CARE HOMES FOR OLDER PEOPLE
Sherdley Court 91 Rainhill Road Rainhill Merseyside L35 4BD Lead Inspector
Miss Diane Sharrock Unannounced Inspection 9th January 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.V277490.R01.S.doc Version 5.1 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.V277490.R01.S.doc Version 5.1 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.V277490.R01.S.doc Version 5.1 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. 23/3/05 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, although it is not being used at the moment for rehabilitation as staff are awaiting further maintenance to this area. 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.V277490.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over 4.5 hours. It was an unannounced visit and was carried out as part of the regulatory requirement for care homes to be inspected at least twice a year. There has been no cause for any visits to the home since the last routine inspection in 23/3/05. A partial tour of the home was carried out. Care records and other care home records were inspected. Some Staff on duty chatted informally with the Inspector and general discussions took place with approximately 6 Residents and a selection of comment cards were left. During this unannounced inspection, feedback from everyone involved was very positive. It was evident that the Manager continues to implement all parts of the National Minimum Standards. What the service does well: What has improved since the last inspection?
The home has undergone further redecoration and refurbishment including the replacement of corridor carpets and redecoration of the corridor and main lounge. 11 bedrooms have also been redecorated and new carpets provided. A new washing machine and dryer have been purchased in the independent kitchen for Residents own personal use. The garden area has also been provided with 2 waterfall feature’s. The ongoing purchasing show’s a regular investment to the home to either improve or enhance the home. Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 6 The home now has new documentation for care plans and covers most areas of the standards and covers various positive points such as, “a persons individual strengths”. Staff produced regular supervision records for staff at the home which helps provide one to one support for all Staff. What they could do better:
Full feedback was given to the Staff in charge at the end of this inspection. This was a very positive inspection with some points raised for the homes attention and for further development. Since the home was inspected the Manager has responded in writing to CSCI regarding all points raised stating what actions have already been carried out. An environmental health report dated 1/11/05 gave details of what actions should be taken in the home to improve on various points. A written response has been submitted to CSCI detailing the actions taken by the home to improve on all points raised. Care plans should be reviewed and developed further. Including updates to care plans when a Residents needs change so that Staff have the necessary information to assist them in giving the appropriate care and support. The Manager has submitted details of reviews of the present records and has given details of some changes carried out to the daily monitoring sheets. The Statement of Purpose must have the commitment from the company of the basic numbers of staff provided each day. This will ensure that everyone is aware of the numbers of Staff assessed as needed to give the appropriate care and support to all Residents. Personnel files should have evidence of identification and police checks to ensure safe practices to recruitment and selection are carried out. The Manager has submitted in writing details of were the police checks for all Staff are stored. The Manager has also stated that they will immediately ensure that all Staff have photographic evidence of identity in their personnel file. Most Staff at the home had received training in “abuse awareness” however some staff had not yet received it. All Staff should receive this training on a regular basis to ensure they are up to date in this subject and aware of the homes policies to follow to ensure good practice. The Manager has submitted in writing that they will immediately ensure that all Staff including general Staff will have access to “Protection of Vulnerable Adults training and ongoing updates”. Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 7 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.V277490.R01.S.doc Version 5.1 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.V277490.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not measured during this inspection EVIDENCE: Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 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 There continues to be progress made within care plans which include details for health, personal and social care needs of Residents. Medication procedures were found to be in good order and met the standards. EVIDENCE: The care records seen had a lot of detailed information to meet these standards. The home has developed new documentation for care plans and covers most areas of the standards and covers various positive points such as, “a persons individual strengths,” ”Educational needs,” ”Cultural needs”. Some parts of standard 8 should be reviewed to include any necessary actions or tools that would benefit Residents needs, such as “nutritional screening”, “continence assessments”. The medication and administration of medicines at the home were found to be very detailed and organised. The home receives regular audits and visits from the local Pharmacists and Primary care team. The processes in place provide a safe and organised process for administering medications by senior members of staff who receive regular training. Residents were very happy with the care provided at the home and openly discussed the staff and care received.
Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 11 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. Social activities are well managed and there are a variety of choices available for Residents. Residents confirmed they are supported to maintain contacts with friends and family. EVIDENCE: The Residents were happy with the activities on offer and explained that they could just go to their bedroom if they didn’t t want to take part. The Staff explained that they try to organise an activity each day and try to do this between them. There are also notices displayed on each lounge area which keeps everyone informed of the events organised by the company. Various activities displayed included, Crafts, games, quizzes, movement to music, indoor gardening, bingo, TV, sports, hairdressing, grooming, mediation and relaxation. Residents explained that their Relatives and Visitors are welcome to visit at any time of the day and made to feel at home. Some Residents stated they felt they were supported to do what they wanted and that the Staff were very good. Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 12 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. The home has a complaints policy that Residents and Staff know how to use. Staff are trained in “Abuse Awareness” and know about the policies that should be carried out. EVIDENCE: The complaint record book was seen and gave details of any actions taken by the Manager following a complaint. Some Residents stated if they had a problem they would “…fill a complaint form in and give it into the office.” Residents stated that many staff had been at the home many years and that they are very good and they had no problems and were very happy at the home. Staff described their policies and what they would do if there was a problem. It was noted that some Staff had not been included in the homes ongoing training for “abuse awareness”. The Manager has already responded following this inspection and submitted immediate actions they will take to ensure that all Staff will have access to this training session. Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 13 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 The environment is well managed and kept clean and tidy. EVIDENCE: Residents were very happy with the homes facilities. The home was very clean and tidy especially the sample of areas seen. During this inspection the home was in the process of having new corridor carpets installed. Staff explained this was due to the present carpet causing some problems so they had organised the replacement of the carpets to improve the safety and comfort of Residents and staff at the home. Sherdley Court continues to be a safe and appropriate facility for the care of adults with a mental disorder. 11 bedrooms have also been redecorated and new carpets provided. A new washing machine and dryer have been purchased in the independent kitchen for Residents own personal use. The garden area has also been provided with 2-waterfall features. The ongoing purchasing show’s a regular investment to the home to both improve and enhance the home. Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 14 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): 27.29.30 Residents and Relatives say they are very happy with the home and the care provided by Staff. Personnel files have been developed and most are up to date. The homes training schedule offered a varied amount of training which meets this standard. EVIDENCE: Residents said they were happy with the care and say the Staff are lovely. Everyone in the lounge was seen to be given a good level of support and respect, the atmosphere was very informal and happy were everyone was helped to feel comfortable. Most Staff had worked at the home for many years and offered a great stability to the workforce. It was noted while reviewing staffing rotas that staffing levels are sometimes different on different days and at weekends. During this inspection the cook was off sick and the deputy had to cook the Residents meals. The Statement of Purpose must have the commitment from the company of the basic numbers of staff provided each day. This will ensure that everyone is aware of the numbers of Staff assessed as needed to give the appropriate care and support to all Residents. Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 15 In reviewing personnel files they should have evidence of identification and police checks to ensure safe practices to recruitment and selection are carried out. The files seen were noted to have been developed and contained a lot of information necessary for the protection of Residents in providing good recruitment and selection policies. The Manager has submitted in writing details of were the police checks for all Staff are stored as the Inspector was not shown them during the visit. The Manager has also stated that they will immediately ensure that all Staff have photographic evidence of identity in their personnel file. Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 16 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): 32.33.36.38. The Manager runs a well managed home. The home is run in the best interests of Residents. Staff receive supervision every 2 months. The health, safety and welfare of Residents are promoted and protected. EVIDENCE: The home was found to be well managed and consistently shows evidence in meeting the National Minimum Standards. Residents consistently expressed positive comments about their home and how they enjoyed living at Sherdley Court. A review of supervision records identified that Sherdley Court have formal supervision at intervals required by the National Minimum Standards (NMS). Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 17 The care home has comprehensive health and safety policies and procedures. Detailed risk assessments were also seen inclusive of in-house records such as the fire book and accident book. An environmental health report dated 1/11/05 gave details of what actions should be taken in the home to improve on various points. A written response has been submitted to CSCI detailing the actions taken by the home to improve on all points raised. Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X X X X X 4 STAFFING Standard No Score 27 2 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X 3 X 3 Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 19 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 OP18 Regulation Requirement 13 6 The Responsible Person must ensure that all staff receive suitable training for “abuse awareness.” The company have already submitted details of immediate action following this inspection The Responsible Person must ensure that the homes commitment to staffing levels covering each day are published and accessible to all parties and included in the statement of purpose. The Responsible Person must ensure all personnel files are in line with Schedule 2 of the Care Home Regulations 2001 The company have already submitted details of immediate action following this inspection . 08/01/06 2 OP27 18 08/01/06 3 OP29 19 08/01/06 Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations The Responsible Person must ensure that care plans are developed to meet standards 8 in full Sherdley Court DS0000022410.V277490.R01.S.doc Version 5.1 Page 21 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
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