Inspection on 14/04/05 for Shernbroke

This inspection was carried out on 14th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shernbroke 13/03/09

Shernbroke 25/09/08

Shernbroke 01/05/07

Shernbroke 03/05/06

Shernbroke 30/09/05

Shernbroke 19/08/04

Shernbroke 16/04/04

Shernbroke 13/01/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Shernbroke 1-6 Shernbroke Road Waltham Abbey Essex EN9 3JF Lead Inspector Neal Cranmer Unannounced 14th April 2005 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 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 Stationary 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 I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Shernbroke Address 1-6 Shernbroke Road Waltham Abbey Essex EN9 3JF 01992 700545 01992 761735 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Essex County Council Mrs Geraldine Sonia Elliott Care Home (CRH) 25 Category(ies) of LD Learning Disability (25) registration, with number LD(E) Learning Dis - over 65 (1) of places PD Physical Disability (6) Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1 2 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 3 4 Date of last inspection 19/08/04 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. Accommodation is arranged on a unitary basis, each of the houses has domestic style facilities. Two of the houses are designed to meet the needs of people with a physicl disability. The houses and grounds were seen to be generally well maintained and clean and tidy on the day of the inspection. The home is situated close to local shops and amenities.. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one day in April. Twenty-five of the fortythree standards were inspected, of these one was exceeded, twenty were met, with the remainder being partially met. During the course of the inspection one service user was spoken to; due to the profound and complex needs of the service user group it proved difficult to speak to any more. Three staff were spoken with and there was opportunity to spend a considerable period of time with the relative of a service user and of great benefit in informing the content of this report. Although, as mentioned above, the complex needs of the service user group made communication difficult, observation of service users during the course of the inspection indicated that they appeared happy and at ease within their environment. Staff were observed interacting with service users in a positive and appropriate manner. On the day of the inspection all of the houses visited were seen to be homely and domestic in appearance, there was not any evidence of any unpleasant odours. What the service does well: What has improved since the last inspection? Since the last inspection the manager has spent considerable time in developing the home’s pre-admission assessment process and documentation, which are now comprehensive in the level of detail required before admission is considered. In addition, a comprehensive process for measuring the quality of the home’s service provision has been developed to what is considered to be of a very high standard. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 7 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 Standards Statutory Requirements Identified During the Inspection Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 4 and 5. Both the home’s pre-admission assessment and contract of residency contained evidence of service users having opportunities to visit the home on a trial basis, prior to admission. The contracts of residency seen clearly identified the service provided to service users. EVIDENCE: The care plan sampled of the service user most recently admitted to the home evidenced that the service user had visited the home on a number of occasions prior to their admission. Contracts of Residency sampled were seen to detail what was provided to service users upon their admission to the home, as well as the level of fees for the service which they were to receive. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 Care plans and risk assessments sampled were seen to contain evidence of service users involvement, where the service user was able to participate.. EVIDENCE: The care plans sampled were well detailed; evidence was seen of service user participation in the care planning process. In addition, the plans were supplemented by clear management guidelines. Risk assessments were also seen to be held on file, with clear guidelines for staff on actions to be followed to minimise the likelihood of the identified risk presenting. Staff spoken to during the course of the inspection spoke of their awareness and understanding of the care plans. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 15 and 17. Although social activities within the home are generally well managed, opportunities for activities within the local community are fairly limited, unless service users attend the local resource centre. EVIDENCE: Care plans sampled contained some evidence of activity planning and recording, although this was minimal and further development is required to ensure that plans take into account the likes and dislikes of service users and to ensure that activities are appropriate to the identified needs of the service users. The home has an open door policy on the receiving of visitors, with service users being free to receive their visitors in the privacy of their own rooms if they so desire. The relative of a service user spoken to during the course of the inspection spoke of staff always being welcoming and friendly whenever they visited. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 11 The home operates four-weekly rotational menus, which were seen to be varied and nutritious, and offered a range of choices. Meals are prepared in the home’s main kitchen, although each house has a small domestic style kitchen adequately equipped to prepare snacks, etc. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The home’s healthcare arrangements were adequate and seen to be comprehensively detailed. EVIDENCE: The care plans sampled pertaining to service users’ healthcare needs were seen to be well documented and recorded. Records of healthcare input into the home were detailed. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home’s Complaint, Whistle Blowing and Adult Protection Policies were adequate to ensure service users were protected from harm or abuse. EVIDENCE: The home’s Complaint policy/procedure was comprehensively detailed and available in a format that is appropriate to the needs of the service users. The relative spoken to during the course of the inspection was, however, unaware that they could, if they so wished, refer complaints directly to the Commission for Social Care Inspection. The home’s Adult Protection and Whistle Blowing policies were both comprehensively detailed. Staff spoken to during the course of the inspection spoke of having received training in recognising and responding to abuse. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30. The environmental standards at the home are good. All the houses visited were homely, clean and tidy and free from any offensive odours. EVIDENCE: The home is organised on a unitary basis, with each house providing accommodation to no more than five service users. The home is suitable for its stated purpose, being safe and accessible, and maintained to an acceptable standard. Although service users’ bedrooms are suitable to meet individual needs, consideration needs to be given to meeting the environmental standards pertaining to room sizes by 2007. Furniture and fittings seen in service users’ rooms were suitable to individuals’ needs. Toilets and bathrooms at the home were seen to be appropriately positioned close to service users’ bedrooms. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 15 Kitchen facilities in each house are domestic in nature. Communal space at the home was deemed to be adequate to meet the needs of the service users accommodated. A range of environmental aids and adaptations were seen to be available, designed to optimise service users’ independence. On the day of the inspection the home was clean and tidy and free from any offensive odours. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 34. Staffing levels at the home are adequate to meet the basic needs of service users, but left little scope for any quality time. The recruitment procedures at the home were appropriate to the protection of service users. EVIDENCE: Discussion with a relative of a service user, the registered manager and staff during the course of the inspection, indicated that the staffing levels of the home are adequate to meet the basic needs of the service users, but leave very little space for any quality time. The home has a high usage of agency staff, although the registered manager endeavours to ensure consistency. Whilst the relative spoken with had no concerns at the time in relation to the care of their relative, where they had had past concerns was with agency staff, and it was in this area where they felt the need for consistent staff was a priority, particularly when supporting service users with such diverse complex needs. The recruitment practices at the home were of a good standard and were adequate to keep service users safe. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41 and 42. The registered manager is qualified equivalent to NVQ Level 4 in management (this has been confirmed by an external NVQ provider), and has significant experience of working in the care sector. EVIDENCE: It was evident from conversation with the staff that they felt they receive guidance and direction from the registered manager. The visiting relative spoke highly of the registered manager and how much they felt the service had moved forward since their arrival. Since the previous inspection the registered manager has developed a process for the home to measure the quality of their service provision. This was a comprehensively designed document, which gave a real flavour for the service provided. The registered manager was commended for an excellent piece of work. Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 18 A number of records required under Schedule 3 of the Care Homes Regulations continue to require some further development. The registered manager was referred to Schedule 3 for further guidance. A range of safety certificates were viewed, which were seen to meet with regulatory requirements. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Shernbroke Score 3 x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Score Version 1.20 Page 19 LIFESTYLES Standard No 11 12 13 14 15 16 17 Score 2 2 x x 3 x 3 31 32 33 34 35 36 x x 2 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x 4 x 2 2 x Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 20 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 YA11 Regulation 16 (m) Requirement The responsible person must ensure that service users choices around activities in which they partake are recorded in their care plans. This is a repeat requirement . The responsible person must ensure that service users plans include up to date activity plans. This is a repeat requirement . The responsible person must review staffing levels of the home to ensure that they are adequate to meet the assessed needs of the service users . The responsible person must ensure that information in the service users plan is sufficient and current. This is a repeat requirement . Timescale for action End of July 2005 2. YA 12 15 End of July 2005 3. YA33 End of july 2005 4. YA41 15 Schedule 3 End of July 2005 Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 21 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 Good Practice Recommendations Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 22 Commission for Social Care Inspection 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shernbroke I56-I05 S30743 Shernbroke V219962 140405 Stage 4.doc Version 1.20 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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