CARE HOMES FOR OLDER PEOPLE
Sherdley Court 91 Rainhill Road Rainhill Merseyside L35 4BD Lead Inspector
Miss Diane Sharrock Key Unannounced Inspection 12:00 2nd July 2007 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 Sherdley Court DS0000022410.V332536.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 Older People. 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. Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Sherdley Court Address 91 Rainhill Road Rainhill Merseyside L35 4BD 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) 0151 4263096 0151 4939382 Making Space Hayley Rowson de Vares Care Home 25 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (19) Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 30th November 2006 Date of last inspection Brief Description of the Service: Sherdley Court is a 25-bedded care home for people with a mental disorder. It is registered to accommodate 19 service users over the age of 65 years and 6 under 65 years. It is owned by a charity, Making Space and the Manager is Mrs Haley Rowson de Vares. It is a purpose-built facility on one floor. It is divided into three units, each with its own lounge and dining area as well as bedroom space. Each bedroom is for single occupancy. The care home also has a large communal lounge area as well as a conservatory, which is used as a smoking room. There is a rehabilitation kitchen, which has been refurbished to the highest standards. Sherdley Court has two rooms for management purposes and a well-appointed kitchen and laundry. It is not registered to provide nursing care but when necessary calls on nursing services, via the district nursing and community psychiatric nursing services. The care home is fully equipped with grab rails and other aids to assist disabled service users manage the premises. It has a call system located throughout the building. The care home integrates easily into the local environment being of a pleasant appearance with accessible garden areas. Sherdley Court is located in an established Residential area of St Helens with easy access to local facilities. The Manager advised that fees for the home are £360 per week. Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day. Inspections involve measuring a number of standards considered as important by the Commission for Social Care Inspection. Information for this site visit was gathered in a number of ways, this included, a tour of the building, informal discussion with some of the residents, reading records and documents in the home and general discussions with staff on duty. Selections of comment cards were left in the home to offer people further opportunity to give their opinion about the home. The manager explained that she had not received pre inspection documentation from the Commission however the manager was able to give all the necessary information to assist at this visit. Feedback was given to the manager at the close of the inspection. What the service does well:
Sherdley Court offers a friendly, warm environment; it is a small facility where everyone knows each other. The home continues to meet a lot of the national minimum standards for older people and exceed them in some areas. The Décor and maintenance standards are very good and offer a very well maintained and attractive environment to live in. In-house maintenance records continue to be well maintained and provide evidence of a safe, well-managed environment. Staff, residents and relatives were very positive about the manager and senior staff and felt they were all very approachable. There were many positive and complimentary comments from residents, including comments such as, “Its nice here, we are well looked after…” One resident said they had been “fine with no problems”. Positive interactions were observed with staff supporting residents throughout the day especially during meal times and during the medications being administered. The medications were observed to be administered in a safe, personal and respectful way, ensuring each persons privacy and welfare were reviewed and maintained Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 6 The home-managed resident’s health and personal care needs to a very good standard Each of the 3 units have their own small lounge and the home also had a large main communal lounge which provides a programme of activities 6 days a week each morning and afternoon, all organised by the Staff and advertised on the notice boards. Residents were complimentary about the food. Meals were seen to be well presented with various choices offered. One resident said the food was good and that she had enjoyed her meal that afternoon. What has improved since the last inspection?
