This inspection was carried out on 4th October 2005.
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.
CARE HOME ADULTS 18-65
Sherbourne Grange 18-20 Sherbourne Road Acocks Green Birmingham West Midlands B27 6AE Lead Inspector
Donna Ahern Unannounced Inspection 4th October 2005 10:45 Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 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.V257050.R01.S.doc Version 5.0 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.V257050.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Sherbourne Grange Address 18-20 Sherbourne Road Acocks Green Birmingham West Midlands B27 6AE 01564 200016 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.V257050.R01.S.doc Version 5.0 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 NCSC subject to all requirements being met 22nd June 2004 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. Both clusters have sitting and dining rooms and there is a 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.V257050.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced. The inspector met and spoke to five residents. A partial inspection of the physical standards was undertaken. Residents care plans and risk assessments were inspected. A number of Health and Safety records were inspected. The inspector had the opportunity to talk to the manager, owner and deputy manager and two support staff. What the service does well: What has improved since the last inspection?
The home has been registered for two years. There is evidence that the manager has continued to build on good practice and develop the service gradually. The previous inspection was unannounced and four requirements were raised three were of a development matter. Progress had been made on all requirements. Sherbourne Grange is a large property, which requires almost ongoing maintenance. It is positive that the owners have continued to invest in the building and enhance the physical standards of the home for the comfort and benefit of residents. Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 Page 6 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.V257050.R01.S.doc Version 5.0 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.V257050.R01.S.doc Version 5.0 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): 1, 2 and 3 Information was available about the home and had been reviewed so that it was current. Prospective residents are able to have a trial place at the home so that they can ensure it is the right place for them to live. EVIDENCE: The previous inspection required the manager to review the Statement of Purpose and to include room sizes this had been actioned. The manager stated that the document continues to be kept under review. There were twelve residents living at Sherborne. New residents have gradually been introduced to the home. The manager has demonstrated a commitment to ensure that Sherbourne is the right place for each person and that resident’s needs are compatible. As the numbers of residents have gradually increased there have been moves towards ensuring that the home operates as two separate clusters. Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 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 and 9 Care plans and risk assessments have been developed for all residents. These required review so that they reflect the current and changing needs of each resident. EVIDENCE: Detailed care plans have been developed for each resident these were briefly sampled and were due to be reviewed. The manager stated that they were also working on developing P.C.P (Person Centred Plans) in conjunction with the local Day Centres that residents attend. Progress on residents care plans will be monitored at the next inspection. A number of risk assessments were in place and these now cross reference to the care plans. The risk assessments were also due for review. The manager stated that formal reviews will take place alongside the reviewing of the relevant documentation. Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 Page 10 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): EVIDENCE: Not assessed at this inspection. Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 Page 11 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): 18,19 and 20 Residents receive a good level of support with their personal care and healthcare needs. EVIDENCE: Residents are supported to access a range of health care professionals including consultants, G.P, dentist, Opticians and dietician. One resident had a Health Action Plan and the manager stated that these are to be developed for all residents. The arrangements for the administration of medication was well managed. The Boots monitored dosage system was in use. The manger was in the process of reviewing the storage arrangements for medication and it was recommended that she took advise from the CSCI pharmacist inspector. Residents said that routines in the home are flexible and they can go to bed and get up when they choose. Residents who were at home on the day of the inspection were observed getting up at different times and having breakfast when they required it. There was good attention to residents personal care needs including hair care, clothes and their general appearance.
Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 Page 12 The manager demonstrated a good understanding and awareness of the need to support residents with their emotional and psychological needs and the importance of ensuring that staff have time to listen and talk to residents. Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 Page 13 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 and 23 Resident’s views are listened to. The Adult Protection procedure required some further development so that it reflects the good practice established in the home. EVIDENCE: The manager had received no complaints about the home. Most residents who live at Sherbourne 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 Adult Protection Policy had been developed since the previous inspection however some further development was required so that it clearly states that Social Care and Health are the lead agency in all protection matters. 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 must also include the company’s commitment to invoke procedures in relation to staff employment to protect both residents and staff. Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 Page 14 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): 24 and 30 Residents live in a homely, comfortable and safe environment. EVIDENCE: Sherborne Grange is a large renovated property that was registered in November 2003. It meets the required physical standards for its current stated purpose. The home was in a good state of repair and there was evidence that maintenance matters are dealt with promptly. Work to the outside of the property, the roof, guttering and a window was in progress. Internal upgrading had continued including new carpets and flooring. A mattress in one resident’s bedroom required replacing. West Midland Fire Service undertook an inspection of the premises on the 13 April 2005 some matters requiring attention were raised. These had all been actioned.
Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 Page 15 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): 33 and 35 Residents are supported by a competent staff team in sufficient numbers to meet their needs. EVIDENCE: Staffing levels were four care staff 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 manger stated that some updates were required on staff training including Manual Handling and Food Hygiene and that these were in hand. Three staff had just completed their Ldaf (learning disability award framework) training. Staff had received Basic First Aid training and four were trained to Advanced First Aid level. Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 Page 16 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 and 42 Resident’s benefit from a well managed home. Some minor Health and Safety matters required action so that resident’s safety and welfare is promoted and protected. EVIDENCE: A number of Health and Safety records were examined and generally were in good order. It was advised that the Workplace Fire Risk Assessment is an active document with information added to the assessment when any fire measures are reviewed. The fire evacuation procedure required review. The manager stated that this would link into the development plans of the move towards operating as two separate clusters. The revised procedure must include a full evacuation plan as well as the phased evacuation plan. Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 Page 17 The date that the Fire alarm was serviced was required and evidence of the service must be kept in the home and available for inspection. Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X 2 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Sherbourne Grange Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 2 X DS0000050474.V257050.R01.S.doc Version 5.0 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 4 5 5 Standard YA6 YA9 YA23 YA26 YA42 YA42 Regulation 15 (1) (2) 13 (4) 13 (6) 16 2 (c) 23 (4) c (iii) 23 (4) c (iv) Requirement Care plans required review Risk assessments regarding residents required review. The Adult Protection Policy required further development. One mattress required replacing. The Fire procedure required further development. The Fire Alarm required servicing. Records of the test must be available in the home. Timescale for action 31/12/05 30/11/05 30/11/05 31/10/05 31/10/05 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sherbourne Grange DS0000050474.V257050.R01.S.doc Version 5.0 Page 20 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
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