CARE HOME ADULTS 18-65
Shernbroke 1-6 Shernbroke Road Waltham Abbey Essex EN9 3JF Lead Inspector
Ann Davey Unannounced Inspection 1st May 2007 09:30 Shernbroke DS0000030743.V337950.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 Shernbroke DS0000030743.V337950.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. Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Shernbroke Address 1-6 Shernbroke Road Waltham Abbey Essex EN9 3JF 01992 700545 01992 761735 ged.elliott@essexcc.gov.uk www.essexcc.gov.uk Essex County Council 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) Ms Geraldine Sonia Elliott Care Home 25 Category(ies) of Learning disability (25), Learning disability over registration, with number 65 years of age (1), Physical disability (6) of places Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 25 persons) Persons of either sex, under the age of 65 years, who require care by reason of a learning disability who also have a physical disability (not to exceed 6 persons) One named service user, over the age of 65 years, who requires care by reason of a learning disability The total number of service users accommodated in the home must not exceed 25 persons 3rd May 2006 Date of last inspection Brief Description of the Service: Shernbroke is a purpose built home for people with a learning disability. The building is in keeping with the local community. There is a communal administration area and five separate houses/bungalows. Accommodation is arranged on a unitary basis, each house having domestic style facilities. Two of the houses are designed to meet the needs of people with a physical disability. The manager said that fees for the home range from £61.35 – £1113.56 per week. The Statement of Purpose indicated that additional charges are made for chiropody, hairdressing, aromatherapy and massage sessions. This should be discussed with the home. The homes Statement of Purpose and Service User’s Guide were on display. The houses and grounds were seen to be generally well maintained, clean and tidy on the day of the inspection. The home is situated reasonably close to local shops and amenities. Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a key unannounced site visit. It started at 9.30am and finished at 5.30pm. A partial tour of the home was made. Staff on duty were spoken with and time was spent with some of the residents accommodated. In addition, a relative and two visiting professionals were spoken with. Care practices were observed and a random selection of records was viewed. A notice advising all visitors to the home that an inspection was taking place was displayed, with an open invitation to speak to the inspector. The home has a good Quality Assurance system in place and the current report was available and displayed which included the views of residents, staff and stakeholders about the home’s provision of care. It was interesting to note that shortfalls identified at this inspection were in some cases the same as recorded in the report e.g. staffing levels and lack of activities. In addition, the inspector left a number of questionnaires with the home. Any feedback from them will be included in the next inspection. The home was friendly, hospitable and cooperative towards the inspector. The inspection process was carried out with no problem and the co-operation of all those involved was appreciated. The Commission received an application from the home on 24th April 2007 requesting a variation in their conditions of registration. This was in connection with residents admitted to the home whose primary need of care was in connection with a physical disability. Matters associated with this application took up a significant period of the day and the situation became quite complex. The home has agreed to discuss the ‘primary need for care’ and the ‘focus of care’ for all new admissions to the home with the registered provider, and then review and amend the current Statement of Purpose. Also, demonstrate that it can meet the assessed care needs of all current residents. The manager agreed that the home has become ‘all embracing’ and has lost their focus of care. This matter is referred to within the report. The manager agreed that the immediate way forward is to withdraw the current application until the home is in a position to submit a document that is current, accurate and can be supported by the home’s Statement of Purpose and the home is in a position to demonstrate that additional proposed assessed care needs can be met. It was agreed that until matters are resolved, no changes would be made to the registration certificate. The manager understands that no resident should be admitted to the home unless the assessed care needs can be met. Caution must also be exercised when consideration is being given to any proposed
Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 6 admission under the ‘emergency admission criteria’. Full details are within the report. All matters relating to the outcome of this inspection were discussed with the registered manager. Full opportunity was given for discussion and/or clarification both during and at the end of the inspection. What the service does well: What has improved since the last inspection?
