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Inspection on 18/07/05 for Shervale Home

Also see our care home review for Shervale Home for more information

This inspection was carried out on 18th July 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Both Mr and Mrs Greensill are very committed to providing a service to the people accommodated at the home. The proprietors have invested in providing service users with an attractive and homely place to live. Observations made between Mrs Greensill and a service user present during the inspection, indicated that positive relationships have been developed. Good links have been established between the home and local day service provisions. Records seen indicate that service users are supported to access NHS healthcare facilities and their health is closely monitored and regularly reviewed.

What has improved since the last inspection?

Since the last inspection Mr and Mrs Greensill have moved out of the home into private accommodation. The proprietors have consulted with numerous professionals in the work of learning disability and agencies such as the Fire Department and Environmental Health in an attempt to provide an environment that meets the needs of the people currently accommodated at the home. A number of risk assessments have been developed to ensure service users are enabled to take responsible risks within a risk assessed framework for all daily living tasks, in-house activities and community activities. The home has made progress towards raising the standard of record keeping systems generally and health and safety procedures to ensure the health, safety and welfare of the service users is being promoted. The proprietors have joined the National Care Homes Association and since the last inspection they have obtained advice from a number of professionals such as the Senior Manager of the Learning Disability Team, Planning and Development officer, Reviewing Officer, Occupational Therapist, Fire Officer and Environmental Health Officer in order to work towards the requirements made by the CSCI at the previous inspection.

What the care home could do better:

Current recruitment practices are placing vulnerable adults at risk. The proprietors must ensure that all recruitment procedures are robust in order to safeguard the people accommodated at the home and that new staff must not commence working at the home until the necessary checks have been undertaken and references obtained. The proprietors need to demonstrate that they are able to fully meet the individual needs of the people accommodated.

