Inspection on 16/07/08 for Sherwell

This inspection was carried out on 16th July 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sherwell 13/01/09

Sherwell 17/12/07

Sherwell 12/09/06

Sherwell 03/03/06

Sherwell 25/04/05

Sherwell 22/11/04

Sherwell 25/05/04

Sherwell 05/04/04

Sherwell 17/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE Sherwell St Ives Road Carbis Bay St Ives Cornwall TR26 2SF Lead Inspector Ian Wright and Melanie Hutton Unannounced Inspection 16th July 2008 09:00 X10015.doc Version 1.40 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 Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 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 Older People. 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. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sherwell Address St Ives Road Carbis Bay St Ives Cornwall TR26 2SF 01736 796142 01736 798621 carricklodge@btconnect.com 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) Mr Ronald James Cottam Manager post vacant Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th December 2007 Brief Description of the Service: Sherwell is double fronted Victorian style property, situated on the main road between Carbis Bay and St Ives. The care home offers accommodation and personal care for up to nine elderly people. All people who use the service have their own bedrooms, and all bedrooms have an ensuite toilet and wash hand basin. There is a lounge / conservatory at the front of the care home, which looks out on to the road with the sea in the distance. There are car parking spaces and there is also a lawned area at the front of the property. Mr Cottam, the registered provider does not currently employ a registered manager. He manages the home on a day to day basis directly with the assistance of a senior carer. A copy of the inspection report is available from management on request. A copy of this or previous inspection reports can also be obtained from CSCI on 0845 015 0120 / 0191 233 3323 or via our website at www.csci.org.uk. The range of fees at the time of the previous inspection in December 2007 was £309-£325 per week. There are additional charges e.g. for hairdressing, chiropody, and newspapers etc. Please contact the registered provider to ascertain if there has been any change in these fees. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This unannounced key inspection took place in ten hours in one day. Two inspectors completed the inspection. All of the key standards were inspected. The methodology used for this inspection was: • To case track four people who use the service. This included, where possible, interviewing the people who use the service about their experiences, and inspecting their records. • Informal discussion with staff and other people who use the service. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection such as notifications received from the home (e.g. regarding any incidents which occurred) were used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: This inspection has resulted in the issuing of eighteen statutory requirements. Although an improvement on the last inspection, this is a very high number of statutory requirements. We have referred some of our concerns, particularly Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 6 about some requirements which we have renotified several times, to our enforcement team. In brief, improvement is required to: • Ensure appropriate information about the service provided is developed and issued to people who use the service (and their representatives as appropriate.) • Ensure there is improvement to the care planning system. • Ensure records are stored at the home and available at all times for inspection. • Ensure staff are appropriately trained regarding medication. • Improve opportunities and the provision of activities for people who use the service. • Review and improve food provided to offer more choice and variety. • Improve some aspects of the environmental standards in the home. • Improve policies, procedures and training regarding the management of allegations of abuse. • Improve downstairs bathing facilities • Improve staffing levels in the afternoon and at night. • Improve staff recruitment checks • Improve staff induction and training • Improve management arrangements including the appointment of a registered manager • Improve quality assurance systems • Improve the system regarding the management of residents’ monies. • Improve health and safety precautions. The Commission will monitor suitable action is taken in these areas. Compliance with the statutory requirements issued is required in the timescales set. The commission is concerned that some of the requirements issued have been renotified from previous reports. Action to be taken regarding these concerns is being considered by our enforcement team. 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. The summary of this inspection report can be made available in other formats on request. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information provided to people who use the service, and their representatives, needs improvement so people who use the service have appropriate information about the service they can expect. Assessment procedures need improvement to ensure people’s needs are fully assessed, and the registered provider only accommodates people for whom they are registered to provide care for. This will ensure people’s needs are met appropriately. EVIDENCE: The statement of purpose / service user guide is currently a combined document and this was inspected. It generally provides satisfactory information regarding the service at Sherwell. However, within the document the registered provider does need to provide: • The range of needs that the home intends to meet. For example if the commission agrees with the registered provider that people who have other needs, apart from older persons requiring personal care (for example dementia), this needs to be outlined in the document. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 9 • A copy of the document to all people who use the service (and/ or the persons next of kin; for example if the person lacks capacity or limited understanding). Technically the information issued to people who use the service is a condensed version of the statement of purpose known as the ‘service user guide’. This should contain information as outlined in National Minimum Standard 1.2. However, as long as supplementary information as outlined in the regulations (e.g. statement of terms and conditions of residency / contract is issued), it is satisfactory to provide people who use the service with the current document. The registered provider said each person using the service receives either a contract issued by the registered provider (if their care is funded privately), or from the Department of Adult Social Care (DASC- social services) if this authority funds them. Copies of contracts are kept at the registered provider’s other home and are not readily available for inspection. However, when requested the documentation was brought over to Sherwell. As we stated in the previous report, this documentation (or at least a copy of it) does need to be maintained in the home-as is outlined in the regulations. However the documentation provided was satisfactory. Copies of pre admission assessments were inspected for one person who had been admitted to the home since the last inspection. A senior member of staff completed this, before admission appeared to be arranged. However information gathered can only be judged as adequate. The person was described by staff who we spoke to as having ‘dementia,’ and appeared to exhibit some behaviours associated with this range of conditions. The registered provider said the staff group did not have any information regarding whether a firm diagnosis had been made. Before the person was admitted to the home, the person who completed the assessment, should have ascertained this e.g. via the persons GP. The home is currently only registered to provide care and support to people in need of care due to their age. As long as the person’s needs could be met at the home, the commission may not have objected to admission of the person. However this matter should have been discussed with us first, and appropriate arrangements regarding the registered provider’s registration agreed beforehand. The registered provider needs to clarify what the person’s diagnosis is, and inform the commission if there is a need to vary the home’s current registration. The registered provider must not admit people outside the categories of need the home is registered for, unless there is discussion and agreement with commission first. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. Improvement is required regarding care planning and staff training regarding the management of medication. We feel arrangements need to be improved to offer people higher levels of respect and dignity regarding some aspects of the service. Improvement in these areas will assure people using the service that they can be confident their health and personal care needs are being met in a respectful and dignified manner. EVIDENCE: Care plans for most people who use the service were inspected. Each person has a care plan and there is satisfactory evidence these are being regularly reviewed. The contents of care plans are adequate, and contain some information to assist staff to provide care. However care plans do need to contain more information. For example: 1. There needs to be a manual handling assessment for each person using the service. 2. If there are other risks either the person presents, or significant risks to that person, a further risk assessment needs to be completed. 3. The format currently used is very basic i.e. appears to be a list of tasks the person needs help with. Care plans should clearly direct and inform care to be provided. Information, which should be included in the care Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 11 plan, is outlined in NMS 7.2 /3.3. One of the inspector’s spoke with the senior carer about expanding the current information provided. 4. There needs to be fuller and clearer information regarding medical interventions. Information regarding GP and district nurse involvement appears satisfactory, however there needs to be more information regarding other professional involvement. For example, as stated in the previous inspection report, there should be a sheet in the care plan to document the interventions of other professionals (e.g. optician / dentist). This will ensure staff can track what treatment people have received and ensure people obtain appointments at appropriate frequencies. Although people who use the service, who the inspector spoke to, did not appear to be aware of their care plans, all said care was appropriate and carried out in a manner according to their wishes and needs. All people living in the home looked clean, well dressed and well cared for. People who use the service spoke positively regarding the attitude of staff. Health care support appears to be to a satisfactory standard. People who use the service said they could see a doctor or other medical practitioner when this is necessary. We have outlined above how information regarding medical interventions could be better recorded. We also pointed out that one person’s oxygen mask needed to be cleaned. The senior carer said she would arrange this. The medication policy inspected is satisfactory and appears to contain appropriate information. The medication system was inspected. Since the last inspection the storage of the medication has much improved. Medication generally appeared to be suitably stored and locked away. However, we advised the registered provider to check the cabinet provided for the storage of controlled drugs is satisfactory. The registered provider said the pharmacist advised him it was satisfactory, but he also felt that it might not be correct. We have stated the registered provider consults the current Royal Pharmaceutical Society guidelines, which the home now has a copy or contacts the manufacturer of the cabinet. Stocks kept of medication appears satisfactory. Arrangements regarding the administration, and recording of medication also appear to be satisfactory. At the last inspection in December 2008 we said staff needed to have training regarding the storage of medication. This has partly been complied with as the pharmacist has visited the home and had a discussion with the staff group. Mr Cottam, the registered provider, said he planned to arrange a further training course for the staff group. CSCI provides information regarding what training should be provided. This can be found via the attached web link: http:/www.csci.org.uk/professional/default.aspx?page=7328&key= Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 12 We are concerned about arrangements to ensure the privacy and dignity of people who use the service are maintained: 1. The bathroom and toilet downstairs do not offer appropriate levels of privacy- These concerns are outlined in the ‘Environment’ section of the report. 2. The glass in one of the external doors, which is no longer used, needs to be replaced. The door is in one of the resident’s bedrooms- We also expand on this in the ‘environment’ section of the report. 3. The two front bedrooms, adjacent the conservatory, now do not have full net curtains. This could compromise privacy. 4. We do not feel people are provided with a sufficient choice of food- this is expanded on in the next section of the report 5. At times there is only a male carer on the night shift- and subsequently the choice and privacy of the people who use the service, who are primarily female may be compromised-See the staffing section of the report. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Routines are generally satisfactory to meet the needs of people who use the service, however more opportunities to improve activities and social interaction need to be offered. There also needs to be more opportunity to have a choice of food-particularly in regard to the evening tea arrangements. EVIDENCE: We arrived at the home at 9am. Most people had just had their breakfast, although staff were in the process of assisting people to get up and come down stairs if they wished. Most people spend their time in the lounge / conservatory at the front of the house, although some people choose to stay in their bedrooms, and this is respected. Staff seem supportive, and routines seemed relaxed and unhurried. An activities organiser, from the registered provider’s other home in St Ives, comes once a week on a Thursday morning. Activities on offer include gentle exercise, quizzes and other activities to get people to interact as a group. This seems a really positive session. The registered provider said people are also offered the opportunity to go over to Sherwell’s sister home to attend concerts, or the recent fete. The senior carer said the staff would also be trying to arrange a trip to Marazion (St Michael’s Mount) in the future. The registered provider also said the mobile library visits the home. The registered provider Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 14 said staff do try to organise other activities but it is difficult to motivate people to participate in these. The activities