Inspection on 01/08/08 for Sherbutt House

This inspection was carried out on 1st August 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sherbutt House 06/09/06

Sherbutt House 17/11/05

Sherbutt House 28/06/05

Sherbutt House 08/03/05

Sherbutt House 07/09/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Sherbutt House 106 Yapham Road Pocklington East Yorkshire YO42 2DX Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 1st August 2008 09:30 Sherbutt House DS0000019724.V369374.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 Sherbutt House DS0000019724.V369374.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. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sherbutt House Address 106 Yapham Road Pocklington East Yorkshire YO42 2DX 01759 304149 01759 828336 gillianlilley@sherbuttservices.co.uk 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) Mrs Linda Woodhead Mrs Gillian Lilley Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include one service user with a physical disability. Date of last inspection 6th September 2006 Brief Description of the Service: The home is registered to provide personal care for 15 people with a learning disability. People live in two houses, which are on the same site, Sherbutt House and Coach House. Eight people live in Sherbutt House and seven people live in Coach House. Apart from one shared room all accommodation is in single rooms. The rooms in Coach House have en-suite facilities and there is one en-suite room in Sherbutt House. The buildings do not have a passenger lift and the accommodation in Sherbutt House is on three floors. The premises are located on the outskirts of Pocklington, which is a small town with local facilities including shops, cafes, and a swimming pool. There are large lawned gardens, which are safe for people to enjoy. The home is well furnished, domestic in style and in keeping with the local community. The home owns two vehicles, which are used by people who live at the home. A copy of the latest Commission for Social Care Inspection (CSCI) report is available at the home. The weekly fees on the date of the inspection range between £360.15 and £903.00. People who live at the home are supported in arranging and paying for goods or services like hairdressing, with their own money. Sherbutt House DS0000019724.V369374.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 1 star. This means the people who use this service experience adequate quality outcomes. The Commission for Social Care (CSCI) inspects care homes to make sure the home is operating for the benefit and well being of the people who live there. More information about the inspection process can be found on our website www.csci.org.uk The last key inspection was carried out in September 2006. This inspection took place on 1st August 2008. Before this unannounced visit we reviewed the information we had about the home and the manager completed an annual quality assurance assessment (AQAA). We used this information to help us decide what we should do during our inspection visit. Surveys were sent out to people who live at the home, staff and health care professionals. Ten surveys were returned. Comments from the surveys have been included in the report. One inspector was at the home for one day from 9.30am to 5.45pm. During the visit we looked around the home and talked to people who live at the home and people who work there. We observed staff caring for people in the communal rooms and looked at care plans, risk assessments, daily records, menus and staff records. Feedback was given to the registered provider at the end of the visit. What the service does well: We talked to people who live at the home. They said they are happy living at the home. One person said, “I like it here.” Another person said, “I do like it.” People who have recently moved into the home told us they have settled in well and are happy living at the home. One person said, ‘It’s better here.’ They told us they chose to live at the home and met people before they decided to move in. Staff have good knowledge about the people who live at the home. They understood people’s current needs. Information in the care plans was very good and gave sufficient information about how people’s individual needs should be met. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 6 People enjoy an active lifestyle. People talked about going out with staff and said they go out often. One person said, “There are lots of thing to do”. Another person said, “We go out a lot.” A professional said, “They are good at supporting people to access community resources and are always keen to work with individuals to improve their quality of life, e.g. having holidays, going on outings.” Good systems are in place to make sure people’s healthcare needs are met. A professional told us “Sherbutt House promptly refer to professionals when required. People’s healthcare needs are always properly monitored and attended to.” People live in a clean, pleasant and homely environment. Bedrooms are personalised; people said they like their rooms. The management team provide good support to people who live and work at the home. What has improved since the last inspection? What they could do better: People who live at the home should have more involvement in the care planning process. This will make sure they have goals and aspirations to work towards, and more control over their lives. Some risk assessments should be more comprehensive and show how risks have been assessed. This will make sure people lead the life they want and any restrictions are in the person’s best interests. Staff should not have their breaks and meals in one house at the same time and use a listening device (baby monitor) to check that people who live at the home are alright. Staff practices should promote active involvement rather than create segregation. This will make sure privacy and equality is respected and promoted, and people have ownership in their own home. