sherbourne Grange DS0000050474.V326347.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.V326347.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.V326347.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 Caron Jordan Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can provide care for thirteen service users with learning disabilities. Service Users will be aged 18-65 years of age Date of last inspection 28th February 2006 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 thirteen 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 18 years to 65 years. The manager said that the outcome of CSCI inspections is shared with residents and inspection reports were available in the Home. The current fee level for the Home is from £699 per week. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork visit was unannounced involved one inspector and took place over one day lasting nine hours. This was the homes first key inspection for the inspection year 2006-2007. During the fieldwork the inspector met all residents, observed the opportunities and support provided to residents, looked at the premises, and read records about care, staffing, and health and safety. The inspector spoke to the manager and spoke to three staff informally. The home is required to report incidents, accidents and other events that occur in the home to CSCI. These are called regulation 37 notifications. All information reported via a regulation 37 notifications since the last inspection was analysed prior to the fieldwork visit. A pre inspection questionnaire was completed by the manager and returned to CSCI. Information from the questionnaire was used to help complete this report. What the service does well: The home is well managed. As new residents have come to live at the home there is evidence that the manager and staff team are committed to ensuring that the home is right for each person. A resident has been supported to go on their first holiday abroad. Residents said staff talk to them about their care plan and they can look at their care plan if they want to. A resident said, “Staff really help you to find the things you want to do”. House meetings take place so that residents can talk about what they want on the menu, choice of activities and décor of the Home. Residents also meet and comment on staff who have applied to work in the Home. Residents are supported to keep in touch with people important to them so they maintain and develop personal relationships. A resident said, “I can talk to staff and they will listen”. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 6 It is a comfortable very spacious home. Residents are encouraged to be independent. There is good attention to resident’s personal care and health needs. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 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.V326347.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s):1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives have information to enable them to make an informed choice about whether or not they want to live in the home. EVIDENCE: Registered numbers were increased from 12 to 13 in June 2006 following the successful conversion of an additional bedroom on the ground floor. The assessment documentation for the most recently admitted person was looked at and the file contained details of assessments completed by Social Care and Health. The manager also completed her own assessments prior to admission including a daily living and needs assessment to ensure that the home could meet their assessed needs. The statement of purpose and service user guide was looked at and describes the services and facilities provided at Sherbourne. The service user guide has been produced in an east read format so it is more accessible to the people who live at the Home. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 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. 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. Some further development of care plans is required so that a comprehensive plan is in place for staff to follow so that residents assessed needs are met. Some risk assessments required implementing so that the risk residents face are well managed. EVIDENCE: Three care plans were looked at during this visit. Much work has been done and is ongoing to ensure that comprehensive plans are in place for staff to follow. Care plans seen include information about people’s likes and dislikes, good detail regarding how to support residents communication, personal care and social and cultural needs. A care plan looked at was for the person who had recently moved to the home and work was still under way so that a comprehensive care plan is established. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 10 It is really positive that the manager has instigated reviews for all residents where appropriate these have taken place in conjunction with peoples day service. The reviews identified individual aims and goals for residents and the manager was implementing a system for ensuring that residents receive the support to achieve their goals. This had already been achieved for a resident who had recently moved into the Home and wanted to go on holiday; they were supported to go on their first holiday abroad. The manager was in the process of implementing “Me and My life” booklet, which are a person centred plan approach to planning with people. Discussions with staff on duty demonstrated that they have good understanding of resident’s needs, which was consistent with the care plans looked at. Residents spoken with said that staff talk to them about their care plan and they can look at their care plan if they want to. A number of risk assessments have been implemented so that residents receive the right support from staff to manage identified risks. Risk assessments seen included bathing, use of the kitchen, accessing the community these were due for review so that the control factors in place are still appropriate. Some additional risk assessments required implementing to safe guard residents including one for the risk of choking at meal times. Further development of the risk assessment for the use of wheelchairs is required so that these contain specific information about the use of lap belts so staff supports residents safely and according to manufactures guidance. House meetings are held every few months. There was evidence within the records sampled that residents had been supported to make decisions about menu planning and choice and planning of activities, décor of the Home and to meet and comment on new staff, indicating that residents views are encouraged within the running of the home. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are regular opportunities for residents to take part in activities they enjoy, based on their individual preferences. Residents are supported to keep in touch with people important to them so they maintain personal relationships. A healthy diet is offered and individual needs are well planned for so that residents enjoy their meals and mealtimes. EVIDENCE: Some of the residents go to day centres and some attend local colleges. One of the residents had recently started at the B.I.T.A and they said, “Its really good I am learning at the moment and asking lots of questions”. Another resident does some voluntary work with animals. A resident returned from an Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 12 introductory visit to a day centre and said they were looking forward to returning next week. The manager said that she was in the process of finding suitable day centre for one 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. A resident was really excited about an annual pass to Dudley Zoo they said when they get a chance from their busy schedule they go off for the day and they really enjoy the day out. For the people who don’t attend day centres full time then different activities take place at home. Some residents help out with household tasks and jobs and some residents will help to do some shopping at the local shops. Staff spoken to said residents are supported to go out most days even if it is just for a short walk. Staff said that it has been difficult to engage some residents in developing their independence skills and they try and promote this on an individual level. A mobility, interactive and music session takes place every other week and this was taking place during the fieldwork visit. Residents seemed to really enjoy the activity and were supported by staff to take part in the session. Some of the residents said they go to college in the evening to do sewing and art and craft another resident said they go to a disco on a Friday night. Residents said “staff really help you to find things you want to do” and “Staff helped me get a place at college”. Residents said that they could go to bed when they choose and get up when they want to. Some people have drink-making facilities in their own bedroom, which supports people’s personal development and independence. Residents said friends and family could visit the Home. A resident was making arrangements with staff for their friend to come for an evening meal. Some of the resident’s family contact arrangements are complex. Sampled care plans had details of contact arrangements and where applicable risk assessments and guidelines had been implemented for staff to follow. Some residents have received specialist support and guidance to enable them to develop personal relationships. A payphone is available in the hallway for residents use. Residents were seen receiving support from staff to use the phone. Menus looked at offered two choices for each meal and a record of what each person has eaten is kept. Healthy eating options, plenty of fresh fruit snacks and a choice of drinks were readily available. A resident said they have money to buy their own food and cook all their meals. They also have their own cooking equipment and storage place to keep their food in the kitchen. This is really positive that the person is being supported to maintain and develop their independence skills, records of food eaten was required for this person so there is an audit trail of food served and so staff can ensure that healthy eating is promoted. Some residents require assistance to eat and this was given in a sensitive and unhurried manner and staff were present throughout Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 13 most of the meal time but left for a few minutes to get puddings. It was advised that the planning of mealtimes is looked at so that a staff member is present at all times with the residents who require supervision, so that their safety is paramount. Specialist equipment as detailed on peoples care plan was available, including slip mats and adapted cutlery so that assessed eating needs can be met. Some residents attend a nutrition clinic and have been supported to loose weight. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s):18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in a way they prefer. Their health care needs are generally well met. The medication procedures in place ensure that residents receive their medication safely. EVIDENCE: Residents individual care plans seen had details of people’s personal care routines and preferences including cultural needs so that they receive personal care in a way that meets their assessed needs. Residents were appropriately dressed in accordance to their age and culture. Health care notes looked at indicate that residents are supported to attend routine G.P, dentist, and optician appointments. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 15 Records seen and discussions with staff indicated that health professionals are involved in the care of individuals. These include the Community Nurse, Psychiatrists, Continence Nurse, Physiotherapist and Speech and Language Therapy. 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. The monitoring of peoples weight is important for the early detection of other health problems or complications. Residents have been supported to monitor their weight regularly. Some people attend the weight clinic so that accurate monitoring could take place. Medication is stored in a secured wall mounted cupboard in the office. Medication is provided to the Home using the monitored dosage system. The medication administration records (MAR) cross-referenced with the blister packs indicating medication had been given as prescribed. Medication reviews take place with the person’s consultant or the G.P to ensure that medication is still required. It was advised that self-administration of medication is explored with some residents on a risk assessment basis to further enhance people independence skills. Staff have received training through a distant learning pack on how to safely administer medication staff do not give out medication until assessed as competent to do so by the manager. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 16 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. The Home has a robust complaints procedure that would ensure residents’ views would be listened to and acted upon. Arrangements are in place to protect residents from abuse. EVIDENCE: The complaints procedure included all the required information to enable residents or their representatives to make a complaint to the organisation. The procedure was available in an easy read format using pictures so it was easier for residents to understand. A summary of the procedure was on display in the office and a copy given to all residents. The complaint log seen and the manager confirmed that no complaints have been received in the last twelve months. CSCI had not received any complaints about this home. Staff have received training on adult protection matters so they would know what to do if an issues was raised in the home. There is an adult protection policy available for staff to refer to and follow. The No secrets document is also available. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable, safe and clean environment that meets their assessed needs. EVIDENCE: Considerable investment has been made and a maintenance and replacement programme is in place so that the home is well maintained for residents’ comfort. The kitchen has been relocated since the last inspection this ensures that there is better access for residents living in each cluster. A new boiler has been fitted to improve the heating system. A new roof was fitted and windows replaced. The lounge in cluster two has had a new floor and fire place and is a welcoming and comfortable lounge area. Decorating was taking place on the first floor and plans were in place to replace the flooring along the corridor so that it is brighter and fresher. Some residents had just had their rooms painted. A resident explained how the top part of their bedroom was painted Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 18 and agreements had been made with the manager and decorators that the rest of the room would not be painted until the residents was at home to oversee the moving of their personal items. They said they were asked what colours they wanted and used a colour chart to make their choice. Plans were also in place to paint a toilet on the second floor. The manager agreed to review and replace a light fitting in the assisted bathroom to ensure there were no risks to resident’s safety. To the rear of the home there is a pleasant garden an additional patio area has been provided so that there is plenty of room for residents to sit out on, in the good weather. Both clusters share the laundry room. Some of the residents said they do their own washing and ironing. The COSHH (Control of substances hazardous to health) cupboards were locked to minimize any risks to residents. Colour coded mops for designated areas to minimize the risk of cross infection were stored in the laundry. The Home was clean and fresh throughout. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the Homes recruitment policy and practices. Staffing levels are adequate to meet the assessed needs of residents. EVIDENCE: Residents made positive comments about staff including “my keywoker helps me to sort my room out” “I can talk to staff and they will listen” “I like the staff”. The rota indicated that between five and six staff are on duty across the working day. The manager said staffing levels were seen to be flexible increasing when all residents are at Home. 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. If one of the residents is unwell then the manager said two staff would be on duty throughout the night. An on call system is in place providing Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 20 support to staff at night should an emergency situation arise. This ensures the safety and wellbeing of residents. The manager indicated that staffing levels would be kept under review so that as needs change staffing levels can be adjusted. Rotas seen indicated that staffing levels were adequate for the current needs of residents. The manager stated that some updates were required on staff training including Manual Handling and Food Hygiene and that these were in hand. A training plan was available indicating that required training had been booked. The manager to support training and development within the Home had recently purchased training videos. Three staff are completing level 3 NVQ. 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 thus ensuring a robust recruitment procedure is established to protect residents. Staff receive regular supervision from the manager and were on target to meet the required six sessions per year. 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 meting 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.V326347.R01.S.doc Version 5.2 Page 21 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, 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 health and safety and welfare of residents is promoted and protected. Residents’ benefit from a well managed Home. EVIDENCE: Throughout the inspection the manager was open and welcoming to the inspection process. She has been the registered manager since the Home was registered in December 2003 and has completed NVQ level 4 and the registered managers award. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 22 The relationships between the manager, service users and staff were good. Progress had been made on previous requirements indicating compliance with the regulations. A number of health and safety records were looked at. The manager had also completed the pre inspection questionnaire 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 to the inspector and indicate a commitment by the provider to providing a safe environment for both residents and staff. 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 residents and staff have the opportunity to practice safe evacuation in the event of an emergency. The manager had developed the fire procedure further and this was now available in each resident’s room so residents and staff know what to do in the event of the fire alarm being activated. Water temperature checks are completed monthly to prevent the risk of scalding. Testing of the water system and storage was taking place during the fieldwork to prevent the risk of legionella. COSHH records had been updated in January 2007 to reflect the change in products purchased so that the right data sheet and the required safety action were available for staff to follow. Certificates were in place, which showed that electrical appliances, gas and bathing equipment and the passenger lift had been tested and serviced for the protection of residents. There is a quality audit system in place. Residents are asked their views about the home through residents meetings and surveys are also used and sent out to resident’s relatives. Residents said they are told about inspections and what needs to be done. Polices and procedures seen had been kept under review. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 23 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 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 24 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. 2 3 Standard YA6 YA9 YA9 Regulation 15 (1)(2) 13 (4) 13 (4) Requirement Further development of peoples individual care plans is required. A risk assessment must be implemented for the risk of choking for one person. Further development of the risk assessment for the use of wheelchairs is required so that these contain specific information about the use of lap belts so staff support residents safely and according to peoples assessed needs. A record of food eaten was required for one person so there is an audit trail of food served and so staff can evidence that healthy eating is promoted. Replace a light fitting in the assisted bathroom to ensure there are no risks to resident’s safety. Timescale for action 31/03/07 16/02/07 16/02/07 4 YA17 16 (2) (i) 16/02/07 5 YA24 23 (2) (b) 16/02/07 Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 25 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 YA17 YA20 Good Practice Recommendations The menu should be provided in a format that benefits all residents. To explore self-administration of medication on a risk assessment basis so resident’s independence is promoted. Sherbourne Grange DS0000050474.V326347.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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.V326347.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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