Inspection on 19/05/05 for Shervale Home

This inspection was carried out on 19th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Shervale Home 14/09/07

Shervale Home 17/05/06

Shervale Home 21/11/05

Shervale Home 18/07/05

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 1 Shervale Close Penn Wolverhampton WV4 5TU Lead Inspector Rebecca Harrison Unannounced 19 May 2005 10:25 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 V220178 UAI 190505 Stage 4.doc Version 1.30 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 and Mr John Greensill Care Home 6 Category(ies) of Learning Disabilities (4) registration, with number Learning Disabilities over 65 yrs of places (2) Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 4th November 2004 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 V220178 UAI 190505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and commenced at 10.25 a.m. and lasted just over four hours. The Lead Inspector was Rebecca Harrison who was accompanied by Sue Woods, Regulation Inspector. At the beginning of the inspection Mrs Thelma Greensill was present at the home and was later accompanied by Mr John Greensill, Joint Proprietor. The inspection included talking to one service user present at the home, the proprietors, examination of records, case tracking and a full tour of the premises. Mr and 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 of Social Care Inspection (CSCI) on 1st March 2005 as a care home for a maximum of six adults with a learning disability. The last inspection conducted under the national minimum standards and regulations for Adult Placement was undertaken on 4th November 2004. The inspection was announced and conducted by Mr Ian Harris, Regulation Inspector. There were no requirements or recommendations made as a result of this inspection. This is the first statutory inspection undertaken since the home was registered as a care home with CSCI on 1st March 2005. The home was inspected against the national minimum standards for care homes for adults (18-65) and the Care Homes Regulations 2001. 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 being accommodated at the home. The proprietors are still living on site in a registered room situated on the first floor. The proprietors stated that they are looking to move out of the property shortly. What the service does well: Discussions held with Mr and Mrs Greensill demonstrated that they appear 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 at the home, indicated that positive relationships have been developed. Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 6 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 regularly reviewed. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,and 5 The home has a clear admissions procedure in place however, the Statement of Purpose and Service User Guide do not present an accurate reflection of the current service provided at the home. EVIDENCE: Three out of the four people currently accommodated at the home have lived at the home under the Adult Placement Scheme. A fourth person was admitted to the home on 11.04.05, placed by Wolverhampton City Council. The home has a Statement of Purpose and Service User Guide in place and copies of both of these documents were provided to the inspectors. Neither document presents an accurate reflection of the current service offered at this home. A Community Care Assessment was seen on file in addition to a service user plan and a set of personal goals for the individual placed at the home. Mrs Greensill had developed the service user plan and personal goals. The home has a clear admissions procedure in place, which is included in the Statement of Purpose and the Service User Guide. Care records for three people accommodated at the home were scrutinised. Records seen, observations made and discussions held with the registered proprietors indicated that the home is working outside of its category of registration by accommodating people with dementia. Discussions held with Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 9 the providers indicated that the home is unable to meet the individual needs of two of the people currently accommodated at the home. The proprietors reported that the service user recently admitted had a planned admission to the home following a series of introductory visits before making a decision to move into the home on a long term basis. The home is in the process of having contracts reviewed. It was reported that a review for one person had already been undertaken, relating to the service user with the highest of support needs. Mr and Mrs Greensill reported that they were awaiting a contract from the placing authority and to date they had not received any payment for the service user recently admitted. A contract/statement of terms and conditions between the home and service user was not available at the time of this inspection. Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 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 The home is currently unable to demonstrate that they can appropriately meet the care and support needs of the individuals accommodated. EVIDENCE: Care files of three people were scrutinised during this inspection. Files were generally well presented however they contained much of the paperwork supplied under the Adult Placement Scheme (APS). Community Care assessments were available however one was not dated or signed for the person most recently admitted to the home. Care plans and personal goals for the service users had been developed by Mrs Greensill. Care Plans seen were insufficiently detailed and do not provide the staff with the relevant information for care delivery. The manager stated that care plans are currently only reviewed once a year. It was reported that the review for one service user was due in April 2005 but had yet to be carried out. The care plan for one service user stated that additional funding is required for a ‘night sitter’. The current rota demonstrates that only two nights are covered with Mr Greensill carrying out the role. However Mrs Greensill is not ‘sitting’ she is sleeping. It was not possible to establish if the care package funds this additional support. Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 11 One of the service users has regular contact with an independent advocate who visits her either at the day service or at the home. Risk assessments were seen on the care files scrutinised, however these were generic and insufficiently detailed and only covered areas of risk such as falls, eye infections, scalding, mobility and skin breakdown. It was identified that Mrs Greensill has not received training in developing risk management strategies. Mr Greensill stated that he has had previous experience in risk management, however this was not in a social care role, but he was willing to assist in this process. Risk assessments need further development 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. Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 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 standard(s) 12 Service users are supported to access local day service provision so enrich their social and educational opportunities. EVIDENCE: Due to the nature of people’s disabilities none of the current service users access paid employment however, all four people currently accommodated at the home attend a variety of day services five days per week. These day services are Oxley, Albert Street and Stowheath. It was reported that the people thoroughly enjoy attending these day services. Mrs Greensill stated that if a service user did not wish to attend a day service at any time then this choice would be supported and staffing would be available for any individual wishing to remain at home. On the day of this unannounced inspection one individual remained at the home for health reasons. Inspectors had the opportunity to speak with the service user during the visit. She stated that she is happy and likes living at the home but is unable to access the first floor due to her physical disability. For the duration of the inspection the service user remained in her room knitting and watching the television. Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 13 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 Good procedures are in place to monitor service users health, however the home is unable to meet the physical healthcare needs of the people accommodated at the home. The home maintains appropriate records for the administration of medication however may be putting service users at risk by not checking with the GP the appropriateness of some homely remedies used. EVIDENCE: Care plans seen identify that people require assistance and supervision with all daily living tasks and personal care. Due to environmental factors two people are unable to access preferred showering or bathing facilities and are therefore provided with strip washes – see comments made under the environmental section of this report. One service user has technical aids and equipment available to include a hoist, sling, electric bed and wheelchair. Wheelchair ramps to assist with independence and accessibility were seen however these were stored in a cupboard and not in place around the home. It was reported that service users get up from 6am in preparation to attend day services however; people have more flexibility during weekends. Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 14 Care files reviewed evidenced that the health of service users is monitored. Service users are supported to access NHS healthcare facilities and all appointments were clearly recorded on the care files seen. It was reported that three service users are currently on prescribed medication and no one is currently prescribed controlled drugs. A medication agreement was seen on one of the service users care file signed by the service user. The inspector reviewed current MAR sheets. The administration of medication was found appropriately recorded on all occasions. Homely remedies had been hand written on to the sheets although there is no evidence that the GP had been consulted prior to their use. Mrs Greensill stated that the home has a policy for homely remedies in place, however this was not reviewed by the inspectors on this occasion. The medication cabinet is situated in the utility/storage area of the home. An unlabelled glass of ibuprofen was found in the cabinet. Mrs Greensill stated that this medication was to be returned to the pharmacy, as the service user no longer requires such medication. Staff have not received training relating to the safe handling and administration of medicines. Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 15 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. Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25, 27, 28, 29 and 30 The standard of the environment is good providing service users with an attractive and homely place to live however, the physical layout of the home restricts movement and opportunities for at least two service users. The home cannot maintain the dignity and independence of service users because they cannot offer suitable bathing and toilet facilities to meet the individual needs of the service users currently accommodated. The home is placing staff and service users at risk by not providing adequate washing and waste disposal facilities. EVIDENCE: Shervale offers a homely environment however it is considered that it is unsuitable for at least two of the service users living there due to environmental factors and current staffing levels. The home was clean and tidy throughout at the time of the unannounced inspection. Upstairs bedrooms were fully fitted with wardrobes and cupboard space to maximise space. Rooms were bright and airy. Although the home is Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 17 registered for 6 people the manager and her husband are currently living on site. This home could only currently support five service users. The service user in the downstairs bedroom has significantly restricted access to the home, as there are ‘steps’ in to some rooms including into the garden. The steps also pose a risk to a service user with a visual impairment. Mr Greensill stated that he had ramps to overcome this problem but at the time of the inspection they were locked in a shed. It was also evidenced through discussion and review of care plans that at least two service users could not use their showers. The shower downstairs was totally inappropriate for the service user with a physical disability as there is a step into it. It was reported that one service user does not like the shower. However there are not alternative bathing facilities for either of these people. 