Inspection on 17/12/07 for Sherwell

This inspection was carried out on 17th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Sherwell 13/01/09

Sherwell 16/07/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sherwell St Ives Road Carbis Bay St Ives Cornwall TR26 2SF Lead Inspector Ian Wright Unannounced Inspection 08:30 17 December 2007 th 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.V345262.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.V345262.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 Position Vacant Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2006 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 Cottram, the registered provider does not currently employ a registered manager. He has managed the home on a day to day basis since 1984. A senior carer is employed who supervises care on a day to day basis. 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 inspection is £309-£325 per week. There are additional charges e.g. for hairdressing, chiropody, and newspapers etc. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place in seven and quarter hours in one day. All of the key standards were inspected. The methodology used for this inspection was: • To case track three people who use the service. This included, where possible, interviewing the people who use the service about their experiences, and inspecting their records. • Interviewing staff on duty about their experiences working in the home. • 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 twenty-five statutory requirements. This is an unusually high number of statutory requirements issued by CSCI, and is of major concern. Action regarding these is required by law within the timescales set. In brief improvement is required to: • Ensure appropriate information about the service provided is developed. This must be issued to people who use the service (and their representatives as appropriate.) • Ensure there is an improved care planning system, and individual plans are reviewed regularly and appropriately. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 6 • • • • • • • • • • • • Ensure records are available at all times for inspection. Improve the management of medication, and ensure staff are appropriately trained regarding this. Review staffing levels, particularly in the afternoons. Ensure there are appropriate staffing levels to assist people who use the service with educational and recreational activities. Review the menu to offer more choice and variety. Improve policies, procedures and training regarding the management of concerns, complaints and allegations. Improve bathing facilities Improve staff recruitment checks Improve staff induction and training Improve management arrangements including the appointment of a registered manager Improve quality assurance systems Introduce a system regarding the management of residents’ monies. Improve health and safety precautions. The Commission will monitor suitable action is taken in these areas. The commission is concerned that some of the requirements issued have been renotified from previous reports. Enforcement action could follow if the registered provider fails to comply with the statutory requirements which have been issued, within the timescales set. 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.V345262.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.V345262.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 are satisfactory, for example, the registered persons ascertain people’s needs can be met before a service is offered to them. EVIDENCE: Copies of the statement of purpose and service user guide were inspected. Some improvement is required to both documents: • The statement of purpose needs to contain information as outlined in schedule 1 (Regulation 4(1)(c) of the Care Homes Regulations 2001. • The service user guide should contain information as outlined in the National Minimum Standards (See NMS 1.2) • Correct information regarding how to contact CSCI. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 9 The registered provider said a copy of the service user guide is kept in the office but has not been issued individually to people who use the service. This needs to occur as outlined in the regulations. Where appropriate the person’s next of kin should also receive a copy. 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 receives a contract issued by the Department of Adult Social Care (DASCsocial services) if they fund them. However copies of contracts are kept at the registered provider’s other home and were not readily available for inspection. Copies of pre admission assessments were viewed for one person who had recently moved to the home, and this appeared to be satisfactory. A copy of a social services assessment was also viewed for another person. Sherwell DS0000009163.V345262.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 poor. Improvement is required regarding care planning and the management of medication. The management of the medication system is particularly poor and needs urgent attention. Improvement in these areas will assure people using the service that they can be confident their health and personal care needs are being met. EVIDENCE: Care plans for most people who use the service were inspected. Most appeared to be adequate, and contained suitable information to assist staff to provide care. However the care plan for one person, who moved to the home in November 2007, was very basic and needs to be completed more fully. Also there must be a manual handling assessment for each person using the service. Improvement to the review of care plans is required. For example care plans were previously reviewed either in January 2007, May 2007, August 2007 or September 2007. These need to be reviewed monthly, and the review appropriately documented. 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. Staff who the Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 11 inspector spoke to also said people were cared for well. 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, and said staff respected their privacy and dignity. 