Inspection on 30/05/08 for Sheridan House

This inspection was carried out on 30th May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sheridan House 17/04/09

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Sheridan House Sheridan House 8 Bedford Road Sandy Bedfordshire SG19 1EL Lead Inspector Andrea James Unannounced Inspection 30th May 2008 09:00 Sheridan House DS0000071702.V366025.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 Sheridan House DS0000071702.V366025.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. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sheridan House Address Sheridan House 8 Bedford Road Sandy Bedfordshire SG19 1EL 01707 332244 01707 332255 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) na Brookdale Healthcare Limited Renee Hughes Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD The maximum number of service users who can be accommodated is 9 2. Date of last inspection N/A Brief Description of the Service: Sheridan house is a residential care home that provides 24 hour care. The home is situated in the village of Sandy and is in close proximity to local community amenities. The service is owned by Brookdale and was registered on the 20th of March 2008. The home currently has 5 people using the service but can accommodate a maximum of 9 people. The fee structure averages at about £2800 per week. This information was provided from records on the day of the inspection. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was undertaken on the 30th May 2008 by Andrea James and Nicky Hone. The inspection was instigated from complaints received from the neighbours. The inspection process lasted for 14 hours between both inspectors and the acting manager Nikki Grauwiler (covering for the registered manager) was available for the duration, the director and service manager also joined the inspection for a short time. The inspection process followed a case tracking methodology where sample of people using the service were randomly selected. Their files and records were inspected and where possible their key workers spoken to. This was also a key inspection and the information recorded will form the basis for the service first star rating. The report consists of information received from people using the service, care staff, various records and views of relatives to the service spoken to. We found it difficult to communicate with the users of the service due to their limited communication skills, so this report will not reflect quotes from user’s just observations of the inspectors. The inspectors would like to thank the people using the service, the care staff, the manager and the relatives for their co-operation and contribution to the inspection process. What the service does well: The service focuses on people’s individual needs, for example people’s individual activities were put in place using picture boards on a daily basis. Relatives spoken to said, “staff take them out on a regular basis”, one relative gave an example of this by saying she arrived at the home without letting them know and her son was out at a local zoo. Relatives also spoke positively about the staff team saying they were knowledgeable about the needs of the people using the service and showed such understanding and concern about each person. One relative described the home as “these people are the ball”. Staff and management of the service were found to be friendly, professional and in control of the situations presented to them at all times. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 6 The service was good at recording information for people using the service on a daily basis and systems were in place to suggest effective communications both internally and externally. One relative spoke positively about the communication in the home by saying, “I receive weekly updates on the progress of my son which is absolutely brilliant”. Most staff spoken to were complimentary of their working environment and felt competent in meeting the changing needs of people who use the service. The service also employed a full time therapist who assists the care staff and the users to better understand each other. Care staff were observed to respect people’s privacy and dignity. We observed most carers knocking on doors before entering bedrooms and from observation were treating people with respect and dignity. What has improved since the last inspection? What they could do better: This is the first inspection for this service and as a result some work is needed in order to meet the requirements set out in the National Minimum Standards. The service should ensure that records such as care plans are not presented in a generic format and the wordings are considered to be more user led. This would mean having less jargon and more specific guidelines. The service should also ensure that health records are accurately recorded for example when a user is next to visit the GP for follow up appointments. The procedures for recording and administering of medication also needs further development (an immediate requirement was issued for this on the day of the inspection). The service should ensure staff recruitment is robust enough as some references appeared unsatisfactory due to limited information provided. The service should also ensure staff training to include staff receiving NVQ level 2 and above is available for inspection. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 7 There’s also a need to ensure the complaints procedure for people using the service has more detail for who to contact if they have concerns or complaints. There’s a need to ensure all electrical appliances received in the home are tested on an annual basis. Some environmental issues are in need of urgent attention these include the lack of curtains or privacy equipment for some people, the steep steps exiting from the back door, the overhead showers and sink units. The home also have an emergency alarm system in place but this was not in operation as a result staff and people using the service could be at risk as they were unable to call for help if needed. The service needs to ensure effective monitoring systems are implemented in the form of quality assurance policies that seeks the views of people using the service. 