and opportunities outlined above are good. We agree with the registered provider that it would be wrong to force people to participate in activities- people must be free to make a choice. However, some people who live in the home do not feel there is enough to do. People have said this to us at the previous inspection, and at this inspection. Even if people do not wish to participate in group activities, individual one to one activities such as writing a letter, reading the newspaper, manicures, a visit to the local Tesco’s for a cup of tea, or general chit chat may better suit people’s needs. We remain concerned that there is not enough staff on duty in the afternoon. We understand from inspecting the staff rota that there is only one member of staff from either 13:00 or 14:00hrs to 16:00hrs. Not only does this prevent there being satisfactory opportunity for staff to engage more with people, but as outlined in the staffing section, having only one member of staff may mean there is inadequate staffing to provide essential care. There was only one member of staff on duty in the afternoon that could provide any activities, but this person appeared to be tied up with basic, but necessary, care tasks. More activities need to be arranged according to the needs of people who use the service. Subsequently we are repeating the requirement which was issued at the last inspection. If satisfactory staffing is not provided we will consider taking enforcement action. People who use the service said they felt they could exercise choice over their lives; for example where to spend their time in the home, what they could wear etc. We are however concerned about the ability of people to make a choice for example regarding food, as outlined below. People can look after their own money, although there is some need for improvement if they receive assistance as outlined later in the report. It was evident people who use the service could bring their own furniture and belongings into the home. For example bedrooms are individualised with people’s personal belongings such as photographs and ornaments. Relatives and friends can visit people who use the service when they wish. The inspector spoke to several visitors who were all positive about the service provided by staff, and they raised no concerns. The main meal is served at lunchtime. People who use the service said food was nice and of good quality. We did raise concerns at the last inspection that if people did not like the main meal there is no alternative. However, at this inspection the registered provider did say that staff do know if a person does not like something which is prepared, and an alternative will be provided. However, the people we spoke to during this inspection did not appear to know in advance what main meal was going to be provided. Subsequently it seems Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 15 difficult to understand how people will be able to tell staff they do not like what is going to be prepared. We understand that currently there is no choice of meal in the evening. According to records either sandwiches or a hot snack are provided on different evenings. According to the records there can be sandwiches several evenings running. People have expressed to us that they are particularly unhappy about this and find it monotonous. We have suggested, in the previous inspection report, that staff sat down regularly to review the menu with people living in the home e.g. through residents’ meetings. It also would also be quite straightforward to tell people what lunch will be first thing in the morning, so they could receive an alternative or variation if necessary. Also people could be offered either sandwiches or a hot snack each evening. This would be simple, not costly, avoid waste and help to ensure people received an enjoyable balanced diet. It also would resolve this concern shared by us, and people who live in the home. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Suitable policies, procedures, training and staff recruitment checks must be in place. This will assist people who use the service to have greater protection from poor and abusive practice. EVIDENCE: Information regarding what people can do if they have a concern or complaint is in the statement of purpose / service user guide. This information is currently not issued to people who use the service or their relatives. However, since the last inspection, notices have been put up around the home stating how people can make a complaint. Although such an overt display is not necessary, the arrangement is satisfactory. The registered provider said he would try and resolve any complaints and / or concerns if they occurred. People who use the service were positive about staff practices and said they were not aware of any poor or abusive practice. The knowledge of the registered provider of safeguarding issues needs to be developed. From what Mr Cottam has said to us, it appears he would not tolerate any poor or abusive practices. He said he would dismiss any staff as necessary. However, we are not feel totally assured the agreed multi agency procedures would be followed if there was any suspected safeguarding issues, and we need to be assured of this. We think it would be helpful if Mr Cottam attended the adult safeguarding training modules, which are run by the county council. This would not only outline the registered provider’s responsibilities if there was a safeguarding issue, but also would provide guidance what to do if a safeguarding issue arose Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 17 in the home. The senior carer has attended some of this training and does appear knowledgeable what to do. The registered provider’s adult safeguarding (protection) policy still needs to be more detailed. Since the last inspection the registered provider has printed off some information regarding adult safeguarding (protection) from the county council. There is a copy of a leaflet from the county council regarding abuse, and what to do if abuse is suspected. This also includes emergency contact numbers of the relevant authorities. There is also an outline of what types of abuse there are, and the relevant legislation. However, the registered provider, or senior carer need to put all this information together into a coherent policy and procedure, clearly outlining what staff and the registered provider should do if there are any safeguarding issues. Records show that the senior carer has attended adult safeguarding (protection) training recently. The registered provider said two further staff have been booked on to a training course in September. Other staff should attend this training as places become available. The registered provider said no allegations of abuse had been made. No exstaff had been referred to the Protection of Vulnerable Register (POVA) list (A list of people who are considered unsuitable to work with the vulnerable). Procedures regarding the registered provider obtaining Protection of Vulnerable Adults checks (POVA First) and Criminal Records Bureau checks (CRB), as detailed in the ‘staffing’ section, are not satisfactory. This subsequently could put people who use the service at risk of abuse. Evidence of this breach of regulation is contained in the ‘staffing’ section. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 26 Quality in this outcome area is adequate. Although the accommodation is generally to a good standard, improvements are required to some parts of the home and in particular downstairs bathroom facilities. This will help to ensure more appropriate facilities are provided for people who use the service. EVIDENCE: The building was inspected. The building was warm, clean and hygienic on the day of the inspection. Decorations, fixtures and fittings are generally in good condition. However, some of aspects of the facilities, in some of the rooms, do need improvement. For example: 1. Decorations in one of the downstairs ensuite toilets needs improvement. The external door is marked ‘fire exit’, but this is now not a designated fire route, and the door is no longer used. The maintenance man said he would attend to this. 2. Privacy in the front two downstairs bedrooms needs improvement, for example, by having full net curtains. 3. There may be a need for blinds in the front conservatory, or for an electric fan. This room did get very bright and warm on the day of the Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 19 4. 5. 6. 7. inspection. However, the people using it liked to have the front door open which kept it cooler. There should be locks on the doors of en suite facilities (with an over riding facility as necessary). Storage should be improved e.g. Christmas decorations are left in the corner of the conservatory, and a mop and bucket left in the bathroom. An old chair was partially blocking one of the upstairs bedroom doors. Due to some building work in the upstairs bathroom, lots of equipment and building materials were being stored in the boiler room. Two fire doors were propped open. The registered provider said the chair would be taken to the dump, and he would attend to the items stored in the boiler room. The laundry room should be improved. The floor and wall surfaces should be impermeable. An extension is currently nearing completion. This will provide two further en suite bedroom facilities. Work appears to be to a good standard. The registered provider said he was not sure if he would increase the number of people the home is registered to provide care for. He said he may convert two existing bedrooms to increase communal space, and the home would continue to provide accommodation and personal care for nine people. If registration is increased, the registered provider will need to submit an application for a major variation as appropriate. It must be noted this can take up to 3 months to complete. Although decorations, fixtures and fittings of the new extension are generally to a high standard, vinyl floor covering has been put on the floor of the bedrooms and the hallway. It is not acceptable for there to be vinyl floor covering in bedrooms. The commission may agree to this in certain, specific situations, for example, if a person has severe problems with continence (and there was no other reasonable alternative). Usually the ‘default’ position in all bedrooms is for these to have fitted carpets. There are some excellent carpets now available which can be properly cleaned. As these rooms are not currently being used, we are not issuing a requirement regarding this matter on this occasion. However, we do expect the rooms to be carpeted if they are to be for the use of people who use the service. A member of staff is currently occupying one of the new bedrooms. Although this may be satisfactory, the person should use the side exit to come and go, particularly in the evening and at night. This will ensure the privacy of the people resident at the home. There is a conservatory at the front of the home which is used as the lounge. This appears comfortable. Laundry facilities are adequate but some improvements are required to these facilities as outlined above. The kitchen has been refurbished in the last few years, and was clean. Some foodstuffs Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 20 were not being stored correctly and some items were out of date. The registered provider said he would arrange for their disposal. The registered provider said he plans to put a conservatory on the rear of the home, and improve the garden. This will be of genuine benefit to the people who live in the home. Hallways are clean and pleasantly decorated. A stair lift assists people to move to the first floor if required. There is a very small office for the storage of files etc. All bedrooms are of a satisfactory size; all are decorated and furnished to a good standard. Currently locks are not fitted to bedroom doors. These need to be fitted if required by people who use the service. People who move into the home should also be offered a lock on their bedroom door. Current bathing facilities need improvement. The upstairs bathroom has been recommissioned and is now finished to a high standard. However bathroom facility downstairs is not satisfactory. There is a door with frosted glass between the bathing area and a laundry area at the rear of the home. Although staff said the laundry area is not used when people are bathing, it would be possible for someone to get some view of people washing through the frosted glass. The problem has got worse since the last inspection, as the glass in one of the doors is cracked. The gap between the two doors is now wider and there is a gap of approximately one centimetre. This is totally unsatisfactory. The registered provider initially said to us he would not improve the facility, however when we pointed out how the facility had deteriorated, he agreed to improve it. Any improvements must ensure: 1. People using the bathroom can lock themselves in it and nobody from the laundry can enter the bathroom when the bathroom is being used. 2. It is not possible for some one from the laundry to see into the bathroom. We also saw that there is a separate downstairs toilet facility, which has a frosted glass door. This is not acceptable. Staff working in the home said they would not use the facility, as it is possible to see someone who is using it from the corridor. It is essential that people cannot see through the door, and it is modified or replaced. If improvements are not made within the timescale taken we may need to take enforcement action. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels need some improvement to ensure staffing levels are appropriate to provide more activities and support for people who use the service. Recruitment procedures, staff induction and training are poor. Subsequently people who use the service cannot be assured they will be supported by enough staff, and by staff who are appropriately recruited and trained. EVIDENCE: On the day of the inspection the rota stated the following staff were on duty: • Two members of staff on duty from 08:00 to 12:00 • One member of staff on duty from 08:00 to 14:00 • One member of staff from 14:00 to 20:00 • One member of staff from 16:00 to 20:00 There is a night member of staff from 20:00 to 08:00. Mr Cottam said he was completing this shift and told the inspectors it was a ‘sleep in’ duty. A cook is now employed. The cook was on duty from 10:00 to 14:00 Monday to Friday. We have a number of concerns about the current staffing arrangements: 1. When we completed an inspection in December 2007 we said staffing levels needed to be reviewed due to limited opportunities for education, stimulation and recreation for people living in the home. We were particularly concerned there is one member of staff on duty in the Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 22 afternoon alone. We asked for a report outlining the review but this was not subsequently provided. An improvement plan submitted by the registered provider (requested by CSCI to outline what improvements would be made following our last inspection) stated that the registered provider believed staffing levels were satisfactory. 