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 7 People should be encouraged to take more responsibility within their own home. People who live at the home told us staff are responsible for cleaning the house, including bedrooms and cooking the meals. One person said they would like the opportunity to cook some fish. This would give people more independence. People enjoy the meals but sometimes they should be given the option of having fresh vegetables rather than frozen. This will make sure people get good variety. There should be robust procedures and risk assessments when people self medicate. This will make sure medication is administered safely. Staff should be more aware of following their safeguarding procedures and reporting incidents to the appropriate agency when people have been assaulted by others who live at the home. This will make sure people are protected. Maintenance around the home should be more thoroughly checked. This will make sure the environment is safe. A more robust recruitment process should be followed when staff are employed. This will make sure people who live at the home are protected. We should have access to information that confirms criminal record checks have been completed before staff start working at the home. This will help us confirm staff are being recruited properly. 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. Sherbutt House DS0000019724.V369374.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 Sherbutt House DS0000019724.V369374.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): 2 People who use the service experience good quality outcomes in this area. In the main, people’s needs are properly assessed before they move into the home and they are assured their needs will be met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: We talked to two people who had recently moved into the home. They both said they had settled in well and are happy living at the home. One person said, ‘It’s better here.’ They told us they chose to live at the home and had a chance to meet people before they decided to move in. One person said they visited the home and had gone out with staff to the local town. Another person said they knew everyone before they moved in. We talked to staff. They thought the admission process was good and said they get chance to know people before they move in. Staff surveys told us that staff are given up to date information about the needs of people they support. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 10 In the AQAA the manager said, “Advocates for the clients are accessed through Mencap Advocacy service as to the need of the individual and the clients family/friends are consulted.” We looked at records for two people who had recently moved into the home. One person had a detailed pre admission assessment that had been completed by the home and an assessment that had been completed by a social worker. The assessments contained good information about the type of support the person required. Recent assessments had not been completed or obtained for the other person. A letter from a service where the person was living provided some information about the person’s needs. A care management assessment was in the file but this was dated December 2006. The home had not completed an assessment before admission. The registered provider said this is not usual practice and explained that they knew the person well because they used Sherbutt House supported living service twelve months previous and had maintained regular contact. The registered provider acknowledged that it would have been good practice to complete an up to date assessment. We looked at the reviewing process for people who move into the home. People attend formal meetings and discuss the placement. This is a good system that makes sure people are happy living at the home, and their needs are being properly met. Surveys from people who live at the home said they received enough information to help them decide if they wanted to move in. Sherbutt House DS0000019724.V369374.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 & 9 People who use the service experience good quality outcomes in this area. People needs are identified and met. More involvement in the care planning and risk assessment process would help people identify goals and aspirations, and increase the amount of control people have over their own lives. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: We talked to people who live at the home. They said they are happy living at the home. One person said, “I like it here.” Another person said, “I do like it.” We asked the staff what the home does well; they all said the home provides a good standard of care. One person said, “We do very well at everything - it’s brilliant and people are very happy.” Another staff member said, “People are caring, staff are caring, it’s a loving environment.” Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 12 Staff had good knowledge about the people who live at the home. They understood people’s current needs and knew about their past. They were able to talk about people’s family members. The care that staff described for each person was the same as the care that was written in the care plans. For example one staff member talked about supporting one person with personal care and a specific routine. This was observed during the day and was also recorded in their care plan. When describing one person’s behaviour, a staff member described the person as a ‘little monkey’ several times. This description is not appropriate when talking about other adults. We looked at four people’s care plans and assessments. The home uses a combined care plan and risk assessment document. The files were well organised. Information in the care plans was very good and gave sufficient information about how people’s individual needs should be met. Files had very good information about any specific conditions that are associated with their disability. For example, two files had detailed information about autism. We talked to people who live the home about the care planning process. They said they meet with their keyworkers but did not seem to be very familiar with the care plans. One person looked through their file and said the list of likes and dislikes was correct. People had signed their care plans. We talked to staff about the care planning process. They said if they identify any changes in people’s needs they ask the manager to make any relevant changes. They said they complete reviews every six months with the people who live at the home. The four files did not contain any information about goals or aspirations. Staff had written a statement in two of the files to say the person ‘does not want to work on a goal plan’. People should be encouraged to have aspirations and future plans no matter how small these are. Overall care plans identify how people’s needs should be met but there was very little evidence to show that people have ownership of the plans or staff use creative ways of involving people in the care planning process. Risk assessments are not comprehensive and do not show how some risks have been assessed. For example, one person administers their own medication at certain times. There was no information to show how this decision had been reached. The care plan/risk assessment provided detail of when and how the person administers their own medication although the times of administration were incorrect. The care plan said the person administers Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 13 their medication at 10:00am but they actually administer their medication a 9:30pm. They had signed two agreements but these were general; one states they are unable to self administer and the other document confirms they can self administer. To make sure that people have the correct information this should be clarified. The registered provider agreed to look at the risk assessment process. Much of the day was spent talking to people and observing the care being given to people. This included how staff interact with people at the home. Everything was done at a relaxed pace. Staff treated people with warmth and they were polite. Throughout the day, staff chatted to people who live at the home and it was evident that everyone felt at ease. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. People enjoy living at the home and have an active lifestyle. Staff practices do not always promote privacy, equality and independence. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People who live at the home said they have a good life and do a lot of different things. People talked about going out with staff and said they go out often. They said they enjoy going into town, bowling, swimming, to the gym and to Burnby Hall Gardens. One person said, “There are lots of thing to do”. Another person said, “We go out a lot.” People go to various organised activities during the week. Some go to day centres; others have organised group and 1:1 activity programmes. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 15 People have recently been on holiday and said they had a good time. Some people went to Lanzarote and others went to Primrose Valley. One person said they were looking forward to going to Primrose Valley in a few weeks. We received information from professionals who have been involved in the service. One person said, “They are good at supporting people to access community resources and always keen to work with individuals to improve their quality of life- e.g. having holidays, going on outings.” We asked people what has improved. Some people told us that there were more varied activities because a sports/activity organiser now works at the home. The home provides a service to people whose ages range from 25 to 71. Staff talked about meeting different peoples needs. They gave examples of how they do this. For example, supporting people to buy appropriate clothing when out shopping. They also said some people go to activities that are for the ‘older age group’. People who live at the home said they can get up when they want on a morning. They said they go to their bedroom at 10:00pm when staff go off duty but they can watch their TV and go to bed when they want. Staff have their morning and lunch breaks at the same time; all staff meet in Sherbutt House and eat together. A listening device (baby monitor) is switched on in the communal area in Coach House and staff can then hear if there are any problems. This is not good practice because it does not respect people’s privacy or promote equality or give people ownership in their own home. Good care practice promotes active involvement rather than having segregated systems. We talked to people who live at the home about daily living skills. Everyone told us staff are responsible for cleaning the house, including bedrooms and cooking the meals. Some people said they do some tasks, which includes making sandwiches, washing up, setting the table and vacuuming. One person said, “If staff are busy I help them make drinks.” Another person said, “When I come home my bed is made.” One person said they would like the opportunity to cook some fish. People should be encouraged to take responsibility within their own home. People said they enjoy the meals. One person said, “The staff are good cooks.” Another person said, “I can have something different if I don’t like it.” We looked at the menus, which are varied and nutritious. One person has a special diet; staff said they devised a similar menu so they do not feel as though they are always eating different meals. There was good information about foods that people like and dislike. We talked to staff about cooking. One staff said the home does not use fresh vegetables because of the time factor. Other staff Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 16 confirmed they use frozen vegetables. More meals should include fresh vegetables to make sure people get good variety. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. People’s general health and personal care needs are well met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Staff said the home was good at meeting people’s personal and healthcare needs. Care plans had very good information about how personal care needs should be met. In the AQAA the manager gave us examples of what the home does well. This included, “All health care opportunities are offered to clients through informed choice and as required clients are assisted to arrange access and attend appointments such as dental, optician, podiatrist, consultant, outpatients etc.” and, “Individual care plans describe a protocol for each individual client to have health monitored and the action to take in the event of complications this includes weight, blood pressure, blood glucose, general health etc.” Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 18 People told us the home was good at meeting healthcare needs. One person talked about health problems and said, “Staff make sure I see a doctor if I am unwell.” We received information from professionals who know the service. They told us “Sherbutt House promptly refer to professionals when required. People’s healthcare needs are always properly monitored and attended to.” They also said, “They can be a little defensive if they think they are being criticised.” We looked at information that showed us people’s health and welfare is properly monitored, and their needs are met. Reviews identify any changes in needs and any significant events. Weight is monitored and healthcare appointments are clearly recorded. We looked at medication systems. Medication is well organised and good systems are in place to make sure the right medication has been administered. The records were completed correctly. Two people self medicate. As stated in the previous section additional information is required to make sure the level of self-medication is right. Staff give the person who self medicates one tablet at a time. They take the tablet from the monitored dosage system and put it in a bottle or a medication container. This is called secondary dispensing and is considered an unsafe practice because it increases the risk of drugs errors. We have pharmacy guidance that states there are exceptional circumstances when the practice of secondary dispensing may be acceptable. Exceptional cases would need a robust risk assessment and written procedure. Details should include , which staff are permitted to do this, what containers the medicines are to be put in, how the containers are to be labelled and what other information is to be given. A clear record should be kept of all staff involved in each stage of the procedure and the actions taken. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 19 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 & 23 People who use the service experience adequate quality outcomes in this area. People are confident that they will be listened to and any concerns will be dealt with appropriately. People who live at the home are safeguarded from most types of abuse but not all safeguarding incidents are being acknowledged and this places people at potential risk. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People who live at the home said they know who to speak to if they are not happy and how to make a complaint. Staff said they report any concerns to the manager or the registered provider, and they are confident these would be dealt with effectively and promptly. In the AQAA the manager said, “The complaints procedure is explained and refreshed with all clients. Also, detailed within the client guide is promoting the option of contacting CSCI and ensuring all are aware of whom to complain to, all complaints are dealt with within 28 days, however the service has not received a complaint for several years.” Staff have received training on safeguarding adults. They were able to say what action they would take if they suspected abuse or had an allegation of Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 20 abuse made to them. They were also able to describe the different types of abuse. However some very obvious incidents of physical abuse had not been dealt with under the safeguarding procedures Each person has a ‘record of behaviour’ in their file. One record stated a person had hit several people. Eight incidents were recorded in 2008, which included hitting people in the face and the head, and punching to the ear. The person had apologised after these incidents but there was no evidence that any action has been taken to safeguard people from further incidents. We looked at accidents and incidents records. From December 2007 three incidents were recorded in the accident book when people who live at the home hit staff. Incidents when people hit other people who live at the home were not recorded in the book. This raises concerns about equality and protection. Staff must be aware that it is as important to record incidents against people who live at the home as it is staff. In the AQAA the manager said no allegations of abuse have been recorded however in the event of suspicion, allegation and incidents the full policy would be implemented immediately. This is not correct. We spoke to the registered provider who gave reassuarce that any further incidents would be reported in accordance with their safeguarding procedure. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 21 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 & 30 People who use the service experience good quality outcomes in this area. People live in a homely and pleasant environment. Overall, the home is wellmaintained but some issues put people at potential risk. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home is separated into two units. Each unit has its own kitchen, dining area, lounge and bathrooms. On the day of the visit the houses were clean and tidy. People told us the home is always clean and fresh. Decoration, furniture and furnishings were of a reasonable standard. Each bedroom is personalised and people said others only come in when they are invited. Bedrooms are very different and reflect people’s tastes. People said they like their rooms. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 22 Not all bedroom doors are fitted with appropriate locks. Some bedroom doors do not have locks fitted; other doors have star locks so people can lock their door from the outside with a chubb key but not from the inside; other doors have thumb-turning locks, which are appropriate. The registered provider agreed that an individual risk assessment should be carried out with each person to find out if they can use a suitable lock and if they would like a key. One person who had a chubb key to her room said she liked locking her room. Since the last inspection a new office has been built. Staff and management said this is much better because they have additional space and an area where they can hold meetings. Staff said they carry out regular health and safety checks. Although when we looked around the home we identified several maintenance problems that needed attention. • • There was no water coming out of the hot tap in the bathroom at Sherbutt House. Paint was flaking and parts of the floorboard were exposed where lino has been cut in a bathroom in Sherbutt House, which causes a risk of infection because surfaces are not impermeable. The water temperature in a shower in one en-suite at Coach House ran very hot and it could scald a person. The room temperature in the double room in Sherbutt House was very warm and became uncomfortable after only a short period of time. It was a hot sunny day on the day of the inspection. One window, on the second floor in Sherbutt House, did not have a restrictor fitted so could be fully opened. Several heavy fire doors banged when they were closing, which could cause injury if the doors closed on people. • • • • The home has a call system in each ground floor bedroom in the Coach House. Staff said this was installed to make sure people with mobility problems could ask for assistance during the night. Staff said the system works well and they did not feel that a call system was needed in any other areas of the house. The home has one laundry with industrial washing and drying facilities. Staff said the laundry system works well although occasionally there is a mix up Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 23 with clothes. People who live at the home said staff do the washing and they are happy that clothes are washed and ironed properly. Clinical waste is properly managed and staff wear protective clothing when attending to the personal care needs of people who live at the home. Staff have received training in infection control. In the AQAA the manager said, “The service compiles fully with requirement of the local fire service and environmental health.” Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 24 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, 34 & 35 People who use the service experience good quality outcomes in this area. Staff are trained and in sufficient numbers to support the people who live at the home. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People who live at the home said staff always treat them well and listen and act on what they say. One person said, “I sit and talk to staff.” Another person said, “Staff are alright.” Staff said staffing levels are satisfactory and they can spend quality time with people who live at the home. They also said they have time to take people out. Staff said they work well together as a team. Staff also told us they are given training that is relevant to their role. Two staff surveys said their induction mostly covered everything they needed to start the job; two said it covered everything very well. One person said, “My induction was very good and I learnt a lot from this.” Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 25 Training records confirmed staff have completed a good range of training courses, including record keeping, autism, diabetes, first aid, medication, health and safety and dental hygiene. Three staff from the management team have completed ‘train the trainer’ courses, which equips them with the skills to train the staff team. The registered provider has purchased some new training material that she described as very impressive, and agreed these programmes would benefit the staff team. The programmes included person centred care and the role of the care worker. It was difficult to establish training that staff had completed because we had to look through training certificates. The registered provider showed us a system that is being introduced which will help identify staff training needs. In the AQAA the manager said, “Currently all staff employed within the service hold or are working towards NVQ 2/3/4.” A member of staff that has recently started working at the home talked about the recruitment process. They confirmed that they attended an interview, and had to wait for a criminal records check and satisfactory references before they could start work. All staff surveys said their employer carried out checks, such as their CRB and references, before they started work. We looked at staff files for three people that had recently started working at the home. Application forms and two references were available for each person. However, the authenticity of one reference could not be verified. It was an employment reference but had not been obtained from the employer’s address. After the inspection visit, the manager contacted us and said they had checked the authenticity of the reference and there was a record of this in the staff file. The manager said the record had fallen out of the file and was in the filing cabinet. We did not have access to information that confirmed (CRB) Criminal Record Bureau checks have been completed. The registered provider said this was always carried out before an employee started work but the information was locked in the Assistant Business Manager’s filing cabinet. Dates and reference numbers of CRB checks must be made available for inspection. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 26 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 & 42 People who use the service experience good quality outcomes in this area. People have confidence in the management team. Health and safety is good, which makes sure people are safe. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home has an experienced and qualified registered manager who has completed the Registered Managers Award. People told us the home is well managed and they will go to the registered manager or duty manager for advice and guidance. The registered manager was absent for a period of time. Staff said the home continued to run smoothly and be well managed during this period. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 27 Staff said they receive good support from the registered provider. One person said, “She is lovely and will sort things out.” They then gave an example when they felt the registered provider had been very supportive. In the AQAA the manager told us the service has achieved and maintained the Investors in People award, which makes sure a quality assurance system is in place that monitors the service and listens to people who live at the home, staff and professionals. Meetings for the people who live at the home are held every month. We looked at the meeting minutes, which confirmed they talk about the home. For example they had discussed employing the sports/activity organiser, new kitchen and window blinds, and some dignity issues. The AQAA contained a lot of detail about what the home does well. It gave good examples for each outcome group and told us where we could find the evidence to support this. There was limited information about what they could do better or how they could improve in the next 12 months. The manager tells us about important events that happen at the home. Since the last inspection we have regulation notifications when significant events have occurred. No concerns around safe working practices were seen on the day of the inspection. In the AQAA the manager said equipment has been serviced or tested as recommended by the manufacturer or regulatory body. We checked when fire equipment was serviced and this corresponded with what had been written in the AQAA. Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 28 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 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X 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 X 12 3 13 3 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No 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) (c) Requirement Potential risks to people who live at the home must be properly assessed and risk management strategies agreed. This will make sure the risk of harm is minimised. Staff practices must be carried out in a way that respects people’s privacy and promotes equality. This will make sure people live an ordinary and meaningful life. Where there are exceptional circumstances when secondary dispensing may be acceptable a robust risk assessment and written procedure must be completed. This will make sure the correct medication is supplied. Safeguarding procedures must be followed when there are incidents of physical abuse. This will safeguard people living at the home. Incidents of physical abuse must be appropriately recorded. This will make sure incidents are properly monitored. The premises must be properly DS0000019724.V369374.R01.S.doc Timescale for action 30/09/08 2 YA16 12 (4) (a) 30/09/08 3 YA20 13 (2) 30/09/08 4 YA23 13 (6) 30/09/08 5 YA23 17 (2) 30/09/08 6 YA24 23 (2) (b) 30/11/08 Page 30 Sherbutt House Version 5.2 23 (2) (c) maintained. This will make sure people live in a safe environment. 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 Refer to Standard YA2 Good Practice Recommendations People who know the service should still have their needs properly assessed if they choose to move into the home. This will make sure any changes in needs are identified and met. People should be more involved and have ownership of the care planning process. This will help people to identify goals and aspirations, and have more control over their own lives. People who live at the home should be given further encouragement to be involved in all areas of daily living in the home. People should be offered more fresh vegetables as part of their meals to make sure they have choice and a varied diet. People who live at the home should be offered a key to their own bedroom, which can be locked from inside and outside. This will help promote their independence. Records to confirm that satisfactory (CRB) Criminal Record Bureau checks have been carried out should be made available for inspection. 2 YA6 3 4 5 6 YA16 YA17 YA26 YA34 Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Sherbutt House DS0000019724.V369374.R01.S.doc Version 5.2 Page 32 - 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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