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. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 8 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 Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems were in place to ensure prospective people had the information they needed to make an informed choice about living at the home; they received needs assessments and had the opportunity to test drive the home prior to admission. However further development was needed to ensure contractual agreements for individual people using the service are available. EVIDENCE: Records inspected demonstrated that the Statement of Purpose and the Service Users Guide was provided for people using the service on admission. These records inspected were presented in a pictorial and written format with relevant information that would enable people to make an informed choice about living at or using the service. Relative’s spoken to said they received this information. The home provided a good transition for people using the service. Relatives spoken to said they received a smooth transition for their son/daughter on the admission to the home. One relative said they were allowed to look around the home, undertook visits and was consulted about how the home met the needs of people living in the home. Care staff explained to the inspectors that Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 10 another user was due to be admitted and had already received all the over nights stay as a part of his transition. The pre- admission assessments for this person were already completed and an initial care plan along with guidelines had been implemented. The home had completed needs assessments for some people using the service however, further development was needed in this area as some records inspected did not have a needs assessment and as a result the care intervention required could not be followed through in the care plan documentation. The service had generic contractual agreements with various local authorities but had failed to produce individual contracts for people using the service that would detail the cost of their placements and how the charges would be broken down. There was no evidence that relatives or the people were asked to sign an agreement and as a result people could be at risk of not knowing what they are paying for. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The individual needs and choices of people using the home were generally well met. However further development is needed to ensure written information is available and easy to understand. EVIDENCE: One user’s file inspected showed treatment managements, behaviour guidelines, social interactions and health action plans all linked in to formulate a care plan. There was evidence that this assessment tool was constructed with relatives before implementation. The care plan summary showed the strengths and needs, the intervention required by staff and how this was to be achieved. The information seen was not recorded in plain English. This was concerning as several staff did not have English as their first language. Words such as facilitates, absconding, aggressive were used without any explanation as to Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 12 what the writer was saying. One care plan said her/she when referring to a male user. The care plans also failed to record who wrote it and when. One care plan seen failed to have any management guidelines or risk assessments and in some places referred to another service “Latham house”. There was sufficient evidence to suggest people using the service were able to make decisions and participate in aspects of the home. On the day of the inspections all users were assisted to make choices about what they would do on that day. The choices were placed under their names in the dining room in the form of a picture of the events to be undertaken. Care staff spoken to said people who use the service were encouraged to undertake household chores but this was limited in some situations due to the dynamics of the other users and the space available. For example in the Statement of Purpose it states that people will be encouraged to carry out their own laundry. The laundry room is situated in the basement of the building and its limited size makes it difficult for a number of people to use it at the same time. Care staff said at the moment only one user was able to use the machines. Staff spoken to said cooking was encouraged and some users were able to participate in this activity. Care records suggested users were encouraged to Hoover their rooms and carry out household chores on a daily basis. The records seen suggested some risk assessments were implemented but several aspects of users lives which were identified in the care plan as needing to be risk assessed had not been undertaken and as a result people could be at risk or limited as they were not allowed to take part in some activities. For example where care staff were allowed to undertake PACT techniques when a user physically challenged the service no risk management was in place to ensure staff consistency. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12,13,14,15 &17. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in the home had opportunities for personal development, cultural awareness, appropriate activities, family involvement and a healthy diet; as a result the people using the service had a fulfilling lifestyle. EVIDENCE: The records inspected suggested that the home investigated ways that would enable people using the service to develop. One relative spoken to said this was the best home ever as his relative was able to access further education colleges as a long tem goal and when he visited on the weekend he was told of the various activities undertaken by his relative to include horse riding, ice skating and other recreational activities. It was concerning to note however that where an activity was identified to be a user’s favourite for example swimming that he was taken to the pool and Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 14 prepared then taken away as the staff felt the pool was too full. This should have been better thought