Inspection on 06/09/06 for Sherbutt House

This inspection was carried out on 6th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sherbutt House 01/08/08

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 09/07/2008.

CARE HOME ADULTS 18-65 Sherbutt House 106 Yapham Road Pocklington East Yorkshire YO42 2DX Lead Inspector Jean Dobbin Key Unannounced Inspection 6th September 2006 09:45 Sherbutt House DS0000019724.V310819.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.V310819.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.V310819.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 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.V310819.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 17th November 2005 Brief Description of the Service: The registration for Sherbutt House now includes the Coach House, which is on the same site, across a paved courtyard. Apart from one shared room all accommodation are single rooms. The rooms in the Coach House have ensuite facilities and there is one en-suite room in the original building. The buildings do not have a passenger lift and the accommodation in the original 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 swimming pool. The home is registered for 15 people with a learning disability. There are large, lawned gardens, which are safe for the service users to enjoy. The home is well furnished, domestic in style and in keeping with the local community. The home owns two people carrier vehicles and a car, which are used to transport residents to the various events they attend in the surrounding area. Details provided in August 2006 outline the weekly fees at a minimum of £332.50. There are no extra costs charged by the service as residents are supported in arranging and paying for their own goods, or services like hairdressing, with their own money. Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report follows an unannounced site visit to the home on 30th August 2006. The inspection lasted 7 hours, with extra time required for preparation work. The manager was present throughout the visit and was provided with feedback at the end of the inspection. A tour of the home including communal, service and private areas was undertaken and staff were observed interacting with residents. Some policy documents were looked at and care records were examined to see how individual care needs were assessed. Discussions were held with residents and staff. Prior to the site visit a questionnaire was sent to the home, which was completed and returned, as requested, within the stated deadline. Requests for views, in the form of a written survey, were sent to 5 next of kin chosen at random and 3 were returned. Forms were also sent to 2 health care services, but none were returned. Surveys were not sent to residents but discussions on the day provided some insight into their service What the service does well: What has improved since the last inspection? The checks that are carried out before someone starts work at the home are now much better. The managers now obtain two references for all prospective employees. These checks are required as a way of protecting residents from harm. Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 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. Sherbutt House DS0000019724.V310819.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 Sherbutt House DS0000019724.V310819.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. There is a comprehensive assessment, including a trial stay at the home, to ensure that the needs of a prospective service user can be met. They can also be reassured that the home is the right place for them to live. This judgement has been made using available evidence including a visit to the service. EVIDENCE: There have been no new admissions to the home since the last inspection. The manager outlined that if there is a vacancy then the staff would first ask whether any current service users wanted to change rooms. The manager explained, that she meets a prospective service user ideally at his or her own home and carries out an assessment. She would then invite them to the home to have a look round before getting the service users feedback. If this was positive, then she would invite them to Sherbutt House for the day. This would be followed by a three-month trial. There would be a discussion involving all staff and service users before allowing a new service user to move permanently to the home, if that was also their wish. Sherbutt House DS0000019724.V310819.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is excellent. Service users are included and consulted in all aspects of their day to day lives and are supported in making decisions and choices to ensure they lead fulfilled lives. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Staff at the home maintain high quality care planning records with clear goals, and how these will be achieved. There are monthly reviews, which are very detailed, and six monthly review meetings, which the service user attends and signs to confirm their agreement with what was discussed. The plans are very individual and include records consenting to receive medication, as well as consenting to be responsible for some treatments. Each service user has a key worker and all those spoken with knew who their key worker was. There is a list of very specific and individual responsibilities for the key worker in each file. This system enables all service users to have a closer relationship with one carer, who has a pastoral role. Service users are encouraged to make decisions. They have their own money and are supported in purchasing their own goods. One resident described how they had been to town that morning to buy some toiletries. Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 10 Residents’ meetings are held monthly. When interviews for new staff are held the prospective employees are introduced and service users are encouraged to give their views about the candidates. There are detailed risk assessments in the care records. One service user travels alone on the bus whilst another is able to make hot drinks in the kitchen. There is an electronic beam alarm on the boundary gate, which can be activated, if necessary, to alert staff if those service users, who would be at risk of getting lost, leave the grounds. The service provides independence and choice for some service users, whilst providing the facility to ensure others cannot wander away without staff being alerted. Sherbutt House DS0000019724.V310819.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. Service users are involved in a wide range of social and learning activities, which contribute towards a stimulating and varied lifestyle. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The service users lead a very active and varied life. Many have regular events which they attend, such as a Day Centre, College of Further Education or Agricultural College. Service users regularly walk into town, whether to buy things or just have a coffee. On the day of the visit two service users were in town in the morning and two others in the afternoon. One service user had gone to visit a friend. Others were on holiday in Filey. There have been other holidays this year in Wales and the Canary Islands and one person recounted the best bits of their holiday in Lanzarote. A discussion was held on the day of the site visit about the theatre trip to York and whether a show would be better than a musical group. The service users had preferences, which were all acknowledged. Other social events include night classes; the pub and one service user said how much they enjoyed the leisure pool in York because of the slides. Visitors are welcome anytime, though there weren’t any on the day of the visit. Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 12 Permission was requested from all service users, individually, before any private rooms could be viewed. All these rooms are lockable and one service user has their own key. Staff were observed including all service users in their conversations and recognised when more time was needed to allow a considered response. There was lots of laughter and non-verbal communication. The meals are served round a large table, where craftwork is also carried out. The menus are devised following discussion and are varied and suitable for a younger age group. Meals are also discussed regularly in the residents’ meetings. On the day of the site visit there were crumpets for lunch. One service user is on a Slimming World diet and the details were clearly outlined. Another has diabetes and they have their own small cupboard in the kitchen, containing their special foods. One service user’s recent birthday cake was filled (and covered) with tinned fruit. This made it very soft and easy to eat, which was ideal as the resident chooses not to wear dentures. The food hygiene records, which are in place to demonstrate the home’s commitment to reducing the risk of food poisoning, were in order. Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is excellent. Service users personal and healthcare needs are very well met and the comprehensive documentation, including the service user’s input, evidences this care. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Care records demonstrate the way staff support and guide service users with their personal care. There is goal setting in evidence and plans are very individual. For example records state how one person likes a flannel over their face when washing their hair. Their key worker is very involved in supporting the individual from day to day. The key worker accompanies the service user if they are attending a hospital appointment or the family doctor. There is also very detailed information about managing difficult behaviours so that staff provide consistent support. There is evidence of visits from a variety of healthcare professionals, including the district nurse, epilepsy specialist nurse and dietician. There are particularly close links with the specialist learning disability nurse, who has given guidance in constructing care plans about how to manage challenging behaviour. One service user has epilepsy and there are comprehensive assessments in place to ensure that the risk of harm is minimised, should they have a seizure. Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 14 Medication systems are robust, are audited regularly and the records show no omissions. There are risk assessments in place for those service users who take medication with them when they attend activities away from the home. Those service users who self medicate have metal locked cupboards in their rooms in which to store the drug or ointment. They sign to say they will behave responsibly with the drug, and all service users sign to consent to receiving medication. The medicines are listed in detail in their records. The care plans discuss end of life care and the home has stated their determination where possible, to keep the service user at the home until their death. The records also provide details about who the service user wants to deal with their affairs, after their death. Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Service users have their complaints acknowledged and treated seriously, and staff are alert to any signs of abuse that may be carried out. This judgement has been made using available evidence including a visit to the service. EVIDENCE: There are monthly residents’ meetings and these are recorded. There is also a ‘grumbles sheet’, which service users (or carers on their behalf) can complete if unhappy about something. These grumbles are all taken seriously and recorded, and an action plan is devised in consultation with the people involved. There have been no true complaints over the past year. All staff have attended abuse awareness training this year. The manager has also attended training to enable her to discuss ‘speaking out against abuse’ with the service users. Staff were very clear about their responsibilities, and provided examples, which demonstrated their knowledge and understanding. The home stores some money for service users, however each has their own bank account. Service users are supported to save and make withdrawals. They are encouraged to take responsibility for their own personal money and staff give them varying amounts of support, depending on their capabilities. Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. The service users live in a safe, wellmaintained and comfortable environment. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A tour of the home demonstrated that it is clean, comfortable and well maintained. There are two buildings, the main house and the Coach House, which are separated by a courtyard. Both buildings have their own kitchen and communal spaces. In the Coach House all the rooms have en suite facilities, whereas in the original building there is only one en-suite single room and one shared room. There are enough toilets and bathrooms for the remaining service users. There are no malodours. There is a large kitchen to which the service users have free access and an alarm can be activated if necessary to guard against more vulnerable service users leaving the site and facing potential danger. The gardens are attractively laid out, and well maintained with seating areas. One service user was observed watering the flower tubs. There is a handyman at the home and as well as routine checks the staff can request work to be done. The ‘repairs file’ evidenced this. The laundry area is in the courtyard and is satisfactory. Service users are supported in doing their own washing if that is their wish. Staff explained clearly how they would prevent the spread of infection in the home Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. Service users receive high quality care from well-supported, well-motivated and well-trained staff, and good recruitment processes ensure that service users are protected from harm. This judgement has been made using available evidence including a visit to the service. EVIDENCE: There are at least four staff on each morning, three in the afternoon and evening and two staff at night, who sleep but are on call. These numbers are flexible according to activities in, and away from the home. The manager has some supernumerary hours each week. There is an administrator and two housekeepers, one of who organises craft activities once a week. There is no use of agency staff as staff support each other to cover the rota. Service users therefore do not have unfamiliar carers working at the home. All staff have key worker responsibilities, and new staff are mentored in this role until they are familiar with their responsibilities. One carer commented on how much she enjoyed this role and how it was a very rewarding part of her work. There is a training plan in place and staff are supported in new learning. Only one carer does not have at least Level 2 National Vocational Qualification in Care. Staff have received training from a specialist nurse to enable them to give emergency medication in a safe manner. This means that staff can administer Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 18 this treatment by following guidelines, without having to wait for professional support. The service user can then benefit from the prompt treatment, provided by staff at the home. Staff meetings take place monthly and are recorded. The recruitment processes are robust and no one starts work at the home until a Criminal Records Bureau (CRB) clearance is available. This police check confirms that individuals are not barred from working with vulnerable adults. All new staff receive an induction programme and two members of staff who have worked at the home for only a short time confirmed this. This programme ensures all staff follow the same learning process and service users are more likely to be supported in a safe and consistent manner. Staff say that they receive regular supervision and feel valued and part of a team. Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. The home is well run, with good systems in place to monitor itself, and the welfare of service users and staff is recognised as very important. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The manager is very experienced and has an excellent understanding of her client group. She is described as approachable and supportive. The home promotes an inclusive culture where all views are encouraged and valued. There are monthly residents’ meetings and monthly staff meetings. The unit manager leads the discussions about meal choices and ensures the menus reflect what the service users like. There are suggestion sheets that can be completed and questionnaires are used to gain the views of other professionals, family members and visitors. Many relatives live some way from the home, so conducting relatives’ meetings would be difficult. The home produces a twice-yearly newsletter and an annual report, giving information about the service. There is an annual plan of refurbishment in place, and some of these areas have been addressed. This ensures the home remains a pleasant environment Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 20 for the service users. A maintenance man was working at the home on the day of the visit. There are comprehensive policies in place, which are reviewed regularly. There are a range of health and safety policies and procedures in place. The home has made proper provision to ensure that there are safe working practices by providing staff training in first aid, fire, food hygiene, infection control and safe moving and handling techniques. Hazardous products are stored appropriately and records maintained as required. Annual checks carried out randomly, showed that the gas service, portable appliance test and tests to minimise the risk of Legionella were all in order. Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X X 3 X Sherbutt House DS0000019724.V310819.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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.V310819.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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.V310819.R01.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!