The home will not admitted any resident on a planned admission basis now unless sufficient care hours are allocated within the care package for social and leisure activities. A new panic alarm system is being fitted. The home is now more aware of it’s limited resources in terms of meeting assessed care needs and dialogue about this is current and active with the registered provider. Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 7 The ‘embargo’ on staff recruitment has now been lifted. Staff recruitment files were compliant with regulation. 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. Shernbroke DS0000030743.V337950.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 Shernbroke DS0000030743.V337950.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose needs reviewing and updating to ensure that information to interested parties is accurate and current. There are ‘flaws’ in the emergency preadmission criteria assessment process that means that the home does not always have sufficient information to make a judgement about whether or not the home can meet needs. There is no ‘timeframe’ within the document, so emergency admissions have become ‘open-ended’. EVIDENCE: The manager completely agreed that the Statement of Purpose requires a review and update. For example, there is repeated reference to The National Care Standards Commission, the complaints procedure requires an update and the emergency admission criteria requires urgent review. Also, the information on the registration certificate does not accurately reflect the details of the ‘focus’ or ‘primary need’ of care stated within the document. The manager had come to the conclusion some time ago that the ‘focus’ of care within the home needs review. It was understood that this is currently
Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 10 subject to further discussion with the registered provider. The home provides care for young adults with very diverse and complex care needs. The manager feels that some residents may have been admitted on an emergency criteria basis, when in fact, their care needs would have been more appropriate met in another establishment. This is mainly because insufficient information was available at the time of admission. The difficulty now, is that having admitted some residents and finding that the home is unable to meet all their assessed needs, the home is experiencing difficulty in finding a more suitable placement. In addition, the emergency criteria for admission document, does not provide any timeframe/timescale. Therefore, once a resident has been admitted under the criteria, there is no formal mechanism by which further assessment is carried out and if required, a more appropriate placement is then found. Pre admission records for other residents admitted on a ‘respite’ or ‘long stay’ were adequate in content and detail. Some records were better than others when it came to recording individual residents wishes, preferences and expectations. The manager agreed that the recording system itself could do with a ‘tidy up’ so that paperwork in files would be easier to find. One file was very disorganised as the paper work was too bulky for the folder and paper were loose. All case papers requested by the inspector were readily available. The home said it was committed to resolving the issues around ‘focus’ of care, the current ‘category of registration’ and the emergency criteria for the benefit and wellbeing of residents. The home understands that this is a registration issue and has regulatory implications. Shernbroke DS0000030743.V337950.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 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents needs were reflected in care plans, but the issue of regular care plan reviews remains outstanding. Residents are supported whenever possible and to the best of their individual abilities, to make decisions about their lives. EVIDENCE: Three residents care plans were sampled. Each one had been developed from a Care Management Assessment or from the homes own pre admission assessment. Care plans were detailed and identified care/health needs. However, having identified care needs, in two cases, the home finds that it is unable to fully meet them. The difficulty the home now has, is that more suitable placements have not been found. In addition, the home is not able to facilitate an adequate social/community activity programme (see next section of the report) to meet the assessed needs of residents.
Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 12 Risk assessments were current and in good order. Daily record sheets were detailed but some contained undignified terminology such as ‘turned nasty’, bad mood’ and ‘had messed herself’. The manager agreed that this is not acceptable. The issue of regular reviews of care plans came up at the last inspection. At this inspection, it was noted that a gap of 12 months had been recorded before a formal care plan review was due to take place. This is not adequate as the care plan in question was complex and care needs were diverse. The manager agreed about this. In addition, this practice is not compliant with the information within the Service User Guide. Residents living in the home have very complex and diverse health/care needs. Many residents would have difficulty in making decisions for themselves on a day-to-day basis. However, staff were seen to communicate with individual residents in a variety of ways very well. At every opportunity, staff were seen to try and include each resident about whatever was going on. Staff spoken with had a good understanding of residents needs. Residents looked kempt and wore clothing that was in keeping with their age, gender and activity. Two residents able to express an opinion about the care the home provides, were positive in their comments. A relative also expressed satisfaction about the care the home provides, but was disappointed about the lack of social and recreational input. As noted, this matter is referred to in the next section of the report. Shernbroke DS0000030743.V337950.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): 12,13,14,15,16 & 17 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Opportunities for residents to pursue any community activity remain very limited. Opportunity for leisure and social activities within the home is also limiting. There is inadequate documentation demonstrating that residents eat a balanced, nutritional diet EVIDENCE: Records demonstrate that there is very little opportunity for residents to participate in an appropriate social, recreation activity programme. Due to the lack of adequate transport, the home is unable to take out more than one or two residents at a time. Therefore, residents are denied a right to participate in
Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 14 meaningful social, community and leisure pursuits. This was raised at the last inspection. Staff said that they are unable to develop this area of care because of staffing levels and lack of appropriate and adequate transport. The manager said that although the matter has not been resolved, no resident is admitted now unless adequate 1:1 staff costs are included to provide/facilitate this aspect of care. However in the meantime, the lack of transport and allocated staffing hours, means that a home that is registered to provide care for young adults with a learning disability and/or physical disability is unable to meet assessed needs. The manager agreed that the continuing situation is not acceptable. The home operates on a 4 weekly menu rota. The projected menu was varied and the chefs on duty were able to demonstrate that the home can provide a variety of different diets to meet the complex needs within the home. Records were available to demonstrate that residents (where possible) are given choice. The manager explained the home is current putting together a ‘picture/photo menu’ where residents can point to a photo of the dish of their choice. The kitchen area was clean and tidy. The kitchen was a blaze of colour from the fresh fruit, fresh vegetables, salads etc being prepared for lunch. The two chefs on duty expressed enjoyment in the work. Residents, a relative and staff spoke well of food provision within the home. Unfortunately the home was not able to demonstrate that it maintains any consistent means of recording what each resident has actually eaten and in what quantity. The reason for these records was explained to the manager. Forms used for this purpose were poorly maintained. The manager agreed that the current situation this was not acceptable. Shernbroke DS0000030743.V337950.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Community health care links are accessible. Medication practices require review to minimise potential risk to residents. EVIDENCE: Care plans demonstrate that resident’s health care needs are recorded and the community health care agencies play an active part in the care of residents. Many residents have complex health care needs and the home is supported by the respective appropriate healthcare agencies. During the course of the inspection, conversations were overheard regarding the pending admission of a resident who had a specific health care need. The manager was very clear during those conversations that the resident would not be admitted unless a clear and agreed health care support package was in place. Medication practices must to be reviewed. Mediation records were sampled on ‘House 1’. Of the four records sampled and completed by staff in the past week, all had anomalies. Medication seemingly administrated had not been recorded on nine occasions, and on 4 occasions handwritten medication data
Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 16 and administration detail had been written by a member of staff, but there was no signature or countersignature. These records were shown to the manager who agreed that the situation is not acceptable. Shernbroke DS0000030743.V337950.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place. Staff spoken with had adequate knowledge of ‘Safeguarding Adults form Harm’ reporting procedures. EVIDENCE: The home’s complaints procedure was displayed and is within the Statement of Purpose and Service User’s Guide. A ‘user friendly version’ was readily available as well. The manager agreed to review the content of the document as some information was outdated i.e. contact details. Although not examined on this occasion, the home had a formal ‘complaints record’ file in the office. Two residents spoken with said that they would be happy to raise any concern with a member of staff and a relative spoken with said that the home had supported her well through a difficult situation. Two staff spoken with were familiar with the ‘Safeguarding Adults from Harm’ reporting procedures. Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 18 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was clean, safe and comfortable. EVIDENCE: On arrival, a partial tour of the home was made. The home comprises of a central administration area and five houses/bungalows. Each house/bungalow provides care for a different client group i.e. complex care needs, special care needs, respite care etc. The home was busy, probably due to the fact that many residents require wheelchair assistance and there was a lot of physical activity around the home. The home felt comfortable and friendly. The more able residents were seen to be ‘visiting’ other houses/bungalows talking and engaging with different residents and staff. Residents accommodation was clean, fresh, comfortable and homely. Bathrooms were ‘functional’ in style and design, but were clean and adequately maintained.
Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 19 The inspection coincided with a warm spring day and many residents were in the pleasant garden area during the afternoon. Staff were on hand to provide support. All areas of the home were free from any foul or unpleasant odours. Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 20 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): 32,34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are not sufficient to provide/facilitate leisure, social and community opportunities for residents. Recruitment processes are robust. Residents are supported by trained staff that understand their assessed care needs. EVIDENCE: The current staffing rota was accurate and reflected staff on duty. Two recruitment records belonging to the most recently recruited staff members were assessed to be in good order. The home maintains an ‘agency staff’ induction record book. Staff confirmed that they receive staff supervision and the minutes of a recent staff team meeting was displayed. Although not sampled on this occasion, staff training files were evident. Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 21 The manager and staff said that they are unable to take residents out into the community for social and leisure opportunities because of staffing levels and the lack of adequate transport. The manager acknowledged that this was raised at the last inspection and discussions have taken place with the registered provider but there has been no resolution. The manager said that there had been an embargo of staff recruitment and this had only just been lifted. At present the home has 301 vacant care hours. These hours at present are ‘filled’ by staff doing extra shift or by the use of agency staff. There is continuity of care because the home only uses one agency and therefore there is some degree of staff continuity. The manager said that sickness levels were improving and there had been a minimal turnover of staff mainly because of the embargo in staff recruitment. The inspection process involved a number of staff because of the layout of the home i.e. staff are allocated to different houses/bungalows and everyone was helpful, courteous and friendly. Two administration staff were on duty and their cooperation was especially appreciated. Staff looked clean and tidy. Their rapport with residents was seen to be natural and friendly. A relative said that staff were kind to the residents. Staff spoken with were clearly frustrated that they are unable to support their residents by taking them into the community, and they felt that some residents in the home were not suitably placed and therefore were uncomfortable as they could not provided the care that is seemingly required. Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 22 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): 37,39,40, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by a team of staff who are managed by an experienced manager The home has in place a Quality Assurance mechanism for reviewing and keeping under review that quality of its provision. Some identified working practices are not compliant with regulation and/or the home stated polices and procedures. EVIDENCE: The registered manager is qualified at NVQ 4 level in management and holds other relevant social care qualifications. In addition, the manager has significant experience of working and managing in the social care sector. The
Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 23 manager has overall responsibility for the running of the home. Staff spoke very well of the manager and found her to be friendly, approachable and supportive. A relative and two visiting processionals that were spoken with briefly also supported this view. The manager demonstrated commitment in providing good quality care for all residents. Her demeanour was open, transparent and positive. This was reflected in the way the home is managed on a day-to-day basis. The home has a mechanism in place for reviewing and keeping under review the quality of its provision; this includes seeking and recording the views of residents, staff and other stakeholders. The most recent Quality Assurance Report (06/07) was on display. Those safety and maintenance records sampled at random were in good order. It is of concern that a number of identified regulatory shortfalls were found at this inspection that was not evident a year ago. These have been detailed through the report and form part of the ‘requirement/recommendation’ section. The manager acknowledged the shortfalls and expressed surprise at some of them because it was thought that staff were meeting requirements. Not only were regulatory shortfalls noted, but also the home is not always compliant with its own policies and procedures. In addition, two of the three regulatory requirements made at the last inspection have not been addressed in full. Therefore, the manager should review ‘in house’ training and staff supervision to ensure that staff are trained and assessed as competent to carry out their respective responsibilities. It is also important that the registered provider through the provision of the Regulation 26 visits (visit by person in control) provides the necessary assistance to the home to bring it back up to registration standards for the wellbeing and benefit of residents. The day for the inspection was a very busy time for the manager because of the demands a number of other professionals were making on her time, therefore her cooperation must be acknowledged. Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 1 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 2 2 2 X Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 25 Yes 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 YA1 Regulation 4 Requirement The Statement of Purpose must be reviewed so that the content reflects current practice within the home and the content meets with regulatory requirements. The content must be clear in terms of what care the home can provide, how it is going to provide it and who by. The given timescale acknowledges that discussions will need to take place before an amended document is agreed and available. However, if the home wishes to pursue a variation to their condition(s) of registration, it will have to submit an amended document with the application. The ‘emergency admission criteria’ document needs to be reviewed alongside the Statement of Purpose. This is to ensure that the home can meet the assessed needs of any prospective residents before admission. In addition, residents assessed needs must be kept under
DS0000030743.V337950.R01.S.doc Timescale for action 31/07/07 2 YA2 YA3 14 15/06/07 Shernbroke Version 5.2 Page 26 review and if the home is unable to meet those needs, then a more suitable placement must be found in the interest of the resident. This includes the home being able to facilitate/support/provide appropriate community activity. All care plans must be kept under regular review. The National Minimum Care Standards provides guidance on what is appropriate. This is a repeat requirement from the last inspection. The timescale to meet this requirement was 30/06/06. 4 YA7 YA9 YA12 YA13 YA14 YA15 16 Adequate provision in terms of 15/06/07 transport and staffing resources must be made for residents to be able to go into the community if they so wish. Opportunity taking into full consideration assessed risks, must be made for all residents to participle in appropriate in-house and community based activities/events. This is a repeat requirement from the last inspection. The timescale to meet this requirement was 30/06/06. The home must maintain a form of record to demonstrate that residents are provided with food and drink which are in adequate quantities, suitable, wholesome, nutritious and varied. Current medication practices must be reviewed to ensure that all practices are in line with legislation and current guidance. Details of the shortfalls are within the report.
DS0000030743.V337950.R01.S.doc 3 YA6 15 15/06/07 5 YA17 16 31/05/07 6 YA20 13 31/05/07 Shernbroke Version 5.2 Page 27 7 YA32 YA33 YA35 YA39 YA40 18 Suitable, qualified, trained, 31/05/07 experienced and competent staff must be on duty at all times and in sufficient numbers to meet the assessed needs of residents. The home must conduct itself in accordance with its Statement of Purpose and its philosophy of care. This is in relation to: 1 -Adequate staff on duty to meet the assessed social, recreational and activity needs of residents. Provision must be made for residents to go out into the community if they choose or wish to. Because of assessed risk, this may mean two staff per resident. The views, rights and interests of all residents need to be addressed with regard to this issue. This matter was raised at the last inspection and remains outstanding. Residents should not be admitted unless the home can meet care needs. 2 -The competencies of staff must be assessed to ensure that regulatory records are maintained to the required standard. Records required by regulation 31/05/07 must be maintained in accordance with regulatory requirements and the homes own practices and procedures for the health, safety and wellbeing of all residents. Full details are within the report but included matters such as care plan reviews, medication administration records, and nutrition records. 8 YA42 YA41 12,13 Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 28 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 Shernbroke DS0000030743.V337950.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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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