2. The commission has always understood there is a waking night member of staff on duty. Previous CSCI reports clearly state this. We noticed a fold up bed at the home on this inspection. Mr Cottam said this was for the sleep in member of staff, and told the inspectors there had always been a sleep in person at the home. 3. According to the rota; Mr Cottam is rostered to provide night duty 2-3 nights per week. We are concerned that there is not a choice of providing a female member of staff to assist the predominantly female residents with personal care. When we discussed this with Mr Cottam, he said this had not presented a problem. He said usually by the time he was working alone in the evening, the female staff on duty before he came on duty at 20:00, had assisted people to get ready for bed. We are still concerned about arrangements for personal care during the night, and also that people who use the service have limited choice when they have to get ready for bed. CSCI remain concerned that only one member of staff is on duty in the afternoon between 14:00 and 16:00. People who use the service have also told us their concerns This limits choice for people who use the service to have much opportunity for social interaction or activity. We are also concerned that people who use the service subsequently have limited support for mobility and continence during this time, or if they do receive this support, other people in the home have limited or no support. We note that there are a number of very vulnerable people in the home, some of whom need an increasing level of supervision. Our regulations clearly state there must be a suitable number of staff, and people’s health and welfare needs must be met. The regulations are also clear regarding the opportunity for the provision of activities for people who use the service. We did ask the registered provider to provide us with a review of current staffing and this was not completed. We are now issuing a requirement that satisfactory staffing is provided at all times, and staffing is increased in the afternoon. If this requirement is not complied with we will consider taking enforcement action. It is also essential that there is always a waking member of staff on duty at nighttime. This ensures people who use the service can have a member of staff to assist them with personal care as necessary. It also ensures that people who use the service are given other appropriate assistance as necessary for example to maintain their safety. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 23 We understand now that a cook is employed. This is good, as it provides care staff with more opportunity to assist people who use the service during the mornings. However the person only works in the mornings five days a week. This means care staff have to complete laundry tasks, cleaning tasks and food preparation when the cook is not on duty. This is particularly concerning when there is one member of staff alone on duty. The registered provider has also said that he intends to submit an application for registration for a senior carer to become the registered manager. Again, this is a positive initiative as it will provide the home with a clearer management focus, and an additional person who would usually work supernumerary to the care staff. People who use the service were positive regarding the support they receive from care staff. Comments were made that staff were caring and supportive. Staff practices observed by us were positive and helpful to people living in the home. The registered provider appears to have a suitable approach to enabling staff to have the opportunity to obtain a national vocational qualification (NVQ) in care. The Annual Quality Assurance Assessment (AQAA), submitted by the registered provider, states that the majority of staff are currently undertaking various levels of NVQ training. However, we were not provided with a percentage of people who are currently qualified to at least NVQ level 2. There is only evidence, on staff files, that only one person has an NVQ in care. It is important that staff bring in, at least, a photocopy of their certificate evidencing they have an NVQ in care. We inspected the recruitment records maintained regarding staff employed at Sherwell. Despite the requirement issued following our visit in December 2007 these are still not satisfactory. At this inspection we assessed the personnel files of 10 staff members. Records show there are details of individual employment histories on most staff application forms. However there was very little information on the application form, or within people’s files, regarding whether individual staff are physically and mentally fit- as is required by the regulations. This statement on the form should be expanded. Seven of the ten staff files assessed had two written references. One person had one reference, and two people had no references. Both people who had no references commenced employment in July 2008. There should at least be notes on these people’s files confirming the registered provider obtained a verbal reference, and this was satisfactory. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 24 Some staff had proof of their identity on their file, although we could not find this information for four of the staff. We are concerned that one person who is employed comes from outside the European Economic Area. We were presented with this person’s staff file and it did not contain evidence that the person is registered to work here. We would advise the registered provider to check the individual situation with the UK Border Agency to ensure the law is being complied with. For example see: http:/www.bia.homeoffice.gov.uk/employers/preventingillegalworking/complyi ngwiththelaw/post280208/ If these checks have been completed, evidence of them needs to be presented to CSCI at the earliest opportunity. At the previous inspection we issued requirements, which in part, stated all new staff have to receive a Protection of Vulnerable Adults ‘First’ check (POVA First), followed by a full Criminal Records Bureau (CRB) check. Records of these checks, and arrangements for the supervision of staff without a CRB check, are still not acceptable. For example on this inspection the following evidence was obtained regarding non-compliance with the regulations: 1. Four staff that have been employed since the beginning of July 2008 do not have a POVA First check. From the staff rotas, and from our observation on the day of the inspection, three of these staff have worked shifts up to 16/7/08. It is against the law for a person to work in a care home-even if they are supervised- without a POVA First check. We have now notified the registered provider regarding this matter on three occasions. Subsequently we have issued an Immediate Requirement regarding this matter, and have referred the matter to our enforcement team. 2. Three staff did not have a CRB check at all. There is a record two people had competed some shifts up to 16/7/08. One of these people had worked on their own on a night shift. Two further staff only had a CRB from a previous employer. These checks are not transferable and must be recompleted by each new employer. A further two people had a CRB check completed by the registered provider. These showed these staff had a criminal conviction. Although this may not necessarily discriminate against the staff from working in a caring capacity, the registered person should have evidenced that the matter had been discussed with them. A subsequent risk assessment should have been completed to confirm the registered person believed the people were fit to work at the home. 3. We are not satisfied that staff who have not received a CRB check (and in at least one case a POVA First check) are appropriately supervised. For example: • On the day of the inspection it was clear a member of staff without either check, any references, proof of identity etc. was left unsupervised. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 25 • Another person has completed night shifts without either check. However it appears from the rota, the registered provider provided supervision. We have now notified the registered provider regarding performing appropriate recruitment checks on three occasions. Previous inspection reports dating back to at least November 2004 also detail this matter has been an intermittent but ongoing problem. This inspection has found further breaches of the regulations, which have occurred since the last inspection. This could put people who use the service at significant risk, if those employed have not been vetted to be suitable to work with vulnerable people. Subsequently we have issued an Immediate Requirement regarding this matter, and have made a referral to our enforcement team. Training records for ten staff were inspected. By law all staff must have: • Regular fire training in accordance with the requirements of the fire authority. • There must always be at least one first aider on duty (at least at appointed person level) and / or in line with a risk assessment. • All staff must have manual handling training. • All staff must have basic training in infection control. • If staff handle food they must receive training regarding food hygiene. • All new staff must have an induction and there should be a record of this. At the last inspection in December 2007 we issued a requirement for the registered provider to provide appropriate training required by regulation. When we met with the registered provider we outlined why the training is required (e.g. legal obligations to minimise health and safety risk). We said the registered provider needed to put a training programme in place so staff would receive appropriate training within six months of commencing employment. We said urgent action must be taken to ensure training regarding fire, manual handling and first aid be prioritised, and should be delivered no later than in the next three months i.e. 01/04/08. We asked that as part of the improvement plan we requested, the registered provider state how and when staff will receive this training, within the timescale set. The improvement plan which was returned stated: ‘All but one member of staff, are presently undergoing NVQ 2/3 training, fire training for all staff has been completed, we are also investigation first aid training for two members of staff’. Records show the delivery of training is still poor: • Fire Training. There has been some improvement since the last inspection when we found there were no records regarding fire training are kept for any of the staff. At this inspection, five of the ten staff in the sample had a record they had received this training. • First Aid. One member of staff in the sample had a first aid certificate. Despite us asking this issue be addressed as a priority, insufficient action has occurred. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 26 • • • Manual handling. Four members of staff have a record that they have a record of receiving manual handling training. This is delivered internally from the registered manager of the registered provider’s other home. We do not believe this matter has been addressed with the urgency we stated was required. Infection control. One person has a record they have received training in this area. Food hygiene. The records in the ‘Better food, Better Business’ logbook state only one of the current staff employed at the home has received training in this area. Two other staff has certificates on their files stating they had attended training in this area. Although the cook states on her application form that she has training in this area, there is no copy of a certificate available. We are very concerned regarding the lack of compliance of the requirement issued at the last inspection. This is because lack of training in these vital areas could put people who use the service at significant risk. There appears to have been very little action taken since our last report was issued, and the registered provider failed to outline either verbally to us, or in writing satisfactory plans for improving the current situation. Some of our previous inspection reports dating back to at least April 2005, also detail concerns about staff training. Subsequently we have referred the matter to our enforcement team. In regard to staff induction, of the sample, only one of the staff (who commenced employment at the registered provider’s other home in December 2007) had a record of induction. The registered provider has set up an induction file. Within this there is a sample induction checklist (which is satisfactory), and policies which staff should read (e.g. Fire procedure, adult protection, dealing with aggression, health and safety). However, there is no record within it that staff have signed the policies; and no record within the file, or individual staff files, that a formal induction has been completed by other staff. The registered provider said staff do receive an induction. A senior member of staff did appear to be showing a new member of staff around the home, and explaining to the person how to deal with certain procedures. The rota also shows that the person was supernumerary. However, it is essential induction is documented, particularly using the induction package which has been developed. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 27 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered provider is not effective in ensuring the service is managed to meet regulatory requirements. Subsequently management systems need significant improvement and failure to do so could put people who use the service at significant risk. EVIDENCE: Mr Cottam has agreed to register the senior carer as the manager of the home. In the previous inspection report we stated there needed to be a registered manager at the home, as Mr Cottam owned two care homes, and it is clear he cannot manage Sherwell on a full time basis. The legal context for this is outlined in the inspection report dated 17th December 2008, and in the Care Home Regulations 2001. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 28 We are also concerned about the failure of the registered provider to comply with certain regulations. From a review of previous inspection reports dating back to at least 2004, it is clear there has been reoccurring non-compliance regarding some of the regulations. Despite Sherwell being included in the Commission for Social Care Inspection’s Regional Improvement Strategy, after our last inspection in December 2007, there has been insufficient improvement and compliance with the regulations in some areas. Consequently we have had to renotify some requirements, and we have referred some matters to our enforcement team for possible enforcement action. By there being a dedicated registered manager for the home, this person should be able to bring improvement to the service, and a clearer focus on meeting regulatory requirements. Although Mr Cottam has said he will submit an application to have a registered manager, we are repeating the statutory requirement as the application has yet to be submitted and the person has not as yet been deemed as appropriate. The registered provider’s approach to quality assurance is poor. As we outlined in the previous inspection report, a statement regarding the management of quality assurance is included in the service user guide, and there is a quality assurance policy in place. However it is clear that the measures outlined in the policy have