Inspection on 17/05/06 for Shervale Home

This inspection was carried out on 17th May 2006.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shervale Home 14/09/07

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 Unannounced Inspection 17th May 2006 10:00 Shervale Home DS0000063187.V293972.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.V293972.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.V293972.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.V293972.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 21st November 2005 Brief Description of the Service: Shervale is a modern property situated in a quite cul-de-sac in a residential area of Penn. The home is registered with the Commission for Social Care Inspection (CSCI) to provide personal care and accommodation to a maximum of five adults with a Learning Disability to include two people over the age of 65 years. The property has been extended to provide five bedrooms in addition to staff sleep-in accommodation. All service users are provided with a single bedroom with en-suite facility. A shared bathroom is also available. Communal space includes a lounge, dining room, sitting room and domestic kitchen. Service users have access to a patio area at the rear of the property providing raised flower beds 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. The fees charged per service user, range from £400 to £625 per week. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mr and Mrs Greensill were provided with very short notice of the inspection due to the necessity of them being available on site given that all service users attend day services throughout the week. The inspection commenced at 10 a.m. and lasted seven hours. The inspector had the opportunity to meet three service users when they returned home from day services late afternoon. The inspection was carried out by talking with Mr and Mrs Greensill, two members of staff on duty, case tracking two service users, observation of work practices, reviewing a number of records and a brief tour of the home. All 22 key National Minimum Standards for younger adults were assessed in addition to Standards 33 and 41 and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The service users, staff on duty and the providers were welcoming and cooperated fully throughout the inspection. Six requirements and one recommendation were made as a result of the last inspection undertaken on 21st November 2005. The providers have worked hard towards meeting these. No complaints have been referred to the manager of the home or the Commission for Social Care Inspection since the last inspection and no referrals have been made under adult protection procedures. What the service does well: Both Mr and Mrs Greensill continue to be committed to providing a good service to the people living at the home. Service users are provided with an attractive and homely place to live and are supported by a dedicated trained staff team who appear committed and have a good understanding of the needs of the people they support. Service users are provided with social and educational opportunities and continue to be supported to keep in contact with their families. The healthcare needs of service users are well monitored and appropriate referrals to the relevant professionals continue to be made as required. All health appointments are recorded and outcomes clearly stated. Mrs Greensill and the staff on duty provided sound examples of how equality and diversity is promoted within the service and how the team support one staff member whose English is not her first language. An equalities action plan has also been developed. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 6 One service user informed the inspector that she likes living at the home, enjoys watching TV, going out for walks, attending an evening club and that the food is good. What has improved since the last inspection? What they could do better: An assessment undertaken by a Community Nurse and discussions held with proprietors and staff evidence that the needs of one individual have significantly increased since the last inspection. It was stated that the person now requires constant supervision, which is having an impact on staffing resources. Additional funding for the individual is currently being negotiated with the placing authority however the proprietors reported that in the interim they are having to work considerable long hours to ensure appropriate staffing levels and to secure the financial viability of the home. This situation needs to be resolved as soon as possible. The staff team would benefit from attending training in the development of Person Centred Planning and for each service user to have a plan in place. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 7 Training records available evidence that staff are accessing training appropriate to their role however some staff still require training in safe working practices. Although a resident’s satisfaction survey has been undertaken, questionnaires should be sent to relatives, stakeholders and advocates and a report of the overall findings made available. General health and safety procedures appeared satisfactory at the time of this inspection however risk assessments must be undertaken on COSHH products and water temperatures and these be closely monitored to ensure service users are not at risk from scalding. The risk assessment for the management of epilepsy in relation to one individual needs to be updated in conjunction with healthcare professionals, given the increase in number of accidents caused through seizures. The duty rota needs to be revised to indicate actual working times that staff are on shift and the full names of employees and job roles clearly stated. 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. Shervale Home DS0000063187.V293972.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.V293972.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): 2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place that would enable the successful admission of new service users to the home. EVIDENCE: The proprietor reported that there have been no new admissions or discharges since the home was last inspected. The homes procedure for admission was found to be satisfactory when assessed at previous inspections. The last admission to the home was in September 2005, followed by a review of the placement in December 2005. Discussions held with the service user, proprietor and staff on duty indicated that the person has settled well into his new home. A requirement was made as a result of the previous inspection that the proprietor develop and agree with each service user a written contract/statement of terms and conditions as specified in national minimum standard 5.2. Case tracking of two service users evidenced that appropriate documentation is now in place, signed and dated by the service user, social worker and proprietor. The proprietor agreed to amend some very minor changes to the document. Service agreements between the placing authority and home were also available on the files reviewed. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. There are clear care-planning systems in place to adequately provide staff with the information they need to satisfactorily meet service users assessed needs. Service users are appropriately supported with decision-making making processes. Individuals are enabled to take responsible risks within a risk-assessed framework. EVIDENCE: No requirements or recommendations were made as a result of the last inspection in relation to the intended outcomes for service users in respect of ‘Individual Needs and Choices’. Two service users were case tracked and their individual care documentation reviewed at length. Each individual has three files incorporating a daily report file, a main file and a personal file. Information was comprehensive with Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 11 evidence of regular review. It was reported that the Reviewing Officer for the local authority had visited the home on two occasions since the last inspection and reviewed three people however the proprietor reported that no formal documentation in relation to these meetings has been received to date from the placing authority. An assessment undertaken by a Community Nurse and discussions held with proprietors and staff evidence that the needs of one individual have significantly increased since the last inspection. It was stated that the person now requires constant supervision, which is having an impact on staffing resources. Additional funding for the individual is currently being negotiated with the placing authority however the proprietors reported that in the interim they are having to work considerable long hours to ensure appropriate staffing levels and to secure the financial viability of the home. Discussions held with two staff on duty evidenced that they were familiar with the individual needs of the people accommodated at the home and stated that they are provided with sufficient information to appropriately support the people in their care. Since the last inspection the proprietor has sought information on the development of person centred plans (PCP’s) however due to time constraints training in PCP’s has not been undertaken to implement the process. The proprietor was advised to achieve some of the documentation to provide support staff with easier access to the latest relevant information. A formal key worker system has recently been developed and implemented and staff spoken with welcomed the system and had a clear understanding of the role. The role of the key worker has also been discussed during staff supervision sessions. Two of the service users continue to have an allocated independent advocate. Advocacy information was also available on the files reviewed. It was reported that the families and friends of service users continue to actively advocate on behalf of the people accommodated. Evidence to support individuals with decision-making processes was available on the records of the individual’s case tracked. Service users are enabled to take responsible risks as much as their ability allows. Risks are assessed and kept under review. The proprietor was advised to review and update a risk assessment regarding the management of epilepsy due to the number of accidents sustained by one service user following numerous seizures. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 12 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): 12,13,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with social and educational opportunities, they are supported to keep in contact with their families and friends and offered a varied diet respecting their individual preferences. EVIDENCE: No requirements or recommendations were made as a result of the last inspection in relation to the intended outcomes for service users in respect of ‘Lifestyles’. It was reported that all service users continue to attend a variety of local authority day services with no individual currently accessing paid or voluntary employment. One person attends college and also enjoys visiting the local library on a regular basis to use the computers. The proprietor reported that people continue to enjoy attending day services throughout the week including the two elderly people accommodated. The proprietor was advised to keep this under review with the individuals concerned, their advocates and day Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 13 service given their ages and very early rising in the morning in order to access transport. Religious observance and the promotion of community links and social inclusion were seen recorded in the files reviewed in addition to personal preferences relating to food and mealtimes. An activity file is maintained and evidenced activities supported by the home and a number of clubs that individual’s access. A holiday to Blackpool has also been arranged with four of the service users. Discussions held with the proprietor and staff on duty evidence that service users continue to be supported and encouraged to maintain links with their family and friends, who are welcome to visit the home at any reasonable time. House ‘rules’ are documented in the service user guide and the home is a no smoking environment. Although bedrooms are currently fitted with privacy locks the proprietors would provide an alternative locking device upon request. A copy of the Residents Charter of Rights was seen on the individual files of the two people case tracked. The menu reviewed during the inspection appeared balanced and a record is maintained of all meals eaten. One individual case tracked is on a low fat and high fibre diet as recommended by the general practitioner. Staff spoken with reported that only one individual currently assists with basic tasks such as laying the table and washing and drying dishes however the team are looking towards developing basic independent living skills with a further individual shortly. A service user spoken with said ‘I like the food here’. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 14 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. This judgement has been made using available evidence including a visit to this service. The personal and health needs of service users are well met with evidence of regular review with healthcare professionals. The home has a satisfactory system of handling, storing and managing medication. EVIDENCE: No requirements or recommendations were made as a result of the last inspection in relation to the intended outcomes for service users in respect of ‘Personal and Healthcare Support’. The healthcare records of the two people case tracked were comprehensive and evidence that people’s health is closely monitored and kept under review. Preferences in relation to personal support are clearly documented and discussions held with the proprietor and staff on duty indicated that they had a good understanding of the healthcare needs of the individuals they support. Health appointments are recorded and outcomes clearly stated. Health Action Plans were available on the files of the two people case tracked and the proprietor confirmed that these had been completed in conjunction with day Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 15 services. CSCI were recently notified of an accident concerning one individual, as required under Regulation 37, and the appropriate action was taken to support the individual concerned. Medication procedures appeared satisfactory at the time of this inspection. All service users are currently prescribed medication to exclude controlled drugs. It was reported that three staff have completed a distant learning course in the safe handling of medication and are awaiting certification. A further two staff are currently undertaking the course. The manager was advised to place a photograph of individuals on the front of their Medication Administration Records. The proprietor reported that she has consulted with the GP in relation to the use of homely remedies and obtained the G.P’s signature. The homes medication policy was not reviewed on this occasion. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 16 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. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system in place and the procedures to safeguard service users from potential abuse have improved. EVIDENCE: Information on ‘How to make a Complaint’ was seen on the files of the two individuals case tracked in addition to the local authorities guide to making a complaint for people with learning disabilities. No entries were logged in the complaints book and the proprietor confirmed that no complaints have been received since the home was last inspected. No complaints have been received by CSCI and there have been no referrals made under adult protection procedures. The two staff on duty had an understanding of the complaints procedure and both had attended training in adult protection. A requirement was made at the previous inspection that the registered person must not pay money belonging to individual service users into a bank account, unless the account is in the name of the service user to which the money belongs. The proprietor reported that one individual has their own bank account, the parent of another person oversees his finances and advice has been sought from the appointee of the other people. Although bank accounts have not been set up, financial procedures have improved with individuals being provided with lockable space in their rooms to keep their finances and new financial records are in place. All transactions are checked and signed by two staff and regularly monitored. The monies of the two people case tracked were checked by the inspector and were an accurate reflection of the records held. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 17 The proprietor has obtained a copy of the local Inter-Agency Adult protection policy and procedures and four staff have undertaken training in relation to the local procedure and further staff are due to access the training as soon as possible. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 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 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. This judgement has been made using available evidence including a visit to this service. Service users are provided with a homely, clean and safe environment to live. EVIDENCE: No requirements or recommendations were made as a result of the last inspection in relation to the intended outcomes for service users in respect of ‘Environment’. During a brief tour of the environment the home was found clean, bright, airy and decorated and furnished to a good standard. Two service users spoken with informed the inspector that they enjoy living at the home and like their bedrooms. It was reported that the home no longer employs a domestic member of staff therefore support staff assist service users with basic household tasks as much as possible depending on ability. COSHH products are appropriately stored and the relevant data sheets in place but risk assessment of the products need to be undertaken. A number of staff are currently undertaking a distance-learning course on infection control provided through a local college. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. Services users are supported by a committed and trained staff team and are protected by the homes recruitment practices. EVIDENCE: Conditions of registration are imposed in relation to staffing levels and training. This findings of this inspection evidence that the proprietors are meeting the staffing requirements and actively working towards meeting the condition whereby all staff must be trained in learning disability and dementia. Two support workers were on duty during the afternoon of the inspection and observations made and discussions held with them indicated that they had a good understanding of the service users needs. They appeared committed and motivated and were very complimentary of the service users, colleagues and their managers. They reported that they have been in receipt of good training opportunities and regular formal supervision. Mrs Greensill and the staff on duty provided sound examples of how equality and diversity is promoted within the service and how the team support one staff member whose English is not her first language. An equalities action plan has also been developed. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 20 Staff stated that the minimum staffing is usually two to three staff on per waking shift and one sleep-in and one waking night member of staff. A recommendation was made at the previous inspection that the duty rota be revised to indicate actual working times that staff are on shift. Perusal of the rota indicated that amendments have been made however the actual hours worked by staff remain unclear and therefore this must be addressed. The proprietors reported that the home employs eight support staff which was reflected on the homes organisational chart displayed in the office. One member of staff has obtained an NVQ level 2 Care award and five staff are registered to commence the award in June. The proprietor reported that three staff have been recruited since the last inspection however one has since left and reasons for this were shared with the inspector. The personnel files were found well presented and contained the necessary documentation required. CRB disclosures had been obtained for all staff employed. The home continues to be a member of the National Care Homes Association and CRB disclosures are now completed through this body. A number of distance learning courses in medication, infection control, healthy eating and dementia have been arranged via Walsall College. Training records available evidence that staff are accessing training appropriate to their role however some staff require mandatory training. A requirement was made at the previous inspection that all new staff must receive structured induction training to LDAF specification. The proprietor has sourced Skills for Care (formally TOPSS) induction packs and commenced new starters using this format. The inspector provided contact details of learning disability organisations and LDAF contact details, which may help with sourcing induction packs for staff working in learning disability services. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 21 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. This judgement has been made using available evidence including a visit to this service. The home is effectively managed, record keeping systems have improved and the home is generally maintained in a safe manner with aspects of performance reviewed. EVIDENCE: Ms Thelma Greensill is the registered proprietor and manages the home on a daily basis. She has over twenty years experience in the care sector and holds a registered general nursing qualification. (RGN). Mrs Greensill reported that she has undertaken training in adult protection for managers, staff supervision and has commenced the Registered Managers Award since the last inspection. Staff on duty were complimentary regarding the management of the home. Discussions held with the proprietors and the duty rota seen evidence that they are both working considerably long hours to support the people accommodated and to secure the financial viability of the home. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 22 A requirement was made at the previous inspection that a quality assurance system be developed in order to measure success in achieving the aims, objectives and statement of purpose of the home. A resident’s satisfaction survey has been completed and surveys are also available to visitors. The proprietor reported that she has not yet had the opportunity to send surveys out to relatives, stakeholders and advocates. Comments about the home stated on service user surveys included ‘I like it as it is’, ‘I would like a blue bedroom’. One service user informed the inspector that she likes living at the home, enjoys watching TV, likes the food and going to a club and for walks out. The proprietor committed to compiling a report based on the results of all the completed surveys. Record keeping systems have improved, records are regularly reviewed and held securely in the new office provided however it is recommended that care records be condensed with old information achieved to aid accessibility. Records reviewed and discussions held with the proprietor evidence that the requirement made for a moving and handling assessment to be undertaken on the changing needs of one individual has since been met. General health and safety procedures appeared satisfactory at the time of this inspection however some staff still require training in safe working practices, which the proprietor is fully aware of and stated that some courses applied for have been oversubscribed. Risk assessments, accident records, fridge and freezer temperature monitoring charts, staff training and service certificates were reviewed and satisfactory however risk assessments must be undertaken on COSHH products and water temperatures and these be monitored to ensure service users are not at risk from scalding. The risk assessment for supporting an individual with epilepsy must also be reviewed given the number of accidents recorded. Staff spoken with confirmed that there is sufficient staff on duty to perform any manual handling tasks required of them. A health and safety policy is available however was not reviewed on this occasion. It was reported that the Environmental Health Officer has not visited since the home was last inspection however the Fire Officer visited and provided advice on the homes evacuation procedures. The proprietor reported that there are no outstanding recommendations from either authority. A maintenance log is maintained and records seen evidence that the proprietor conducted a health and safety audit of the home in April 06. Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 23 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 x 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 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x 3 2 x Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 24 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 YA9 Regulation 13(4)(b) Requirement Timescale for action 19/06/06 2 YA39 3 YA42 4 YA42 The risk assessment for the management of epilepsy in relation to one individual must be updated in conjunction with healthcare professionals, given the increase in number of accidents caused through seizures. 24(1)(a&b)(2&3) The results of service user satisfaction surveys in addition to stakeholders, advocates and relatives surveys must be compiled and made available. 13(4)(a)(b)(c) Risk assessments must be undertaken on COSHH products and water temperatures and these be closely monitored to ensure service users are not at risk from scalding. 12 (1)(a)13(6) All staff must undertake training in safe working practices. 31/07/06 19/06/06 31/07/06 Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 25 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 YA6 Good Practice Recommendations It is recommended that staff undertake training in person centred planning and all service users be provided with a plan completed in conjunction with service users, advocates, key workers and relatives as appropriate. It is recommended that photographs of service users be attached to the divider cards in the MAR charts folder. It is recommended that induction of new staff be to the LDAF specification. It is recommended that the duty rota be revised to indicate actual working times that staff are on shift and the full names and job roles be stated. It is recommended that care records be condensed with old information achieved. 2 3 4 5 YA20 YA35 YA41 YA41 Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Shervale Home DS0000063187.V293972.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!