Inspection on 14/09/07 for Shervale Home

This inspection was carried out on 14th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shervale Home 17/05/06

Shervale Home 21/11/05

Shervale Home 18/07/05

Shervale Home 19/05/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Shervale Home Shervale 1 Shervale Close Penn Wolverhampton West Midlands WV4 5TU Lead Inspector Rebecca Harrison Announced Inspection 14 September 2007 09:30 th Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 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 Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shervale Home Address 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) Shervale 1 Shervale Close Penn Wolverhampton West Midlands WV4 5TU 01902 342811 Mrs Thelma Greensill Mr John Greensill Mrs Thelma Greensill Care Home 5 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2) of places Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. All staff must be trained in learning disability and dementia. Minimum of 2 staff on duty at all times. 1 sleep-in staff/1waking staff at night. Date of last inspection 17th May 2006 Brief Description of the Service: Shervale is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of five adults with a learning disability. The registered providers are Mr and Mrs Greensill. Mrs Greensill manages the home on a daily basis assisted by Mr Greensill. Shervale is a modern two-storey extended property situated in a quite cul-desac in a residential area of Penn, Wolverhampton and accessible by public transport. The accommodation consists of five single bedrooms, all with en-suite facility. Communal space includes a lounge, dining room, recreation room and domestic kitchen. The home provides a patio area at the rear of the property incorporating raised flowerbeds and water features. The homes philosophy is To treat each resident as an individual to maintain his or her dignity and self-respect in a comfortable homely and caring environment. Information about this service is available from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk Fees charged per person range from £410.00 to £615.00 per week. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The proprietors were given very short notice of this inspection to ensure Mrs Greensill was available to assist with the process as the majority of people attend day services. The inspection took place on 14th September 2007 by one inspector over seven and a half hours. A range of evidence was used to make judgements about this service to include a self-assessment completed by the provider and sent to CSCI, surveys completed by the people who use the service, the staff and health and social care professionals, discussions with service users, staff and the manager and a tour of the home. The inspector also looked at a number of records and observed aspects of care provided for two people using the service. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Younger Adults and to review four requirements made at a previous inspection undertaken on 17th May 2006. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: The home has a committed team of staff who try hard to meet the needs of the people in their care. Staff are provided with good training opportunities. The staff team functions well and the service is effectively managed. People are provided with a homely place to live. Bedrooms are personalised and the home is domestic in appearance. Mr and Mrs Greensill are committed to providing a good service to the people living at the home. Peoples healthcare needs are monitored very well and appropriate referrals to relevant professionals are made as required. CSCI received positive feedback from a number of agencies regarding this service and comments include: “The home is very person centred run it meets the needs of each individual, with the care and well being of the people at the heart of the home. …The manager is very good with information sharing and is always available to answer questions you may have… I see no need for the home to improve as people there seem happy and well cared for”. “Shervale is a warm, friendly small scale home that encourages residents to develop social interests and maintain contacts with their network activities/relatives etc”. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 6 “The home is very friendly and warm. You can see the residents are extremely well looked after”. What has improved since the last inspection? What they could do better: One survey stated, “More work/encouragement around day opportunities, leisure and social activities could be improved” The management and recording of service users finances needs to be improved to ensure systems are robust and safeguard both service users and staff. Support plans could be improved as to the level of assistance an individual requires in relation to personal care tasks, particularly given that the home has recently employed three new staff. The manager was advised to source training for staff supporting a service user who has mental health needs. Please contact the provider for advice of actions taken in response to this Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 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 Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 Quality in this outcome area is good People are provided with the information needed to decide whether this service will meet their needs. They have their needs assessed and a contract which tells them about the service they will receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose in place and each service user has been issued with a Service User Guide. The manager was advised to ensure the Service User Guide contains all of the information required following the amendment of The Care Homes Regulations. Once person has been admitted to the home since the last inspection based on an emergency admission. The manager was unable to undertake a needs assessment due to the circumstances however a Level Three Needs Assessment was provided by the placing authority, which supported the individual with the transition. It was reported that the person has settled into the home well and this was evident through discussions held with him. He stated, “I like living here, it’s a nice home and I get on with the staff”. Staff spoken with considered the home is able to meet his needs. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 10 A contract of terms and conditions was available on the two files examined however the manager was advised to develop these further to ensure service users are made aware of any additional costs they may be responsible for. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good Staff are provided with detailed information to ensure service users’ assessed needs are met. The people who use the service are supported to make decisions and enabled to take responsible risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care documentation held on behalf of two people was examined and evidenced that both individuals had been formally reviewed in conjunction with the placing authority involving the service user and significant others. It was reported that the needs of two people have significantly increased and records evidenced that the manager has liaised with the local team to ensure their needs remain under regular review by the necessary health and social care professionals. The manager and staff spoken with considered that the service is able to continue to meet these peoples needs and a number of staff have Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 12 attended relevant training to support them in doing so for example dementia care. Staff on duty were familiar with the individual needs of the people they support and considered that they are provided with sufficient information to appropriately support the people in their care. Since the last inspection a number of staff have attended training in person centred planning and plans have been developed in conjunction with the service user as seen on the two files examined. Two people have an allocated advocate and other people have been referred. Information about advocacy services is readily available. Individuals are supported with decision-making processes as much as their needs allow. The provider completed a self-assessment and sent this to CSCI which states ‘We are very vigilant in making sure we listen to residents views. They have expressed the wish to have more activities...We have also made sure our residents lead an independent life as possible minimizing the risk via risk assessment and respecting there rights’. Care records examined evidenced that people are enabled to take responsible risks as much as their ability allows. Risks are assessed and kept under review. One person told the inspector that he has been provided with a mobile phone to support him going out alone in the local community. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is adequate People who use the service are supported to develop their life, social and educational skills in accordance with their individual needs. They are helped and encouraged to keep in contact with their family and friends and are provided with a varied diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three people attend a range of external day services throughout the week. Two people no longer attend due to their increased needs therefore remain at home supported by staff. One person spoken with reported that he attends day services in addition to college and a leisure centre and is also a member of a club. It was reported that the home has tried to source employment opportunities for him however this proved unsuccessful therefore alternative avenues are being explored. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 14 Preferences in relation to activities and meals were available on the files examined and individual activity charts were displayed in the recreation room. A member of staff spoken reported that she shares responsibility for planning activities with another member of staff and considered that people are now being offered more activities and regularly access the community. Three out of five people have family contact and are invited to attend social events held at the home. Positive feedback from family and friends were obtained through quality assurance surveys undertaken by the provider and numerous complimentary cards from friends of a service user who passed away thanking the home for the care provided. Bedrooms are currently fitted with privacy locks however it was reported alternative locks would be provided and keys made available upon request. A copy of the Residents Charter of Rights was seen on the care files examined. The home provides a two-week menu, which appears balanced and takes into account individual preferences and any special dietary needs. A record of meals eaten is maintained in addition to fluid intake charts for one individual. A service user spoken with reported that he helps with the washing up at the home and attends cookery courses provided through a local college. Discussions indicated that staff could provide greater opportunities for him to develop his skills by enabling him to assist with shopping and meal preparation for the home. He reported that he likes the meals provided. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good The health and personal care that people receive is based on their individual needs and advice is sought from healthcare professionals to ensure their health needs are closely monitored and met. The principles of respect, dignity and privacy are put into practice. The home has a satisfactory system of handling, storing and managing medication, which safeguards the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Preferences in relation to personal support needs were available on the files examined and designated key workers are provided for continuity of care. The records seen stated that the person ‘needs assistance’ with personal care tasks. The manager was advised to ensure records are more specific in relation to how personal care needs are attended to; particularly given three new staff Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 16 have been employed. A district nurse visited the home during the inspection to attend to the needs one person. Health action plans have been developed since the last inspection in conjunction with a healthcare professional. All appointments are clearly documented and evidence that people are supported to access NHS healthcare facilities and appropriate referrals are made as required. Feedback received from four healthcare professionals in preparation for this inspection include: “Shervale appears to be a very well managed home. This surgery has no negative comments to make. “During visits privacy and respect is always maintained with clients. The home always appears to carry out appropriate procedures concerning individuals social and health care needs and certainly seek support or advice when unsure”… “Health Action Plans are in place for all residents and reviewed at regular intervals. The home manager has frequent contact with acute and primary care services, and seeks support from specialist learning disability service when necessary” Medication procedures were discussed with the manager who reported that six staff have undertaken distance learning accredited training provided by the local college. All service users are prescribed medication subject to regular medication reviews. In a survey sent to CSCI a health professional stated “The homes manager would promote independence for service users when administering medicines, with the appropriate levels of support needed. Medication policy and protocols are followed at all times”. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good People who use the service and their representatives have access to a complaints procedure, which enables their views to be listened to. The home has procedures in place to safeguard people using the service and staff receive training in adult protection however the recording and monitoring of peoples finances must be improved to ensure systems are robust. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure and individuals are provided with a copy of this in addition to the local authorities guide for people with learning disabilities on how to complain. A service user spoken with had a clear understanding of who to speak to if he was unhappy with the service provided. No complaints have been received by the home however a referral under safeguarding adult procedures was recently made direct to the Wolverhampton City Councils, Quality Assurance Manager for Adult Protection stating concerns with the care provided. Following two strategy meetings and a visit to the home by the Quality Assurance Manager and Team Manager of the Learning Disability Team it was considered that no further action be taken and the case was closed. The home has the local safeguarding adult policy and procedure and the manager stated that all but four staff have received training in adult protection. The two staff on duty had an understanding of the complaints procedure and one had attended training in adult protection. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 18 The manager stated that all five people require assistance to manage their personal finances and that the council is the appointee for all individuals. The person most recently admitted to the home has his own bank account. Discussions held indicate that it has proved difficult to provide the rest of the individuals with their own account therefore personal allowances are paid directly into the managers current account and withdrawn on a monthly basis and distributed to individuals. It was stated that no interest is accrued. Records are kept and all transactions are signed by two staff and receipts retained for all expenditure. The manager was strongly advised to discuss the management of finances as part of a multi-disciplinary meeting and she committed to reviewing the recording of finances held on behalf of service users and to evidence when audits are undertaken and by whom. A service user spoken with appeared happy with how his finances are managed. Due to health needs one person requires lap belt and records evidence that the use of this restraint has been agreed in the person’s best interests through a multi-disciplinary meeting. It was reported that none of the individuals living at the home require physical intervention therefore staff have not received such training. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good The people living at Shervale are provided with a clean, comfortable and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Shervale is a modern two-storey extended property providing five single ensuite bedrooms to include one bedroom on the ground floor. Communal areas include a lounge, dining room, recreation room and domestic kitchen. Service users spoken with said that that like living at the home. Bedrooms are personalised and reflect individuality. The home was found clean and tidy throughout. Domestic staff are not employed. A service user told the inspector that he helps keep his room clean with the support of staff. Substances hazardous to health are appropriately stored and data sheets available. It was reported that seven staff have undertaken a distance learning course and obtained the Certificate in Infection Control and that he manager has applied for the three new staff to undertaken this as soon as possible. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35 Quality in this outcome area is adequate The people who use the service are supported by a trained and committed staff team however recruitment procedures need further development to ensure people are fully safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were seen to interact with service users in a positive manner throughout the inspection. Two service users spoken with said that the staff are nice and they like living at the home. Of the ten support workers employed it was reported that five have obtained an NVQ award and three staff are due to start their awards shortly. The manager stated that the staffing ratio is a minimum of two staff on duty to support five service users, which was an accurate reflection of the staff rota and confirmed by a service user and the staff on duty. The manager was confident that the staffing levels are appropriate to meet the needs of the people accommodated. The manager has written to CSCI’s Central Registration Team requesting that the homes additional conditions of registration be reviewed to reduce waking night staffing arrangements to one staff member Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 21 plus on-call. A comprehensive risk assessment must be undertaken based on the individual needs of the service users, to include any person requiring manual handling during the night, to ensure service users and staff are not placed at risk. It was stated that three staff have left since the last inspection and due to the increased needs of two people; five new staff have been recruited. The personnel files of all five staff were examined and evidenced that two written references had been obtained prior to staff commencing direct work with service users however not all references had been obtained from a previous employer as required and not all gaps in previous employment