not been implemented. There are also on going failures to comply with some of the regulations, despite the commission clearly outlining, through our regional improvement strategy, what improvements are required to ensure compliance with the regulations. We have now notified the registered provider on three occasions regarding this matter, and may take enforcement action if there is not sufficient improvement in future. We have concerns regarding the registered provider’s compliance with our Annual Quality Assurance Assessment process. The AQAA is an annual return required to be sent to the commission by registered person of each service. It provides a statement how the registered provider intends to bring about improvements to the service, and provides us with numerical data about it. The registered provider failed to complete an Annual Quality Assurance Assessment (AQAA) by 6th July 2007 despite a reminder then being sent on 18th October 2007. We sent out a further AQAA in 2008 to be completed. This was not returned to the commission by this inspection, despite a reminder being sent. We warned the registered provider that if the AQAA was not returned within seven days of the inspection we could take enforcement action. The registered provider then returned the AQAA with 24 hours. However Section 1 of the form, about what improvements would be made to the service, did not contain particularly helpful or useful information. Section 2 (data set) was not completed as the registered provider said he did wish to Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 29 complete this. Completion of the AQAA needs to be more comprehensive in the future. Some monies are looked after on behalf of people who use the service. Some records of money kept were kept. However these were not satisfactory. For example the record of transactions was kept on the envelope that the money was contained in. We were concerned that a person using the service was charged for the dry cleaning of a duvet, as they had been incontinent. Although the duvet belonged to that person, such costs of this nature for bedding would usually be met by the registered provider. We were concerned also that £10 was missing from some of the money held on behalf of a person living in the home. We stated in the previous inspection report that money should at least be stored in a cash tin. A suitable accounting system needs to be in place, with receipts kept in regard to expenditure completed on behalf of people using the service. This has not been complied with. We subsequently: 1. Issued an Immediate Requirement for the registered provider to investigate the missing money and provide us with a report. The registered provider has since written to us with a satisfactory explanation. There does not appear to be any financial abuse. 2. Renotified the previous requirement regarding setting up an appropriate system for the management of the monies of people who use the service. If this is not complied with, within the timescale set we will consider taking enforcement action. The registered provider said he or staff do not act as appointee for government financial benefits, for any of the people who use the service. The registered provider said records are kept of fees paid to the registered provider, although these were not inspected on this occasion. The registered provider said currently valuables are not looked after on behalf of people who use the service. The registered provider has a health and safety policy. An accident book is maintained. There is a service agreement in place for the fire system, and the system appears to have been serviced. A recommendation was made by the contractor for the registered provider to upgrade the fire detectors. Fire extinguishers were serviced in August 2007 and a contract is in place. A fire risk assessment has been completed. There are satisfactory records of the testing of fire equipment by staff e.g. call points and emergency lighting. Health and safety risk assessments have been completed. Although there was some information regarding the prevention of legionella, there is no evidence that a risk assessment has been completed or any control measures have been put in place. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 30 The bath chair and stair lift has been serviced within the last year. Gas appliances have been serviced in January 2008. An electrician has examined the electrical circuit. An electrical hardwire certificate has been obtained, but this deems part of the circuit in need of upgrading. Subsequently the current system is unsatisfactory. Therefore remedial work needs to be completed, and a subsequent certificate of compliance obtained. This needs to be forwarded to CSCI. Although there is a thermometer in the downstairs bathroom there is no record of testing of water temperatures. Water temperatures need to be checked and a record maintained, or alternatively thermostatic controls need to be fitted to control the water temperature at least on all baths and showers. Due to the capacity of some of the people living at Sherwell, the risk of scalding is higher than in an ordinary domestic setting. The Environmental Health Officer has previously visited the home regarding food hygiene and health and safety and copies of the reports are maintained in the home. Food handling standards were deemed satisfactory, at the time of the inspection. Some recommendations were made regarding health and safety standards. We have written again to the Environmental Health Department regarding the issues of non-compliance. Training in various aspects of health and safety needs to take place so the registered provider meets legislative requirements (e.g. moving and handling training, fire training). This is outlined in the previous section of the report. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X 1 2 X 2 X 3 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 1 X X 1 Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? YES 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 OP2 OP16 Regulation 5, 6, 22 Requirement A copy of the service user guide needs to be issued to all people who use the service, and where appropriate their next of kin. This also needs to contain information how to make a complaint. Providing suitable information to people who use the service ensures they are aware of the service they pay for, and helps to improve their awareness of their rights and responsibilities. (Timescale of 01/04/08 not met-Second Notification) The registered person must ensure all records, as required by the regulations, are maintained in the care home. For example: 1. Service user contracts / statement of terms and conditions of residency 2. Staff recruitment and personnel records 3. Staff training records This will ensure these records are available for inspection at any time, and are stored Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 33 Timescale for action 01/11/08 2. OP2 OP29 OP30 5, 18, 19 01/11/08 according to the regulations. (Timescale of 01/02/08 not met-Second Notification) 3. OP3 7, 14 The registered provider must not 01/11/08 admit people outside the categories of need the home is registered for, unless there is discussion and agreement with the commission first. The registered provider must clarify the needs of a person who has been admitted to the service since the last inspection. The registered provider must subsequently inform the commission if there is a need to vary the registration of the home. This will ensure the registered provider is legally registered to provide care for the people accommodated, and subsequently appropriate arrangements are made to ensure the person’s needs are