CARE HOME ADULTS 18-65 Shervale Home 1 Shervale Close Penn Wolverhampton WV4 5TU Lead Inspector Rebecca Harrison Unannounced 18 July 2005 12:00 th 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. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Shervale Home Address 1 Shervale Close, Penn, Wolverhampton, West Midlands, WV4 5TU 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) 01902 342811 Mrs Thelma Greensill Mrs Thelma Greensill Care Home 6 Category(ies) of Learning Disability (4) registration, with number of places Learning Disability Over 65 years (2) Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No conditions apply. Date of last inspection 19th May 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 was previously part of Wolverhampton City Councils Adult Placement Scheme and was registered with the Commission of Social Care Inspection (CSCI) on 1st March 2005, to provide personal care and accommodation to a maximum of six adults with a Learning Disability. The category of registration is four adults under the age of 65 and two adults over the age of 65. The property has been extended to provide six bedrooms. One bedroom is situated on the ground floor and has a shower facility and a further five bedrooms are located on the first floor. Four have en-suite shower facility and one has en-suite bath facility. 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, which has 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. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspectors arrived at the home at 10.30 am to undertake an unannounced inspection of the service, however on arrival to the home the proprietor, Mrs Thelma Greensill was leaving to take a service user to a health appointment. Therefore it was agreed that Inspectors would return at 12.00. Ms Rebecca Harrison and Mr Michael Moloney, Regulation Inspectors carried out the inspection. The inspection took 2.5 hours and included talking to one service user present at the home, the proprietor, examination of records and a tour of the premises. Mrs Greensill and the service user spoken with were most welcoming and helpful throughout the inspection. The home was previously part of Wolverhampton City Councils Adult Placement Scheme and was registered with the Commission for Social Care Inspection (CSCI) on 1st March 2005 as a care home for a maximum of six adults with a learning disability. An unannounced inspection of this service was undertaken on 19th May 2005. Thirty-nine requirements and one recommendation were made at a result of this inspection. The home or CSCI have not received any complaints in relation to this service since it was registered as a care home on 1st March 2005. At the time of this inspection there were four people accommodated at the home. The proprietor reported that there have been no referrals made since the last inspection of the home. Mrs Greensill has requested that registration be reduced from six people to five in order to provide staff sleep-in accommodation. Not all requirements made at the previous inspection have been assessed during this inspection due to varying timescales imposed by the CSCI for the registered person to comply. Therefore any statutory requirements not assessed have been carried forward. Due to the proprietors demonstrating a commitment to meet the National Minimum Standards a number of original timescales for compliance have been extended and will be assessed at the next inspection of this service. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Current recruitment practices are placing vulnerable adults at risk. The proprietors must ensure that all recruitment procedures are robust in order to safeguard the people accommodated at the home and that new staff must not commence working at the home until the necessary checks have been undertaken and references obtained. The proprietors need to demonstrate that they are able to fully meet the individual needs of the people accommodated. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 7 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 E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 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 standard(s) x EVIDENCE: The timescales imposed by the CSCI for the four requirements made in relation to the Statement of Purpose, Service User Guide, meeting needs and contract have not yet elapsed. However, records seen and discussions held with Mrs Greensill evidenced that the proprietors are working towards meeting the requirements made. These requirements have therefore been carried forward and the original timescale for compliance has been extended by one month. As previously stated in the summary of this report there have been no new referrals made to the home and Mrs Greensill has requested to reduce registration from six to five adults with learning disabilities. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 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 standard(s) 6 and 9 Care planning and risk taking is under review to ensure that staff are provided with the relevant information they require to satisfactory meet service users needs in a consistent and safe manner. EVIDENCE: Mrs Greensill is working towards providing more detailed information in service users care plans. The two care plans seen were more comprehensive. It was reported that the Learning Disability Team at Pond Lane has formally reviewed two of the service users since the last inspection. Mrs Greensill is awaiting the minutes of these meetings. Care plans will be reviewed again at the next inspection of this service. Mrs Greensill stated that a meeting has been arranged for 20.07.05 with Social Services in relation to the person whose needs are not currently being met due to the physical environment. Mrs Greensill agreed to keep the CSCI informed of the outcome of this meeting. A number of risk assessments have been reviewed and updated by the proprietors. Both individual and generic risk assessments will be reviewed at the next inspection of this service. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 11 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) 14 Service users are supported to lead active lives. EVIDENCE: Mrs Greensill has designated a member of staff to oversee activities. An activity file containing various leaflets in relation to activities and places of interest was seen at the inspection. A programme of activities was seen for each service user for the month of July to include West Park Show, a trip to the Art Gallery, B.B.Q, and pub meals. One service user attends Gateway Club every Tuesday evening. A programme of forthcoming activities organised by the Club was seen on her file. It was reported that a staff member is planning to take a service user to church in the near future as requested. The service user at home on the day of the inspection enjoys accessing the cinema and theatre. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 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) 18,19 and 20 The personal and healthcare needs of the service users accommodated has improved with evidence of good multi-disciplinary working taking place. Medication procedures have been improved to safeguard service users. EVIDENCE: A requirement was made at the previous inspection in relation to service users receiving additional, specialist support and advice as needed from physiotherapists, occupational therapists etc. Mrs Greensill reported that the Occupational Therapist has visited the home and provided advice on technical aids and equipment available and appropriate to the needs of the people accommodated at the home. The stair lift has recently been replaced with additional hand rails. On arrival to the home the proprietor was preparing to take a service user to a health appointment. Records seen evidence that service users are supported to access NHS healthcare facilities in the locality and all appointments are clearly recorded on the care files seen. Records indicate that service users’ health is closely monitored and any potential complications and problems are identified and dealt with at an early stage, including prompt referral to an appropriate specialist. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 13 Mrs Greensill stated that since the last inspection she has consulted with professionals based within the Learning Disability Team at Pond Lane for support and advice in relation to the people placed by the local authority at the home. Four requirements were made at the previous inspection relating to medication. Three service users are currently on prescribed medication and no one is currently prescribed controlled drugs. The medication administration records (MAR sheets) were found appropriately recorded and cross-referenced with the medication records held on the care files reviewed. PRN medicines found at the last inspection and no longer required by a service user have since been returned to the pharmacy as requested. Three staff have received training in the administration of medication and records seen evidence that Mrs Greensill has now consulted with the GP in relation to the use of homely remedies and obtained the G.P’s signature. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 14 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) x EVIDENCE: The intended outcomes for the above standards were not assessed on this occasion, however, the home or CSCI have not received any complaints in relation to this service since it was registered as a care home on 1st March 2005. These standards will be reviewed at the next inspection of the service. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 15 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) 24,27 and 30 The proprietors are working towards providing an environment which is appropriate to service users assessed needs; ensuring accommodation is safe, comfortable and tailored to meet the needs of the people living there. EVIDENCE: Since the last inspection the proprietors have consulted with numerous professionals in the work of learning disability and agencies such as the Fire Department and Environmental Health in an attempt to provide an environment that meets the needs of the people currently accommodated at the home. Plans have been drawn up to provide a level access en-suite shower facility for the person with mobility difficulties living on the ground floor. The proprietor reported that social workers have visited the home in addition to an Occupational Therapist and spoken with the service user regarding an alternative placement. Mrs Greensill informed inspectors that a meeting has been scheduled for 20th July 2005 with the Learning Disability Team at Pond Lane, Wolverhampton. Mrs Greensill agreed to keep the Lead Inspector informed of the outcome of this meeting. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 16 Mrs Greensill stated that she has obtained the professional advice of the Occupational Therapist who has since visited the home and made a number of suggestions in relation to the provision of environmental adaptations and the technical equipment available for the individuals accommodated. The proprietors have strived to provide an environment appropriate to the needs of the people accommodated and the inspectors saw a number of changes during a tour of the home. The stair lift has been removed and replaced with a hand banister, the stair gate at the top of the stairs has been removed and privacy locks have been fitted to all of the bedrooms. Mrs Greensill was informed that if a service user requested a key to their own room then a suited lock would have to be fitted and the person given a key to their bedroom unless a risk assessment determined otherwise. Mrs Greensill stated that she has obtained advice in relation to appropriate contrasting colours for the person with a visual impairment. As previously stated the proprietors have since moved out of the home and two bedrooms are now vacant, although one room is currently used for staff sleeping in duties. Discussions took place regarding the vacant rooms and providing a bathroom with a bath facility for people whose preferred choice is bathing. Mrs Greensill agreed to keep the CSCI informed regarding these plans. It was reported that the plans to provide a level access en-suite shower facility for the person accommodated on the ground floor who is unable to access the existing toilet or shower facility have been approved by Environmental Health and the Fire Officer. Further discussions took place in relation to relocating the office facility to provide additional shared space in the second lounge overlooking the rear garden. The proprietors must obtain advice from the local planning department. The CSCI and other agencies must be kept informed of any changes to the environment. Six requirements were made at the previous inspection in relation to hygiene and the control of infection. Mrs Greensill stated that she has delegated responsibility of COSHH products, relevant data sheets and risk assessment of products used to a member of staff. It was reported that this is nearing completion. However, COSHH products are still not being stored securely. This will be reviewed again at the next inspection of this service. The appropriate arrangements are now in place for the safe disposal of clinical waste. The Environmental Health Officer (EHO) recently visited the home at the request of the proprietors in relation to the requirement made for handwashing facilities to be fitted in the kitchen. Due to the home having a dishwasher and other hand-washing facilities in close proximity of the kitchen it was reported that the EHO is happy with the current arrangement. It was reported that arrangements have been made for a plumber to fit a hand-wash basin in the laundry and that the washing machine is able to meet specified disinfection standards. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 17 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) 33,34 and 35 The proprietors are currently seeking training opportunities for staff relating to the service user group to ensure service users are supported by a competent and well-trained team. The homes recruitment practices are potentially placing service users at risk. EVIDENCE: A requirement was made at the previous inspection in relation to having a staff team sufficent in numbers and complementary skills to support the service users assessed needs at all times. It was reported that two new staff have been recruited since the last inspection making the team up to five to include the proprietors. Staff rotas were not reviewed on this occasion and will be reviewed at the next inspection of this service. Discussions took place in relation to the waking night and sleep-in cover. It was reported that the proprietors continue to provide night cover for some nights throughout the week. Mrs Greensill stated that she has sought information on training courses available through Beckminster House in order to provide staff with the appropriate courses required to gain knowledge and the skills required to effectively support the needs of the service users accommmodated at the home. Mrs Greenshill stated that she is seeking a trainer to come into the home to provide mandatory training to the staff team. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 18 It was reported that one staff member has NVQ level 2 qualification and one other member of staff is currently working towards completing the award.This will be reviewed at the next inspection of this service. Each staff member now has a personnel file and these were reviewed during the inspection. Staff files seen did not contain all of the documentation as required by Schedule 2, of the Care Homes Regulations 2001. Current recruitment practices are placing vulnerable adults at risk. Discussions held and records seen evidenced that new staff have been recruited without the necessary PoVA First checks being undertaken and the relevant references sought. Inspectors reinforced that prospective staff must not be recruited until all checks are complete and relevant references in place in order to safeguard the vulnerable people accommodated at Shervale. As previously stated Mrs Greensill is currently seeking training opportunities through a training provider. Therefore the requirement previously made has been brought forward and will be assessed at the next inspection. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 19 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, 41, 42 and 43 The proprietors have a good understanding of the areas in which the home needs to improve to benefit the people accommodated at the home. The home has made progress towards raising the standard of record keeping and health and safety procedures to ensure the health, safety and welfare of the service users is promoted. EVIDENCE: Mrs Thelma Greensill is the registered proprietor and manager of the home. Her qualifications and training details are provided in the homes Statement of Purpose. Mrs Greenhill has over twenty years experience in the care sector and holds a registered general nursing qualification. (RGN). Discussions held, records seen and a tour of the environment evidence that the proprietors are working very hard to provide a good service and suitable accommodation for the people in their care. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 20 The action plan forwarded to the CSCI following the last inspection stated that Mrs Greensill would access the Registered Managers Award as soon as the next course becomes available. This will be reviewed again at the next inspection of the service. Interaction seen between Mrs Greenhill and a service user present at the home throughout the inspection was positive. It was evident that Mrs Greensill has developed a good working relationship with the service user and has a good understanding of the individual needs of the service user. Records seen throughout the inspection have generally improved with the exception of staff recruitment. Records will be reviewed again at the next inspection of this service. Advice has been sought from both the Fire officer and Environmental Health Officer. The Fire Officer has requested that emergency lighting units be fitted to the landing, hallway and the outside entrance. Mrs Greensill stated that these will be fitted shortly. Mrs Greensill stated that she has delegated responsibility of COSHH products, relevant data sheets and risk assessment of products used to a member of staff. It was reported that this is nearing completion. COSHH products are still not being stored securely. The proprietors have drawn up a list of health and safety risk assessments required. Portable appliance testing remains outstanding, however Mrs Greensill stated that this is being sought in addition to mandatory health and safety training through Beckminster House Training Organisation. Windows checked on the first floor have now been fitted with restrictors to ensure the safety of the service users accommodated at the home. Privacy locks have been fitted to service user bedrooms. Mrs Greensill was informed that if a service user requested a key to their own room then a suited lock would have to be fitted and the person given a key to their bedroom unless a risk assessment determined otherwise. Opportunities for staff to access mandatory training is currently being sought. The requirement made at the previous inspection has therefore being carried forward under standard 35. Mrs Greensill stated that she is currently in the process of obtaining insurance quotes for the homes insurance cover as the current insurance is currently provided through NAPPS for Adult Placement Schemes. This must be undertaken as a matter of urgency to ensure insurance is sufficient to cover the registered person’s legal liabilities to employers, service users and third party persons as required for a care home. Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x 2 x 2 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 x x 2 Standard No 11 12 13 14 15 16 17 x x x 3 x x x Standard No 31 32 33 34 35 36 Score x x 2 1 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shervale Home Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x 2 2 2 E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 22 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 1 Regulation 4, 5,6 Schedule 1 12 Requirement The Statement of Purpose and Service User Guide must accurately reflect the service offered at the home. The registered person must demonstrate the homes capacity to meet the assessed needs of individuals admitted to the home. Staff must individually and collectively have the skills and experience to deliver the services and ther care which the home offers to provide. The registered manager must develop and agree with each service user a written contract/statement of terms and conditions as specified in national minimum standard 5.2. Care plans for all service users must be more detailed and contain all aspects of personal, social support and healthcare needs to ensure staff deliver the necessary care required in a consistent manner. Service users must be enabled to take responsible risks within a risk assessed framework, which is recorded and regularly Timescale for action 01.09.05 2. 3 01.09.05 3. 3 18 (1)(a) 01.09.05 4. 5 5 (b)(c) 01.09.05 5. 6 15 (2) 01.09.05 6. 9 15 (1) Schedule 3 (1)(b) 01.09.05 Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 23 reviewed and updated. 7. 24 23(2)(a) The premises and physical layout of the home must be suitable for its stated purpose, safe and meet service users individual and collective needs. COSHH products must be stored securely and be supported by appropriate data sheets and risk assessments. The home must have a staff team sufficent in numbers and complementary skills to support the service users assessed needs at all times.. Staff files must contain all information as detailed in Schedule 2 of the Care Homes Regulations 2001. New staff must not commence work until all of the necessary checks and references sought. Staff and management must receive training in all practices as detailed in NMS 42 and also receive training in areas specific to meet the individual care needs of service users living at the home (e.g. dementia awareness). The registered manager must obtain the Registered Managers Award. All records required by regulation for the protection of service users and the effective and efficient running of the home must be maintained and open to inspection.. Risk assessments must be carried out and outcomes implemented for all practices relating to health and safety within the home. The proprietors must review the homes insurance cover ensuring insurance is sufficient to cover 01.09.05 8. 30 13 (3) 15.08.05 9. 33 18 (1)(a) 01.09.05 10. 34 19, Schedule 2 19, Schedule 2 18(1) With immediate effect With immediate effect 01.09.05 11. 12. 34 35 13. 14. 37 41 9 17 (1), Schedules 1,2,3,4. 31.12.05 01.09.05 15. 42 13 (4) (c) 01.09.05 16. 43 25 (2)(e) With immediate effect Page 24 Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 17. 27 23 (2)(j) the registered person’s legal liabilities to employers, service users and third party persons as required for a care home.. Service users must be provided with toilet and bathroom facilities which meet their assessed needs. 01.09.05 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 Shervale Home E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn 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 E56 S63187 Shervale Home V231691 UAI 180705 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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