history had been explored. Three out of the five files examined contained a CRB and the other two staff had commenced work following clear POVAFIRST checks being obtained while awaiting a CRB disclosure. It was stated that these two staff are supervised at all times and the reason for them starting was due to staff leaving and the numerous hours that Mrs Greensill was covering. The home continues to be a member of the National Care Homes Association and CRB disclosures are completed through this umbrella body. Three and six monthly probationary meetings were seen on files and evidenced that the manager challenges any issues that arise. All other documentation was available and the manager committed to ensuring that photographs of newly appointed staff are placed on files at the earliest opportunity. Individual staff training records were available on all files examined in addition to a record of induction. It was reported that three staff have undertaken LDAF Certificate in Working with People with Learning Disabilities and funding has been applied for a further three staff to attend. Records also evidence that staff undertake distance learning courses in a number of areas to include infection control, safe handling of medicines, nutrition and health and three staff have completed training in dementia care. The manager committed to develop an overall staff-training matrix to record dates of when staff have completed training events. It is evident that the providers are keen to provide a qualified and trained workforce and during the inspection an NVQ assessor visited the home. It was also reported that a tutor from a local college had recently visited the home to discuss staff training needs and a schedule of candidates and their training needs was seen at inspection. Staff spoken with confirmed that they receive service specific and mandatory training. One member of staff stated “Training opportunities are good. I have done so much training. I have my NVQ 2 and due to start level 3 shortly”. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. The ethos of the home is based on openness and respect with aspects of performance regularly reviewed to achieve good outcomes for the people who use the service. The home is managed and maintained in a safe manner, which ensures the safety of service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mr and Mrs Greensill are the registered providers with Mrs Greensill managing the service assisted by her husband. Mrs Greensill has numerous years experience in the care sector and holds a general nursing qualification. Since the last inspection she had obtained the Registered Managers Award in Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 23 addition to attending a number of other training events appropriate to her role. Staff and service users spoken with were positive about how the home is managed. The provider completed a self assessment and sent this to CSCI which states ‘We have two service users on our quality review group to get there opinion on the running of the home…..We also have advocates who look after our residents interest and act on their behalf’. Since the last inspection the providers have distributed surveys to service users, relatives and stakeholders to ascertain their views about the service. Feedback was very positive and comments include: “The home is very friendly and warm. You can see the residents are extremely well looked after”. “We consider it to be an excellent home and very welcoming”. “How can I thank you for the loving care since X came to live with you”. In preparation for this inspection CSCI received nine surveys about the service. Comments were positive with a number being included throughout this report. Health and safety procedures appeared satisfactory at the time of this inspection. Safety checks are carried out at the required frequency and all equipment serviced within required timescales. The manager agreed to record water temperatures to ensure service users are not at risk from scalding. During the inspection an engineer was at the home servicing the central heating system. Staff spoken with confirmed that they are happy with health and safety arrangements and that they receive training in safe working practices. Mrs Greensill reported that there are no outstanding recommendations from either the fire or environmental health departments. A maintenance log is maintained and health and safety audits are undertaken. Infection control measures have been triggered in relation to one service user and the manager has sought advice form the District Nurse and taken the necessary action as observed during the inspection. The manager was also reminded that she may seek advise from local NHS Infection Control team. Records evidence that all accidents are recorded. The manager was advised to obtain an accident book, which is compliant with the Data Protection Act. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 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 3 2 3 3 x 4 x 5 3 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 3 33 3 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 x 3 x 3 x x 3 x Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 25 No 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 YA34 Regulation 19 (1) Requirement Two written references must be obtained, to include one from the applicants current employer and any gaps in the employment record explored before making an appointment in order to safeguard people living at the home. Timescale for action 15/10/07 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 Refer to Standard YA18 YA23 YA33 Good Practice Recommendations Support plans should be more specific in relation to the level of assistance an individual requires with identified personal care tasks. The procedures for the management of service users’ finances should be reviewed to ensure service users and staff are safeguarded. A comprehensive risk assessment should be undertaken based on the individual needs of the service users to ascertain the minimum staffing requirement based on the DS0000063187.V355223.R01.S.doc Version 5.1 Page 26 Shervale Home 4 YA35 increased needs of service users. Staff should be provided with training in mental health to ensure they have skills and knowledge to support an individual assessed as having mental health needs. Shervale Home DS0000063187.V355223.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. 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