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 flowerbeds and water features. There was no hand washing facilities in the kitchen. The manager advised that they were not required. However, this is a requirement of the Environmental Health Department. The home has a stair lift brought second hand and maintained by Mr Greensill. In discussions he stated that it could be removed, as it is not used by anybody living at the home. This would provide additional space on the stairs for handrails. COSHH products were stored in the laundry room, however were not locked away. The managers stated data sheets and risk assessments were available to support their use however this turned out not to be the case. Mr Greensill was given details of where to obtain such information. Clinical waste is currently disposed with the domestic waste. Arrangements for emptying bedpans are totally unsuitable. Staff are advised to wash them in the sink. It was reported that soiled clothing is washed in the homes domestic washing machine. Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 18 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 home is failing to safeguard vulnerable service users by not taking up appropriate references and checks prior to staff taking up appointment at the home. The home is failing in its duty ensure that there is sufficient staff, at all times to meet the basic care needs of service users is limiting opportunities for service users to participate in activities, both within and outside of the home. The home is putting individuals at risk by failing to ensure that staff are fully trained to meet the care and support needs of service users. EVIDENCE: Through discussions held with the manager it was identified that the home employs four staff in addition to the manager and her husband. Staff files were minimal and there was information in a variety of locations. The manager could not demonstrate that she had taken up appropriate checks prior to staff starting at the home. One staff member had not had a CRB check. Other staff had been checked while the home was supported under the Adult Placement Scheme. One staff member had two references to support her employment however one staff members reference was inappropriate addressed to ‘whom it may concern’ and other staff had no references on file Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 19 to review. Other documentation as required by schedule 2 of the Care Homes regulations 2001 was unavailable for inspection. The manager was unaware of the storage and destruction guidelines of CRB disclosures. Due to the support needs of one service user the home requires two staff on duty at all times. There was only the manager on site at the time of the inspection although Mr Greensill arrived home after about 30 minutes. The rota was very basic and had not been completed appropriately to demonstrate that the home can maintain this minimum staffing level at all times. The rota suggested that Mr and Mrs Greensill worked very long shifts when all service users are not out attending day services. Certificates of attendance for training were seen on two files reviewed. Training included moving and handling and food hygiene. Other files did not contain certificates to demonstrate training had taken place and there were no staff on duty at the time of the inspection (except Mr and Mrs Greensill) to identify if and when training had taken place. The manager stated that, with the exception of her, no staff had received dementia care training. This is of concern as it was identified that two service users currently have dementia care needs. One member of staff had received manual handling training although it could not be established if it was specific to the needs of the service user who requires the use of a hoist. Other staff have not received the basic manual handling training. Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 20 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 health, safety and welfare of service users and staff are not fully promoted or protected by the safe working systems in place. 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 Greensill has over twenty years experience in the care sector and holds a registered general nursing qualification. (RGN). Mrs Greensill stated that she maintains her PIN and has attended a number of training courses relevant to her post. Mr and Mrs Greensill have accommodated people with learning disabilities in their home for over twelve years under Wolverhampton City Councils, Adult Placement Scheme, prior to becoming a registered care home on 1st March 2005. It is evident through discussions held with Mr and Mrs Greensill that they are both very committed to their roles and the people accommodated at the home. Mrs Greensill must obtain the Registered Managers Award at the earliest opportunity. Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 21 Record keeping systems in the home are in need of improvement. A number of records were found undated and not signed. Information needs to be reviewed to ensure it is up to date and relevant to the registered care home and not an Adult Placement Scheme. Risk assessments were not sufficiently detailed or accurate to demonstrate that they had an effective use in ensuring the health and safety of service users or staff. The manager stated that she had not received training to carry out risk assessments and this was evident as on an assessment in particular, relating to bleach and mouthwash was totally inappropriate. It was positive however, that Mr Greensill has now committed to review all risk assessments and update them. He stated that he had previous experience of the process in his former employment. It was identified through discussion that the home does not have emergency lighting fitted as required by the fire department for a care home, although the manager has acted upon the advice of the local fire officer to have fire doors fitted in all door ways leading onto the stairs, the main escape route in case of fire. The hoist used for one service user who occupies the downstairs bedroom is, according to the manager, serviced by the local Social Services Department. There was no risk assessment to support the use of the hoist and this must be made a priority as space is significantly limited in the bedroom and carers cannot access both sides of the bed. Only one fire door had been fitted with a lock and the access to the loft via a service users bedroom had been boarded up. The manager informed the inspectors that all water outlets were fitted with thermostatically controlled valves. These were not tested on this occasion. Windows checked on the first floor were not fitted with restrictors to ensure the safety of the service users accommodated at the home. The stair gate fitted at the top