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. There is a record of interventions by the doctor, although other records of interventions from medical professionals (e.g. district nurses/ dentists/ optician’s etc) are only in the daily notes which makes monitoring very difficult. For example there should be a sheet in the care plan to document these interventions, which will also ensure people obtain appointments (e.g. optician / dentist) at appropriate frequencies. The medication system was inspected. Medication is stored in a two section wooden cupboard and a filing cabinet, in the office. One part of the cupboard, and the filing cabinet was not locked. The cupboard contained a significant number of analgesics (including controlled medication). The door to the office was not locked and when the inspector first arrived it was possible to walk into the office and take any of this medication as no staff were around. This room should be locked when not in use. An immediate requirement was issued as a result of this concern. When this matter was raised, the registered provider arranged for the purchase for a lock for the cupboard by the end of the inspection, and said the filing cabinet would now be locked. Written confirmation that appropriate action has been taken is still outstanding. Other controlled medication was stored and recorded appropriately. However the keys for the medication cupboard were contained in a drawer in the office, so even when cupboards were locked, medication is not secure unless the keys are kept-as is appropriate- on the person of the carer in charge. The medication policy is very basic and should be expanded (e.g. it is currently one side of A4 paper). There is a copy of the Royal Pharmaceutical Guidelines regarding the storage, administration, and disposal of medication. However this is now out of date (June 2003). A weblink for the up to date version of this document is attached below: http:/www.rpsgb.org/pdfs/handlingmedsocialcare.pdf Some medication is administered via a monitored dosage system. The operation of the system appears to be generally satisfactory. This medication appeared to be administered and was signed for. Stock levels for some medication needs to be kept under observation as there was some excess for items such as emulsifying ointment. However all medication stocked was within the use by period. A bottle of Glyceryl Trinitrate tablets was in the filing cabinet and did not have a label regarding who it was prescribed for. This must be returned to the pharmacist for disposal without delay. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 12 There is no evidence staff have received any training regarding the management of medication. Training needs to be comprehensive and should include instruction by a pharmacist. CSCI guidelines are available on our website. The attached web link will take the registered provider to the policy: http:/www.csci.org.uk/professional/default.aspx?page=7328&key= Staff must receive appropriate training as a priority. Sherwell DS0000009163.V345262.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 satisfactory to meet the needs of people who use the service, however more activities need to be provided to improve recreational opportunities. Food provided needs some improvement e.g. a choice of lunch and evening teas. This will ensure meals that meet nutritional needs. EVIDENCE: The inspector arrived at the home at 8:30 and staff were in the process of assisting people who use the service to get up and have their breakfast. The morning routine appeared relaxed and organised. It was clear people who use the service could get up when they wanted to, and staff support was professional, relaxed and unhurried. People who use the service seemed to be ‘at home’ and the atmosphere was pleasant. The inspector was able to speak to several people who use the service, and all said they could get up and go to bed when they wanted to. The activities organiser, from the registered provider’s other home in St Ives, comes once a week. The inspector spoke to five of the people who live in the home. Two said they would like more activities and one person said they felt there was ‘nothing to do’. One person who had a sight impairment said they obtained talking books, and the library visited. People said there was no religious service offered. No organised activities occurred on the day of the Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 14 inspection. 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. People who use the service said they felt they could exercise choice over their lives for example how to spend their time, what they could wear etc. People can look after their own money, although there is some need for improvement in this area 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 raised no concerns. The main meal is served at lunchtime. Food served was of good quality and looked appetising. Most people who use the service did not have any concerns about the main meal. However some people complained there was no choice of lunch and if people did not like the main meal, no alternative would be provided. Some said the menu was at times repetitive e.g. cottage pie every week, although the inspector did not check this. It would be a good opportunity to increase participation if staff sat down regularly to review the menu e.g. through residents’ meetings. Several concerns were raised regarding the evening tea arrangements. People who use the service said many evenings only a sandwich was offered with no hot alternative. People said this could be repetitive and boring. The evening tea arrangements therefore need to be reviewed, and a hot alternative e.g. beans on toast needs to be offered. A suitable alternative of main meal also needs to be offered. Food provided needs to be documented. Teas and coffees were offered to people who use the service throughout the day. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 15 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 poor. 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 to assist people who use the service being protected 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. However this information is currently not issued to people who use the service or their relatives. The complaints procedure was not displayed. CSCI contact arrangements need to be amended, as the address given is no longer applicable. The registered provider said no complaints had been received since the last inspection in September 2006. People who use the service said they believed staff would try and rectify any problems if they had these, but several said they did not find the registered provider approachable. CSCI has not received any complaints regarding this service since the last inspection. People who use the service were positive about staff practices and said they were not aware of any poor or abusive practice. One relative described the staff as ‘fantastic.’ Staff the inspector spoke to also said practices within the team were to a good standard. The registered provider’s adult protection policy needs to be more detailed. For example it needs to state specifically what staff or the registered provider would do if any allegations of abuse were made. Records show that staff had not received any training regarding recognising the signs of abuse or how to Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 16 deal with this. Such training needs to be provided to all staff. Such training is available from Cornwall County Council (Department of Adult Social Care). Information regarding this can be found at: http:/www.cornwall.gov.uk/index.cfm?articleid=37718 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.V345262.R01.S.doc Version 5.2 Page 17 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 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 all to a good standard. 