met. All people who use the service 01/11/08 must have a comprehensive care plan. This needs to also include a moving and handling assessment, and records of any medical interventions. Comprehensive care plans, which are regularly reviewed, help to ensure people who use the service receive appropriate care according to their needs. (Timescale of 01/04/08 not met-Third Notification) 01/11/08 Staff must receive suitable training, for example as outlined in the CSCI guidelines, regarding the management and administration of medication. This will ensure staff are suitably skilled and knowledgeable to handle and administer DS0000009163.V372031.R01.S.doc Version 5.2 Page 34 4. OP7 15 5. OP9 13(2), 18, 19 Sherwell 6. OP12 OP27 7, 16(2)(m)( n), 18 medication of people who use the service. (Timescale of 01/04/08 only partly met-Second Notification) The registered provider must provide people who use the service with suitable opportunities for example for education and recreation. This will ensure people who use the service can live a more stimulating and interesting life if they wish. (Timescale of 01/04/08 not met 2nd Notification) The registered provider must provide people who use the service with a satisfactory choice and variety of food at meal times. The menu must be reviewed, and a copy of the review forwarded to the commission by the date given. (Timescale of 01/04/08 not met 2nd Notification) 01/11/08 7. OP15 OP14 7, 16(2)(h)(i) 01/11/08 8. OP18 7,12, 13(6) For example: • People who use the service should know what the main meal is in advance, and be offered an alternative / variance of this if they do not like what is on offer. • A hot and cold meal needs to be offered in the evening. 01/11/08 The registered provider must have a clear and comprehensive adult safeguarding (protection) procedure. This will ensure there is clear guidelines what staff should do if there is an allegation of abuse. A copy of the revised policy must be forwarded to the DS0000009163.V372031.R01.S.doc Version 5.2 Page 35 Sherwell commission within the set timescale. (Timescale of 01/04/08 not met 2nd Notification) 9. OP19 OP22 OP24 16, 23 Attend to the issues raised in the 01/11/08 ‘environment’ section of the report. (e.g. decorations in en suite facility, storage, privacy in bedrooms) This will improve decorations, privacy and facilities offered in the home. The downstairs bathroom must 01/11/08 be suitable to meet the needs of the people accommodated in the home. Suitable arrangements must be in place to ensure people can bathe in private. An improved facility will ensure people who use the service can bathe in privacy and with dignity. (Timescale of 28/02/08 not met 2nd Notification) It must not be possible to see people inside the downstairs toilet. The door needs to be modified or replaced. There must be a suitable number 01/11/08 of staff available at all times. For example there must be two members of care staff on duty throughout the waking day (07:00-22:00). This will ensure people who use the service have: • Opportunity to pursue leisure, therapeutic and educational activities. • Suitable assistance with continence and other personal care. • Moving and handling and other needs to keep them reasonably safe. Confirmation of revised staffing DS0000009163.V372031.R01.S.doc Version 5.2 Page 36 10. OP21 OP10 7, 12, 23(2)(j) 11. OP27 7, 12, 13, 16(m)(n), 18, Sherwell 12. OP29 19 Schedule 2, Schedule 4 arrangements, in writing, are required to the commission within the timescale. You are required to carry out appropriate checks prior to staff starting working at the home namely 1. Evidence that CRB checks is applied for in respect of all staff working at the home and that evidence is available for inspection to confirm that these have been applied for. Any staff working at the home have POVA 1st checks prior to commencement of employment. All staff have two written references obtained prior to the commencement of employment and that evidence is available for inspection to confirm that these have been obtained. 16/11/08 2. 3. You must ensure that this requirement is met no later than 16th September 2008. 13. OP30 18. 19 You are required to ensure that all staff receive certificated formal training appropriate to meet the needs of the service users - namely first aid, fire safety, manual handling, food handling and infection control. You must ensure that this requirement is met no later than 10th November 2008. 10/11/08 Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 37 Timescale of 28/02/08 not met 2nd Notification 14. OP30 18, 19 The registered provider must ensure staff induction is documented for each member of staff. This will provide evidence that new staff working in the home have received appropriate help and support to learn the job they are employed to do. The registered provider must employ a registered manager to manage the home. An application for a registered manager must be submitted to the commission. This should help improve the service provided to people who live there, and ensure management arrangements comply with the regulations. Timescale of 01/04/08 (subsequently amended to 1/7/08) not met 2nd Notification The registered provider must develop and implement a suitable quality assurance system. This will help to ensure the service meets the expectations and needs of the people who use the service, and help ensure regulatory standards are met. (Previous timescale of 01/04/08 not met- Third Notification) 17. OP35 13, 20 Where any money is looked after in the home on behalf of people who use the service, this must be stored securely and records maintained which are available for inspection. This will ensure people who use the service can DS0000009163.V372031.R01.S.doc 01/11/08 15. OP31 7, 8, 9 01/11/08 16. OP33 24 01/11/08 01/11/08 Sherwell Version 5.2 Page 38 18. OP38 OP21 7, 13, 16, 23 be more assured that their money is looked after appropriately. (Previous timescale of 01/02/08 not met- Second Notification) The registered provider must 01/11/08 ensure satisfactory health and safety standards to ensure the health and safety of staff and people who use the service: 1. Complete a health and safety risk assessment regarding the prevention of legionella, and ensure appropriate control measures introduced. Control measures and any testing needs to be documented. (Previous timescale regarding risk assessments of 01/04/08 not met. Fourth notification). 2. Where necessary, procedures to check the temperature of hot water (e.g. when bathing) must be introduced, and records maintained. Otherwise thermostatic valves must be fitted, and procedures introduced to check these work correctly. Any checks must be documented. This applies to all bathing facilities. (Previous timescale of 01/04/08 not met. Second notification). 3. Remedial action regarding ensuring the electrical circuit must be completed, and a copy of certification to state the electrical hardwire circuit is safe Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 39 must be obtained. Copies of evidence that the above health and safety checks have been completed must be sent to the Commission for Social Care Inspection within the stated timescale. These measures will help to ensure people live in a safe environment. 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 OP18 Good Practice Recommendations The registered provider should attend adult safeguarding (protection) training. Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 40 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Sherwell DS0000009163.V372031.R01.S.doc Version 5.2 Page 41 - 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. 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