of the stairs is in place to stop one service user from wandering downstairs at night. A risk assessment must be produced to support its use and include how this restriction impacts on other people living in the house. The outcomes for standard 43 were not fully assessed on this occasion. A certificate of insurance is in place however, this is currently provided through NAPPS for Adult Placement Schemes. The proprietors must urgently review the homes insurance cover ensuring 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 V220178 UAI 190505 Stage 4.doc Version 1.30 Page 22 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 3 2 3 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 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 3 2 1 Standard No 11 12 13 14 15 16 17 x 3 x x x x x Standard No 31 32 33 34 35 36 Score x x 2 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shervale Home Score 2 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x 2 1 2 E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 23 NA 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. Timescale for action 01.08.05 2. 3 The registered person must 01.08.05 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 the care which the home offers to provide. The home must not offer a place to someone whose needs it cannot meet. 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 must be reviewed at least every six months and updated to reflect changing needs; and agreed changes are recorded and actioned. 01.09.05 3. 3 18 (1)(a) 4. 5. 3 5 12(1)(b) 14(1) 5 (b)(c) With immediate effect 01.09.05 6. 6 15 (2) 31.07.05t Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 24 7. 6 15 (1) Schedule 3 (1)(b) 8. 9 13 (4)(b)) 9. 18 12 (4)(a) 10. 18 12 (4)(a) 11. 20 13 (2) 12. 13. 14. 20 20 20 13 (2) 13 (2) 13(2) Care plans 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 reviewed and updated. Personal support must be provided in a consistent manner, to maximise privacy, dignity and independence. Service users must receive additional, specialist support and advice as needed from physiotherapists, occupational therapists etc for aids and adaptations they require to maximise their independence and to safeguard themselves and staff. Medicines in the custody of the home must be handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society and the requirements of the Misuse of Drugs Act 1971. Medicines no longer required must be returned to the pharmacy. All staff administering medication must receive external training which meets standard 20.10. The home must evidence that the GP has been consulted prior to the use of any homely remedies. Current registration arrangements must reflect the number of rooms available for occupancy. 11.07.05 11.07.05 With immediate effect 01.08.05 01.07.05 01.07.05 01.09.05 01.07.05 15. 24 16(1) 23(1)(a) 01.07.05 Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 25 16. 24 23(2)(a) The premises and physical layout 01.08.05 of the home must be suitable for its stated purpose, safe and meet service users individual and collective needs. The home must obtain the professional advice and recommendations of an Occupational Therapist for service users requiring aids, adaptations and equipment. The registered person must ensure the provision of environmental adaptations and disability equipment meets the individually assessed needs of the service users accommodated at the home. COSHH products must be stored securely and be supported by appropriate data sheets and risk assessments. Appropriate arrangements are required to be implemented for the safe disposal of clinical waste. Suitable arrangements and facilities must be available for the washing and disinfecting of bedpans. Handwashing facilities must be available in the kitchen as per the requirements of the EHO. Handwashing facilities must be prominently sited in areas where infected material and/or clinical waste are being handled. Washing machines must have the specified programming ability to meet disinfection standards. The home must have a staff team sufficent in numbers and complementary skills to support the service users assessed needs at all times. 01.08.05 17. 29 23(2)(n) 18. 29 14 (2)) 01.08.05 19. 30 13 (3) 18.07.05 20. 30 23 18.07.05 21. 30 13 (3) 18.07.05 22. 23. 30 30 23 (5) 13 (3) 16 (2)(k) 13 (3) 01.08.05 01.08.05 24. 30 01.08.05 25. 33 18 (1)(a) With immediate effect Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 26 26. 34 19, Schedule 2 19, Schedule 2 18(1) 27. 28. 34 35 Staff files must contain all information as detailed in Schedule 2 of the Care Homes Regulations 2001. All staff employed or volunteers used must have CRB checks. 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 home must consult with the local fire authority in relation to the fitting of emergency lighting. The use of the hoist must be supported by a risk assessment carried out with the support of people qualified to do so. The manager must obtain advice from the fire authority in relation to fitting suited locks to the bedroom doors. The issue of bedroom door locks must be reviewed with appropriate risk assessments and any arrangements detailed in the homes statement of purpose. A risk assessment must be produced to support, or not, the use of the stair lift and appropriate arrangements must 01.08.05 With immediate effect 01.09.05 29. 30. 37 41 9 17 (1), Schedules 1,2,3,4. 31.12.05 01.08.05 31. 42 13 (4) (c) 18.07.05 32. 33. 42 42 23 (4) 13 (4) With immediate effect 18.07.05 34. 42 23 (4) 01.08.05 35. 42 13(4) 18.07.05 Shervale Home E56 S63187 Shervale Home V220178 UAI 190505 Stage 4.doc Version 1.30 Page 27 be made to maintain it if it stays. 36. 42 13(4) All first floor windows must be fitted with restrictors to ensure the safety of the service users accommodated at the home. A risk assessment must be produced to support the use of the stair gate at the top of the stairs and include how this restriction impacts on other people living in the house. The proprietors must review the homes insurance cover ensuring 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. Service users must be provided with toilet and bathroom facilities which meet their assessed needs. 01.08.05 37. 42 13 (4) 18.07.05 38. 43 25 (2)(e) 01.07.05 39. 27 23 (2)(j) 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 V220178 UAI 190505 Stage 4.doc Version 1.30 Page 28 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 V220178 UAI 190505 Stage 4.doc Version 1.30 Page 29 - 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!