Inspection on 30/11/06 for Sherdley Court

This inspection was carried out on 30th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Sherdley Court 02/07/07

Sherdley Court 16/03/06

Sherdley Court 09/01/06

Sherdley Court 23/03/05

Sherdley Court 31/08/04

Sherdley Court 05/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sherdley Court 91 Rainhill Road Rainhill Merseyside L35 4BD Lead Inspector Miss Diane Sharrock Unannounced Inspection 30thNovember 2006 11:00 X10015.doc Version 1.40 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 Sherdley Court DS0000022410.V295315.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.V295315.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.V295315.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. 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. Sherdley Court DS0000022410.V295315.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 4 Staff. A selection of Comment cards were also left in the home to offer people further opportunity to give their opinion about the home. No comment cards have been received or submitted to CSCI. Feedback was given to the Manager at the end of the inspection. The homes pre inspection questionnaire gave the details for fees for the home ranging from What the service does well: This was a very positive inspection. The home was found 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 well maintained environment to live in. The homes in-house maintenance records continue to be well maintained and provide evidence of a safe, well managed environment. Both 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 both from Residents, Relatives and Staff, including comments such as, “we have no complaints, we are more than happy.” “its very good here, we bring our families in here and make them a cup of tea.” “we often use the kitchen to bake cakes and usually we have them for tea later in the evening after our meal.” Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 6 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. Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 7 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.V295315.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1/2/3 . standard 6 is not applicable Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home makes sure they are able to meet resident needs and choices prior to them moving in and are 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. These records included all relevant information necessary for people to make a decision about the home. These records were also kept in each unit however some Residents said they couldn’t remember seeing them when they first came to the home but were sure their families had seen them. Two Residents recollected that they had a good look around the home before they decided to live at the home. One Resident said she received some paperwork when moving in and said the home always sent her a letter if the fees were ever increased or changed. One Resident felt the fees were just the same and had never been changed. Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 9 A review of Residents files showed that copies of contracts are signed by the Residents or their Representative and stored at the home. A review of one Residents records showed a detailed assessment carried out prior to their admission. This helped the home to assess that they could meet the person’s needs. There was enough detail for Staff to support the 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. Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7/8/9/10/11 Quality in this outcome area is, good. This judgement has been made using available evidence including a visit to this service. The home managed Residents health and personal care needs to a good standard EVIDENCE: Three 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. The care plans seen were personalised and well maintained with evidence that Residents and Relatives were involved in regular reviews and in the development of the plan. General comments from Residents were very positive about the staff and one person described them as, “The Staff are very good.” “its very good here, we bring our families in here and make them a cup of tea.” In speaking to Residents it was obvious that Staff had taken time and care in supporting Residents with their personal care and helped them dress in clothes they chose. Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 11 Staff members explained that they were due to attend training for “care of the dying person,” which they acknowledged was a difficult topic but something they felt would help them with their job. The management of medications was well managed. A sample of medication records and storage of medicines was seen during this visit. The medications and administrations was found to be in good order. Regular medication reviews make sure that the management of medications are carried out appropriately to safe guard all practices with medications. Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12/13/14/15 Quality in this outcome Area is, excellent this judgment has been made using available evidence including a site visit to the service The home provided good support to Residents to meet their social needs. Visitors are welcomed and included in the home at any time. Meal times are well managed and offer a good standard of dining. EVIDENCE: The main entrance had a large display telling visitors of all of the planned events for Christmas and the month of December covering trips out, Christmas meals and party celebrations and visitors organised for the home. Each unit also had a copy of the ongoing weekly-organised activities. Staff explained that they each have a role for particular activities such as cooking and baking and handcrafts. During this visit Staff and Residents were busy with various activities some were making Christmas cards and doing art work in the day care lounge, and others were in the “independent kitchen” making mince pies and jam tarts. There were many examples of how residents are supported in their choices of daily lifestyle, with some going out regularly. Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 13 The kitchen area was very organised and Residents said they enjoyed the meals and looked forward to baking each week and sampling their own cooking. Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16/18 Quality in this outcome Area is, good this judgment has been made using available evidence including a site visit to the service. Residents are protected by the homes policies regarding abuse and complaints procedure. 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 and Staff stated; “we have no complaints, we are more than happy.” During discussions with Staff most had attended a lot of mandatory training and were happy with the training on offer and that they had received Abuse awareness training helping Staff safeguard Residents at the home. The Manager had also recently purchased a large sample of training videos including one regarding safe guarding adults. Residents are protected by the homes policies regarding abuse and complaints procedures. Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. 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 and offers a good standard of living. EVIDENCE: The home was noted to be well maintained. An inspection of a sample of living areas in the home showed a very clean and pleasant area to live. Residents and Relatives were all saying they were very happy with the facilities. There was plenty of day space and some Residents had chosen to stay in their own bedrooms, some were sat in the dining areas or lounge areas. Those bedrooms seen showed personalised rooms were some Residents had brought some personal items in to help them settle into the home. The home, yet again evidenced that it provides a high standard of living, with the ongoing facilities of an “independent kitchen”, the conservatory available for people who smoke and the landscaped gardens surrounding the home. The laundry and kitchen areas were noted to be very clean and well organised offering a very good standard of hygiene. Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 16 Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27/28/29/30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided sufficient, experienced and trained Staff to meet Residents needs. EVIDENCE: There is a long-standing Staff team who were observed to have a genuinely caring attitude towards Residents. Everyone in the lounge and dining areas were seen to be supported given assistance were needed. Staffing rotas were seen during this visit. A sample of 4 Personnel files were looked at and were noted to be very organised and detailed with all necessary records and checks including police (CRB) and Protection of Vulnerable Adults (POVA) checks. This showed a good recruitment and selection policy which helps to safe guard Residents in the home. A sample of Staff training records showed them to be up to date and clear and Staff stated they were enjoying all the training offered by the company. This showed evidence of experienced Staff to meet the Residents needs. During discussions with Staff and in reviewing Staff training records it was acknowledged that Staff had received their mandatory training. Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31/33/35/38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was 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 meetings to keep people informed. These also offer ways for everyone to give their opinions about developments in the home, There were various positive comments about the Management of the home from both Staff and Residents who felt they could talk about anything. The home does not directly deal with the finances of residents but does provide a system for the safe keeping of personal allowances and supports Residents in Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 19 opening their own individual back account. Receipts are available and records maintained. All monies are securely stored. The company have various procedures in place to show how the home is being managed e.g. the Inspector looked at a sample of maintenance certificates, fire safety checks, risk assessments, accident records which showed what actions were taken to ensure the safety of everyone at the home. Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 20 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 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 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 X 3 X X 3 Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 21 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 Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Sherdley Court DS0000022410.V295315.R01.S.doc Version 5.2 Page 23 - 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!