Care plans were personalised, organised and detailed and gave enough updated information to describe the care and support needed to be given to all residents including any new resident to the home. The manager and residents have developed a gardening project that residents are involved with in planning and developing what they want in their garden. They had organised and put in place in the garden an organic chicken coup called an (eggloo) which they plan to have 6 organic hens. A poster was up in the lounges advertising monthly trips out offering places to anyone in the home who was interested. They had recently been to Stapely water gardens, Blackpool, Llandudno, with a trip to the Lake District advertised for August. The manager has organised a computer for the home, which is up, and running and some residents use it for on line shopping. and other sites on the Internet. The home provides very good support to residents on a daily basis to meet their social needs The staff and residents continue to show that they constantly strive to provide a high standard of living, with the ongoing facilities of an “independent kitchen”, the conservatory is available for people who smoke and the landscaped gardens surrounding the home are well kept. During this visit the manager had organised safety arrangements to the conservatory doors so that this area could still be safely used by residents for smoking. Staff training records were very clear and covered a wide range of training needs. This showed evidence of experienced and well trained staff to meet the residents needs This is a good investment from the company to provide both mandatory and developmental training of their staff. Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 7 The home had been awarded 5 stars from a quality audit called the RDB, which is the highest score that can be achieved with this award. It Stated, ” demonstrates an excellent standard of care” additional award for full wheelchair accommodation stating, “demonstrates full accommodation of all wheelchair users needs.” What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager makes sure they are able to meet resident needs and choices prior to them moving in and is clear in giving residents enough information to make an informed choice. EVIDENCE: The homes Statement of Purpose and Service User guide were openly displayed in reception with various other documents for everyone to look at. They also displayed other useful information including a resident’s manual, a Making Space information booklet, complaints policy and guidance and some comment cards from the Commission. These records included all relevant information necessary for people to make a decision about the home. A review of one residents records showed a detailed assessment carried out prior to their admission. This helped the home’s staff to assess that they could meet the person’s needs. There was enough detail for staff to support the
Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 10 resident with their needs. The documentation in place covered all diverse needs of potential residents to the home ensuring the persons individual’s needs and requests could be met prior to moving into the home and they also included local authority assessments. This persons care plan was also in place and covered a wide range of needs including their health and social skills. In reviewing the notes of a recent residents meeting both staff and residents had welcomed a new resident to their new home. Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7/8/9/10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home-managed resident’s health and personal care needs to a very good standard EVIDENCE: Two care plans were reviewed for case tracking. All of the care plans gave good details of the residents needs and the care and support required and were noted to be very personalised and included the residents name and referred to what choices and preferences they wanted, including any likes and dislikes. The care plans seen were well maintained with evidence that residents and relatives were involved in regular reviews and in the development of the plan. Care plans covered a wide range of specific needs and support of residents including, social skills, personal relationships, educational needs, cultural and faith needs and each person’s individual strength’s. Care plans had monthly reviews and had various assessment tools and risk assessments for i.e. moving and handling, a pressure sore risk assessment, a
Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 12 nutritional score, and a social history which was very detailed about the persons past and what was important to them. The management of medications was well managed. A sample of medication records was seen during this visit. The medications and administrations were found to be in good order. The medications were observed to be administered in a safe, personal and respectful way, ensuring each person privacy and welfare were reviewed and maintained. Regular medication reviews make sure that the management of medications are carried out appropriately to safe guard all practices with medications. Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12/13/14/15 Quality in this outcome area is Excellent This judgement has been made using available evidence including a visit to this service. Staff provide very good support to residents on a daily basis to meet their social needs EVIDENCE: The following events are organised and offered to all residents including, crafts, games, quizzes, music to exercise, indoor gardening, bingo, television, sports, hairdressing, meditation and relaxation. Each of the 3 units have their own small lounge and the home also had a large main communal lounge which provides a programme of activities 6 days a week each morning and afternoon, all organised by the staff and advertised on the notice boards. The manager explained they had developed a gardening project that residents are involved with in developing their garden The manager and residents had organised and put in place in the garden an organic chicken coup called an (eggloo) which they plan to have 6 organic hens. The manager explained they were planning a visit to a local organic chicken farm to see how they manage the chickens. She explained it had been a
Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 14 suggestion to have a pet at the home and after meetings and discussions with residents and staff they felt the chickens would be a good project and pet for the residents to look after. The manager explained they are hoping to have a grand opening ceremony and are hoping that a local celebrity will officially open the chicken coup. In reviewing the notes from recent residents meetings, staff explained they had organised monthly trips out as suggested by the residents at the home. A poster was up in the lounges advertising the monthly trips out offering places to anyone in the home who was interested. They had recently been to Stapely water gardens, Blackpool, Llandudno, with a trip to the Lake District advertised for August. The manager explained they have the computer up and running and some residents use it for on line shopping and they also have Internet access. She is planning to organise computer training and once she identifies enough residents who are interested then a local group have agreed to come in and provide study lessons. One resident may access a local community college for computer training in the interim. Some residents discussed how happy they were at the home. One gentleman said he was looking forward to the trip to Southport organised for the next day and was hoping for the weather to pick up. One Resident said they had been fine with no problems and talked about the weather and said they didn’t bother with the recent trips as they had been on so many in the past with the homes staff. Care plans and daily records gave enough details about how the resident’s social needs would be met and how each resident would be supported with their daily activities and social skills. The above activities and initiatives show good management and support in how staff meet the residents social needs and choice of daily lifestyle. The cook currently caters for different dietary needs e.g. diabetic diets and liquidised meals and has worked at the home for a number of years. The cook was able to discuss the likes and dislikes of all the residents and explained they offer lots of home made meals and birthday cakes for any birthday celebration. Residents were complimentary about the food. Meals were observed to be well presented with various choices offered to residents. One resident said the food was good and that she had enjoyed her meal that afternoon. Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 15 One staff member was seen supporting each resident in their own individual choice of meal, e.g. some had sandwiches one person had toasted bacon sandwich another had salad and soup. Minutes of residents meetings showed that residents are offered lots of choice and supported with their suggestions and requests in lots of areas in the home including the menus. Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16/18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are protected by the homes policies regarding abuse and complaints procedures. EVIDENCE: The homes complaints procedure is available in reception and included in the homes Statement of Purpose. Most people said they would speak to the staff or the manager if they had concerns. Some residents felt they could air their views with the manager and could openly speak up at resident meetings. In reviewing the homes complaints record it was noted that they had not received any complaints since 2006. Residents were positive during this visit and collectively said everything was fine and that they had no problems. In reviewing staff training records, most had attended a lot of mandatory training including abuse awareness training, helping staff safeguard residents the home. Residents are protected by the homes policies regarding abuse and complaints procedures. Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19/26 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home is very well maintained with very good facilities and offers a good standard of living. EVIDENCE: The home was observed to be highly maintained and furnished. An inspection of a sample of living areas in the home showed a very clean and pleasant area to live. Residents said they were very happy with the facilities and that they had every thing they needed. The home has plenty of day space and is set out with 3 smaller units with residents having their own smaller kitchen and open plan dining and living area. There is a main communal lounge were all residents can meet up, especially for the activities on offer. This lounge has been recently decorated to a very high standard and offered a very comfortable sitting area. Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 18 Those bedrooms seen showed personalised rooms were some residents had brought some personal items in to help them settle into the home. The homes staff and residents continue to show that they constantly strive to provides a high standard of living During this visit the Manager had organised safety arrangements to the conservatory doors so that this area could still be safely used by residents for smoking. The laundry and kitchen areas were noted to be very clean and well organised offering a very good standard of hygiene. The company have various procedures in place to show how the home is being safely managed e.g. a sample of maintenance certificates such as fire safety checks and risk assessments showed what actions were taken to ensure the safety of everyone at the home Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27/28/29/30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home provided sufficient, experienced and trained staff to meet all of the residents needs. EVIDENCE: There is a long-standing staff team who were observed to have a genuinely caring attitude towards residents. Everyone in the lounges and dining areas were seen to be supported and given assistance were needed during meals and where appropriately supported and given assistance and advice where needed, especially when medications were administered. The atmosphere was informal and happy and everyone was helped to feel comfortable Residents said that they are happy with the care and that staff are very good. Rotas showed the usual amount of staff on duty and everyone felt that they had enough staff to give the care and support needed, to all residents. A sample of 2 staff Personnel files were looked at and were noted to be very organised and detailed with all necessary records and checks including police (CRB) checks. This showed a good recruitment and selection policy, which helps to safe guard residents in the home. The manager explained that they exceed the basic standards of having in excess of 50 of the workforce with a care qualification (NVQ)
Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 20 A sample of staff training records showed them to be very clear updated and covering a wide range of training needs, such as Psycho social interventions, fire training, abuse awareness, medications, equality and diversity, training the trainer, strokes, mental capacity act 2005, risk management, moving and handling, first aid and dual diagnosis. This showed evidence of experienced and well-trained staff to meet the residents needs and good investment from the company to provide both mandatory and developmental training of their staff. Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31/33/35/38 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of residents. EVIDENCE: The manager offers a good standard of management and ethos in how she manages the home. There are regular minuted staff and resident meetings to keep people informed and involved with developments in the home and recently covered the monthly planned trips out, the gardening club and the purchase and running of the chicken coup. These meetings also offer ways for everyone to openly give their opinions about developments in the home,
Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 22 There were various positive comments about the management of the home from residents saying that they could talk about anything. The manager produced a Quality Assurance file during this visit which had evidence of audits carried out at the home. These documents benefit the management of the home and are regularly used to evidence quality assurance checks, especially for, medications, and resident questionnaires, six monthly pharmacy audits and an annual financial audit from head office regarding the finance records. The manager explained that the home had also been awarded 5 stars from a quality audit called the RDB, which is the highest score that can be achieved with this award. It Stated, ” demonstrates an excellent standard of care” additional award for full wheelchair accommodation stating, “demonstrates full accommodation of all wheelchair users needs.” The company provides a system for the safe keeping of resident’s personal allowances and supports residents in purchasing daily items and local services like the hairdresser. Receipts are available and records maintained. All monies are securely stored. A Sample of maintenance certificates seen in the maintenance file, showed upto-date checks on facilities showing the home was well managed and kept safe and secure. The company have various procedures in place to show how the home is being managed ensuring the safety and comfort of everyone in the home. Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 24 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. 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 Sherdley Court DS0000022410.V332536.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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
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