through before embarking on the activity, as it could cause unnecessary anxiety the people using the service. Again one record showed that this same user was taken to a park lake to have a walk in accordance with the care plan but again staff decided to take him there and decided not to go in and drove away. Relatives of people using the service said the communication between them and the home was excellent. The care staff would call to give an update on a weekly basis. One relative said “when I called they would always spend the time to talk to me. Any carer had the same knowledge about my son, they seem to know how to deal with him”, “and they are the best”. Another relative said “they are on the ball; they are always doing something with the people who live there”. People who use the service were not able to verbally communicate their likes/ dislikes but demonstrated that they liked living at the home using other means. One person invited the inspectors to view his bedroom and displayed positive body language. Relatives said they were able to visit the home on a regular basis. One relative said they visited on a weekly basis. Another said she could not visit as often but received weekly updates. One relative said she was already asked to come to a review of her son’s progress. They all commented that they were impressed with the care the people using the service received. One relative described the home as “excellent”. The home provided a balanced diet for people using the service. We saw the kitchen facilities, which were appropriate to meet people’s needs. The menus were recorded and what people ate each day was recorded on their daily notes. People were able to make choices using pictures. The people using the service also benefited from having the opportunity to be able to go to the local shops to purchase groceries. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The personal support people received to meet their health care needs was satisfactory in some areas but further development was needed to ensure robust procedures are implemented in maintaining health. EVIDENCE: Some medical needs for people using the service were identified and had been addressed. However, there were no health action plans and as a result some medical needs were not satisfactorily addressed. One person had been to see the GP and required a follow up visit in May 2008 but there was no evidence that this visit took place. There were weight charts on the care plans inspected but these records were not filled in, so there was no way of knowing whether there might be a problem with people’s weight. Accidents and incident records were checked and there were 11 recorded incidents but only three were reported using the Safeguarding procedures. The manager said all were reported to CSCI but this could not be evidenced. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 16 Again some incidents seen suggested some users were liable to biting, slapping and drawing blood from care staff but there were no risk management/ assessments in place for this. Medication policies and procedures were available for staff on the files seen. Some further development was needed. Generally, the receipt, administration and disposal of medicines were satisfactory. However, on one MAR (Medication Administration Record) chart, staff had added ‘PRN’ (when necessary) to several of the medicines prescribed to be taken regularly. There was no evidence when the changes were made and by whom, and whether this had been agreed with the doctor. An immediate requirement was left for the home to get this sorted out. There were also some gaps on the MAR charts seen where care staff had not signed to show that medication had been administered. In one person’s file medications were repeated on the MAR charts. Staff had just left these blank, so it was not clear if they were current or not. There was a satisfactory stock of most medicines, except for Midozalam Buccal. There were 10 boxes of this stored in the medication cupboards and it was only needed very occasionally as a PRN medication. The manager said she would return the excess to the pharmacist. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place to ensure people using the service could complain but further development is needed to ensure effective quality assurance systems are in place, and people’s views are monitored. EVIDENCE: The home has satisfactory systems in place for receiving and dealing with complaints. The Home has not received any formal complaints since it opened in March. The complaints form for people using the services was presented in simple English in a pictorial formation. This however needed further developments to include numbers of management and regulatory bodies. We received two verbal complaints stating that the home had applied for planning permission that would extend the current registration from a nine bedded unit to a 20 bedded residential home. The neighbours were also concerned that the people using the service were inappropriately placed and felt that they would be a threat to the community. They also raised concerns about the current users of the service, stating that they were being given too much medicated in order to keep them quiet. The complainers also stated that the noise generated from the home was excessive and disruptive to passers-by and neighbouring children. We received newspaper clippings of the neighbours’ objection of any further development to the current service. A copy of the planning application submitted by the home was also received which showed that the application was submitted requesting permission to extend to 20 beds. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 18 On inspecting the premises and speaking to the providers the providers were concerned that the neighbours failed to give them the opportunity to reply to the complaints, as they did not complain to the home using the complaints procedures. The development manager said at the inspection that the planning application submitted was for the home next door, to have the opportunity to develop a day centre for the current users at the service. However since the inspection information received suggested that the organisation had submitted an application for Sheridan House. On speaking to the providers again they said they had submitted a planning application for Sheridan house two months ago but this “was merely to see the development potential and not to add any further variation to the current registration for the foreseeable future”. The home said they received a verbal complaint about the level of noise from one person when they used the garden, and as a result asked environmental health to install a noise monitoring equipment to monitor the noise levels. The inspectors observed that one user when he became excited, for example playing football in the garden would make loud noises but this was not excessive and the activity was only carried out during the daytime. The home is not adjoining any other property. Since the inspection we have continued to receive further complaints and the neighbours continue to protest against any further development. Petitions have been gathered and now the home is concerned that staff and people using the service could be vulnerable. Safeguarding procedures have been initiated and the police informed. On the day of the inspection the training records seen were not up to date and as a result there was no evidence to demonstrate care staff have received training in Safeguarding of Vulnerable Adults or Whistle blowing. Records inspected showed that 8 incidents were recorded that suggested the health and well being of users may be compromised. The manager said these were reported using the Safeguarding procedures but there was only evidence that we had received three. Procedures for recording users’ monies were in place. Three people’s finances checked were found to be satisfactory. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25,26,27,28 & 30. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service live in a comfortable environment and standards of hygiene are good, further development is needed to some aspects of the home, in order not to compromise the opportunity for people to maximise their independence. EVIDENCE: The home was clean on entering and staff were friendly and welcoming. The people using the service all had individual bedrooms that were decorated to their individual tastes. All bedrooms had en-suite shower and toilets, the showers were situated directly above the persons head and this could be problematic if users did not wish to wash their hair. It was also concerning that the sink units could only be unblocked by immersing your hand in the used water. The home did not have any other bathrooms. On the day of the inspection one user had flooded his bedroom which caused the areas surrounding the room and the room to smell. The manager said the Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 20 person was due to be moved to another vacant room and that room was to be redecorated. The manager said the flooring for some bedrooms were due to be changed from carpets to more suitable flooring. One person was pleased to show us his bedroom where he had items of personal possessions. Staff said people are encouraged to tidy their rooms, one person was seen hoovering their room. One user’s bedroom failed to have a wardrobe in which to put clothing and this same user’s belongings were being stored in another room, as the current room was not big enough to accommodate them. The home had a laundry room that was situated in the basement that was very hot on entering and although people who live at the home are encouraged to use this facility it is not big enough to accommodate them and care staff. The home had several places where communal activities could be undertaken. We saw separate lounge and dining facilities, large kitchen and a separate activity room. The home was complimented with a large back garden but the furnishing in the garden was minimal and was in need of some attention to make it more “user friendly”. It was concerning that the usable space in meeting the needs of the people would be very limited when all 9 users are at home with 7 staff totalling 16 people. The privacy and dignity for some users were compromised as some windows failed to offer protection to the users when in their bedrooms. We were informed that one person would remove any protection provided. The manager was advised to consider other measures to protect the person’s privacy and dignity. There were also several electrical appliances at the home that had not received satisfactory tests. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32,33,34,35 & 36. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service benefited from a dedicated and effective staff team but further development was needed to ensure staff are competent and people are protected through robust recruitment procedures. EVIDENCE: On the day of the inspection 5 staff were rostered on duty with 2 staff sleeping in at night. The rotas showed that there have been times when only 4 staff have been on shift during the day. The expectation is to have 9 staff when the home reaches full occupancy and 2 waking night staff. The manager also plans to stagger the shifts in order to accommodate activities, for example have a mid shift worker from 2- 10. Staff spoken to appeared competent about their job roles and responsibilities. The records inspected suggested most recruitment procedures were satisfactorily undertaken. Their was no evidence the new employees received an induction but it was not possible to say if this was in all cases as some carers were transferred from other services within the company. The records Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 22 showed that in one case the references received was very weak and a further reference was not sought. The training needs of the staff team was not satisfactory and records seen suggested that most staff required refreshers in mandatory training and that some areas of training had not yet been identified, these included Safeguarding, medication training etc. There was no recorded evidence to show how many carers had achieved their NVQ level 2 in care. The manager said an assessor had visited the home but the appointment had to abandoned. The area manager said she had identified a need for staff to receive specialist training and as a result she had decided to implement training in ADA (Autistic Spectrum Disorder), anti-discriminatory practices, de-escalation and epilepsy. It was recommended that a training matrix be implemented so that training needs of all staff could be identified at a glance. The records suggested some carers had received supervision but this was in its early stages and further development was needed. The inspectors saw evidence that staff meetings had taken place and staff acknowledged that they attended. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38,39,41,42 &43. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people using the service benefit from a proactive management style but further development is needed to ensure all health and safety procedures are implemented and people’s views are monitored on a regular basis. EVIDENCE: The registered manager for the service is currently on maternity leave and as a result the acting manager was recruited from another of Brookdale’s services. She holds the Registered Managers Award and has an NVQ level 2 in care. She recognised the need to have her NVQ level 4 in management. She has worked 4 years with the organisation and appeared competent in managing the service. Care staff and relatives spoken to all said she was approachable, had effective communication skills and was effective in her role. We also found her Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 24 to be knowledgeable about the needs of the people in the home and had good ideas about how to move the home forward. The staff meetings notes seen were detailed and comprehensive and focussed on ensuring staff meets users care needs. The quality assurance procedures are not yet fully implemented and as a result the views of people using the service were not analysed. Staff members were asked as to the fire procedures and were generally aware of their procedures to follow. Records seen suggested regular fire checks and evacuations were undertaken. The home also had a fire risk assessment, which was approved by the fire authorities. The home failed to return their AQAA (Annual Quality Assurance Assessment) in time for the report despite several reminders, the last being on the 13th of June. The manager promised that the document would be sent to us via email. The home had a health and safety policy and procedure and several aspects of the home provided safety for the users. There were some aspects of the home that needed to be risk assessed in regards to maintaining safety, for example the steps leading to the garden via the dining area appears unsafe for users with limited mobility or for those unsteady on their legs. The electrical appliances received in the home were also in need of satisfactory safety tests (PAT). Some communal doors were also propped open, which could contravene fire regulations. The hot water temperatures were tested and found to be within the requirements of the National Minimum Standards. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 3 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 1 26 2 27 1 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 2 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 1 x 3 3 1 x x 1 2 Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Not applicable 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 2 3 Standard YA6 Regulation 15 (1) 15 (1) 12 (1) (a) Requirement All care plans must have clear instructions/ guidelines to ensure staff consistency. All care plans must show evidence of consultation. Current accurate health action plans must be implemented as an active part of the users care plans. All activities undertaken by the people who live at the home and that pose a risk to health or safety must have a risk assessment. All medications must be given as prescribed. Guidelines must be available for administering, storing, and recording medication to include PRN. All staff must be trained in safeguarding policies and procedures. Environmental risk assessments must be undertaken to ensure the safety of the users when accessing areas of the home. Furnishings must be provided for each user suited to their needs. Arrangements must be made to DS0000071702.V366025.R01.S.doc Timescale for action 30/07/08 30/07/08 30/07/08 YA6 YA19 4 YA9 13 (4) (b) 30/07/08 5 6 YA20 YA20 13 (2) 13 (2) 02/06/08 30/07/08 7 8 YA23 13 (6) 13 (4) (a) 30/09/08 30/07/08 YA24 9 10 YA25 YA26 16 (1) (c) 23 (2) (f) 30/09/08 30/08/08 Page 27 Sheridan House Version 5.2 11 YA27 12 (4) 12 YA34 19 (1) 13 14 YA35 YA39 18 (1) (i) 24 (1) 15 YA42 23 (4) 16 YA42 13 (4) ensure that the size and layout of rooms occupied by users are suitable for their needs. (a) The privacy and dignity of people must be maintained by ensuring suitable coverings are placed at people’s windows. (c) There must be a robust recruitment procedure in order to protect the welfare of people using the service. ( c) Staff must receive training appropriate to the work they are to perform. A quality assurance system must be implemented so that the views of people using the service can be monitored. Arrangements must be made with the fire authority for installing satisfactory equipment for keeping doors propped open. (a) All electrical appliances over 1 year old must have satisfactory safety tests. 30/08/08 30/08/08 30/08/08 30/09/08 30/09/08 30/08/08 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. 2 3 4 Refer to Standard YA5 YA14 YA22 YA23 Good Practice Recommendations All people should have individual contracts that detail the cost of their placement. Arrangements should be made to ensure activities are delivered in a more structured and well-planned way. Contact numbers should be available on the users’ complaints forms. The provider should provide suitable facilities for users to wash and iron their own clothes and make the laundry room suitable for the purpose stated in the Statement of Purpose. Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1 Capital Park Fulbourn Cambridge, CB21 5XE 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 © 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 Sheridan House DS0000071702.V366025.R01.S.doc Version 5.2 Page 29 - 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. 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