Inspection on 17/11/05 for Sherbutt House

This inspection was carried out on 17th November 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sherbutt House 01/08/08

Sherbutt House 06/09/06

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 09/07/2008.

CARE HOME ADULTS 18-65 Sherbutt House 106 Yapham Road Pocklington East Yorkshire YO42 2DX Lead Inspector Rob Padwick Unannounced Inspection 17th November 2005 2:15 Sherbutt House DS0000019724.V267020.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 Sherbutt House DS0000019724.V267020.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. Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sherbutt House Address 106 Yapham Road Pocklington East Yorkshire YO42 2DX 01759 304149 01759 828336 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.V267020.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include one service user with a physical disability. Date of last inspection 28th June 2005 Brief Description of the Service: Sherbutt House is registered as a care home for 15 service users who have a learning disability. The home consists of accomodation in two adjoining buildings. Apart from one shared room, accommodation is for single occupancy including some with en suite facilities. There is no lift in either buildings and the the original house is on three floors. The home is well furnished, domestic in style and in keeping with the local community. There is a large, lawned garden, which is safe for the service users to enjoy. The centre of Pocklington is close by and provides access to various amenities, including shops, cafes, restaurants, church, market, leisure facilities etc. The home operates two people carrier vehicles for transporting residents to day centres and for trips out. Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and lasted from 2.15 pm until 6.30 pm with a previous half day of preparation time. During the inspection, a tour of the premises was undertaken, and the inspector spent time talking with the service users in the communal areas of the home and observing their daily lives. Further time was spent reading care plans and files, talking to staff and checking the requirements of the previous inspection. What the service does well: 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. Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 6 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.V267020.R01.S.doc Version 5.0 Page 7 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): 2 Residents had received an assessment to ensue that their choice of home could meet their needs. EVIDENCE: The residents spoken to indicated that an assessment of their needs had been undertaken and inspection of their files confirmed this. Assessments of the individual residents self care skills were included within their case files and care plans had been developed from these by staff in the home, together with information that was included within their Local Authority Community Care Assessment. Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 8 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): None EVIDENCE: No Standards were assessed on this inspection Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 9 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): 12, 13, 15, 16, 17 Residents were able to participate in a good range of community and lifestyle activities were good and staff respected their rights. EVIDENCE: Discussion with residents confirmed that they had access to a good range of age, peer and culturally appropriate activities. A senior staff member indicated the home works closely with colleges and day centres and a number of the residents were out at the beginning of the inspection, attending various placements at these. On their return, one resident told of the Christmas celebrations that he was taking part in at a local resource centre. One of the files inspected contained evidence of a referral that had been made to follow up an expressed wish by a resident for work experience, and discussion with the registered person indicated that some residents were funded for periods of one to one staff time, in order to maximise their opportunities for socially inclusive activities. Residents confirmed that they were able to participate in the local community. One resident said she had had gone shopping with a staff member that day and had been for coffee in a local café. The home has a policy on social Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 10 inclusion and has access to two people carrier vehicles. Inspection of the homes records indicated that residents attended the local leisure centre for activities such as swimming and bowling. A group of residents were due to go to the local cinema on the evening of this inspection. Residents indicated that staff supported and encouraged them to maintain family and friendship links. The home has an open visiting policy and welcomes the involvement of relatives. Inspection of case files confirmed this. A letter was seen from a resident’s parents, confirming that they were planning to attend a forthcoming Christmas party in the home. A senior staff member advised that a successful summer fete had been held earlier in the year, and that relatives and members of the local community had attended this. Observation of the care practices and discussion with residents indicated that their individual rights were respected by the ethos that operated within the home. Staff stated that residents were free to choose when to do things and care plans inspected confirmed that residents were encouraged and supported to meet short-term goals that had been set in consultation with them. Bedroom doors were lockable and the inspector observed a positive level of interactions within the home. Service users rights to privacy were respected. Residents confirmed that the food was good and that they “liked the food”. Inspection of the menus indicated that they were offered a healthy diet. Residents indicated that alternative choices were available, if they did not like what other people were being served. Case files documented individual likes and dislikes and confirmed that residents were being monitored for their weight. Discussion with staff indicated that they were aware of the nutritional value of food and that a healthy eating programme was in operation for those residents where there were concerns about their weight. Sherbutt House DS0000019724.V267020.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): No Standards were assessed EVIDENCE: No Standards were assessed on this occasion. Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 12 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 Residents views were taken seriously by the home’s management and staff EVIDENCE: Discussion with residents indicated that their views were listened to and acted on. The home had a complaints policy and examination of the minutes from monthly residents’ meetings confirmed that they were consulted about the home and that the management and staff took their views seriously. Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 13 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, 30 The home was comfortable, clean and safe. EVIDENCE: The premises were safe, comfortable, domestic in style and well maintained. Furnishings were of good quality and discussion with staff indicated residents were consulted about the décor of their bedrooms, in order to ensure that their individual wishes and needs were met. The building was clean and hygienic and policies and procedures were in place for infection control. Discussion with staff and examination of their files confirmed that they had received training in this aspect of practice. The registered provider confirmed that the requirements from the previous inspection had been completed and that the home complied with the recommendations of the Fire Department. Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 Staff training was good but the home’s recruitment procedures needed to be strengthened. EVIDENCE: Discussion with residents and observation of care practices in the home indicated that staff were competent to do their jobs and that they supported the residents effectively. A training programme for staff was seen and inspection of their files confirmed that this was being delivered, in order to meet the residents’ needs. Staff files contained evidence of NVQ training and discussion with the registered provider confirmed that 65 of the staff team had achieved the NVQ level 2 or above, and that other staff were registered on programmes to do this. The home had a recruitment policy to ensure that residents were supported and protected. Copies of the individual staff member’s qualifications and past training details were contained within staff files examined, together with identity, health and Criminal Records Bureau / Protection of Vulnerable Adult (POVA) checks. However, the registered person needed to strengthen the home’s recruitment procedures, as a file inspected indicated that a second reference had not been taken up before the staff member had commenced employment in the home. Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The home was being well run in order to ensure the health and safety of service users. EVIDENCE: Discussion with residents and inspection of the records indicated that the home was well run. The manager was on leave on the day of this inspection, however staff were able to assist the inspector as needed and were confident and knowledgeable in their duties in this regard. The registered manager has substantial experience of working with the service user group accommodated and has obtained her NVQ 4 in Care and Registered Managers Award. Residents stated that they were consulted about developments concerning the home and minutes of regular resident meetings confirmed that the views of residents were taken seriously in the reviewing and management of the home. Quality assurance questionnaires had been developed to obtain the view of residents, cares and relatives and extensive systems were in place to monitor the performance of the home. Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 16 Inspection of the building and maintenance records and discussion with residents indicated that the health, safety and welfare of service users and staff were being promoted and protected. The requirements of the fire departments last visit had been actioned and inspection of a random sample of the home’s service records found them to be up to date and satisfactory. H/s checks ok. Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 17 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 X 3 X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 4 X 1 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sherbutt House Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000019724.V267020.R01.S.doc Version 5.0 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34YA34 Regulation Schedule 2 Requirement The registered person must ensure that two satisfactory references are received before new staff are commenced working in the home 19 Timescale for action 17/11/05 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 Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sherbutt House DS0000019724.V267020.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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