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, or whether existing bedrooms would be used to increase communal space, and the home would continue to provide accommodation and personal care for nine people. 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. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 18 There is a conservatory at the front of the home which is used as the lounge. This appeared warm and comfortable. The conservatory is attached to the front of the house, so the windows of the front two downstairs bedrooms look out to the conservatory. However as there are net curtains this did not appear to have a negative effect on privacy. Suitable kitchen and laundry facilities are available. The kitchen has recently been refurbished to a good standard. 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, which although adequate should be locked when not occupied (see for example concerns regarding medication previously). The registered provider said a new boiler had been installed, and a new roof put on the home. 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 are poor. The upstairs bathroom is still not usable as noted in the previous report in September 2006. The room however was accessible, despite being gutted. This could create danger to people who use the service. The registered provider agreed to lock the door to prevent access. The provider said the bathroom would be reinstated shortly as part of the ongoing improvements. At the last inspection it was agreed only eight people would be provided with accommodation until this bathroom was completed. The registered provider is required to provide an additional bathroom facility within the timescale. Failure to do so could result in enforcement action. There is another bathroom facility downstairs. However this 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. This is not acceptable, and at the very least there needs to be a curtain or blind. In regard to the door from the bathroom to the hall, the door is not lockable and there was a hole in the door. There was no towel in the bathroom for example for people to use after washing their hands. This facility therefore must be improved within the timescale set and the matters outlined above addressed. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 19 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 some activities 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 following staffing was provided: • • • • Two One Two One members of staff on duty from 08:00 to 13:00 member of staff from 13:00 to 16:00 members of staff from 16:00 to 20:00 waking night staff from 20:00 to 08:00 The registered provider said he visits the home several times a day, and also does some shifts e.g. the waking night shift on occasions. A senior carer is employed who has some responsibility for supervising care. No cook or cleaner are employed. People who use the service were positive regarding the support they receive from care staff. Comments were made that staff were caring and supportive. One person who uses the service described staff as ‘kindness itself’. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 20 However CSCI are concerned that only one member of staff is on duty in the afternoon between 13:00 and 16:00. Care staff are also responsible for cooking and cleaning. This limits opportunities for people who use the service to have much opportunity for social interaction or activity. Some of the people using the service said they would like to have more activities as outlined earlier in the report. The registered provider however said staff found it difficult to motivate people to participate in activities. The inspector did note however that people did appear to enjoy a chat with the inspector, and at the coffee and tea breaks with staff. The registered provider must review current staffing levels to ensure there are sufficient staff employed to provide activities and / or recreational time with people living in the home. The registered provider has a suitable approach to enabling staff to have the opportunity to obtain a national vocational qualification (NVQ) in care. The registered provider said 2 staff currently have an NVQ, at least at level 2, and another two staff are completing this qualification. Copies of an NVQ certificates need to be kept on staff files so CSCI can validate this. Recruitment checks completed when staff are employed are not satisfactory. The records of five staff were inspected. Records show there are details of individual employment histories on staff application forms. Four of the five staff had two written references. Only one reference was obtained for a member of staff who commenced employment in September 2007. No staff had evidence of proof of their identity as required by the regulations. However, this must have been viewed where an application for a Criminal Records Bureau check was submitted. A copy of one of these documents e.g. driving licence or birth certificate should be maintained on file. The registered provider has now been notified now at least twice regarding the need to improve recruitment procedures. Any further failures to adhere to the regulations in this area could result in enforcement action. Two staff, who had commenced employment since September 2007, did not have a POVA First check (a check required by law which states whether or not they are not on the POVA list). It is a criminal offence to employ somebody who is on this list, and it is a concern that no checks have been made to ascertain this for these two staff. One of these staff was clearly working unsupervised. As outlined in government guidance when a full Criminal Records Bureau (CRB) check is being applied for (this check ascertains the person does not have a criminal record and is therefore suitable to work with the vulnerable), close supervision arrangements must be put in place for the person, until a satisfactory disclosure is returned. The report dated 12th September 2006 detailed a requirement for the registered provider to ensure new staff had a POVA First check. This has not been complied with. The requirement is subsequently renotified. Failure to comply with the requirement within the timescale set could result in enforcement action being taken by CSCI against the registered provider. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 21 Training records for five 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). • 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. Records show the delivery of training is poor as records show in regard to: • Fire Training. No records of fire training are kept for any of the staff. • First Aid. Only one member of staff in the sample had a first aid certificate. Lack of formal training in this area could put residents at significant risk, and the matter needs to be addressed as a priority. • Manual handling. Only one member of staff in the sample had evidence of any manual handling training. Lack of formal training in this area could put residents at significant risk, and the matter needs to be addressed as a priority. • Infection control. No records were kept regarding staff completing this training • Food hygiene. No records were kept regarding staff completing this training It is essential a training programme is in place for all staff to receive appropriate training, for example training required by law, within six months of commencing employment. Urgent action must be taken to ensure staff have appropriate training required by law. It needs to be clearly detailed by the Improvement Plan, which the registered provider will be required to complete, how and when staff will receive this training required within the timescale set. Of the sample, none of the staff had a written record regarding any staff induction. There is a ‘staff guidelines file’ which contains policies and procedures. A timetable of what staff should do on their shifts is also contained in this file. An induction checklist needs to be developed, and a copy submitted to the commission within the timescale. The induction checklist needs to be completed for all staff employed from the date of this report. The inspector spoke to one member of staff who had commenced employment recently. This person confirmed she had received an induction which included her having to read the policies and procedures. She said the registered provider was also supporting her to enrol in an NVQ 3 in care shortly. The person also said she was aware that a CRB had been applied for. She said she felt the people living in the home are well cared for, and did not believe there is any bad practice in the home. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 22 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 are poor and could subsequently put people who use the service at significant risk. EVIDENCE: The commission has reassessed the management arrangements, as part of a review of registration arrangements. At the inspection the current management arrangements were discussed. Mr Cottam owns another home in St Ives where he has an office. He said he calls at Sherwell several times a day. People who use the service said he also does some shifts for example the waking night shift. No registered manager is employed, although a senior carer has responsibility for supervising care. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 23 The commission is concerned that there is no dedicated registered manager at this home. Regulation 8 of the Care Homes Regulations 2001 states the appointment of a registered manager is required: • When the registered provider is an organisation or a partnership. • When the registered provider is not a fit person to manage a care home; or • Where the registered provider is not, or does not intend to be, in fulltime day-to-day charge of the care home. This report also outlines significant failings regarding the current management of the home. Of particular concern are issues regarding health and personal care (e.g. regarding the management of medication), staffing arrangements (including recruitment and training), and issues around management systems (e.g. quality management and the management of health and safety). Although the registered provider appears honest and well meaning, the inspector did have some concerns regarding the registered provider’s attitude about cooperating with the inspection-e.g. initially he said he did not have the time, and would not be around to assist with the inspection. Several of the people who use the service said they did not feel they could approach the registered provider, and he could be abrupt with them at times. Subsequently an application for a registered manager must be submitted to the commission’s Regional Registration Team within three months. The registered provider’s approach to quality assurance is poor. A statement regarding the management of quality assurance is included in the service user guide, and there is a quality assurance policy in one of the files. This states there will be monthly meetings, an annual audit, a quality assurance system based on a ‘Total Quality Management’ approach, and an annual development plan. However there is no evidence this policy has been implemented. This report also illustrates significant breaches in regulatory requirements. The registered provider must develop a satisfactory quality assurance system. A requirement was issued in the previous report dated 12th September 2006. Appropriate action has not been taken, and failure to address this issue within the timescale set could result in enforcement action. The registered provider was requested to complete an Annual Quality Assurance Assessment (AQAA) by 6th July 2007. A reminder was sent on 18th October 2007, but at the time of the inspection this still had not been returned. This must be returned within the revised timescale. Failure to do so could result in enforcement action. Some cash is looked after on behalf of people who use the service. For example the registered provider said money was given to the home by relatives for hairdressing. The registered provider said this money would be kept in a locked cupboard. However records must be kept for this, and the money should at least be stored in a cash tin. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 24 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. Records are kept of fees paid to the registered provider, although these were not inspected on this occasion. The registered provider currently does not look after valuables on behalf of people who use the service. The registered provider has a basic health and safety policy. An accident book is maintained. The fire prevention system was last serviced in August 2007. A fire risk assessment, which was completed in 2007. The fire brigade visited the home in February 2007 and said at the time precautions were satisfactory. However, at the time of this inspection there were no records kept of any checks on the fire system by the registered provider. For example the emergency call points, the operation of fire doors and emergency lighting etc. needs to be checked at intervals recommended by the fire authority. The registered provider said he had recently put some records in storage, and had probably archived the current fire records. However there were two fire books in the office, both of which were incomplete. The registered provider said he would send a photocopy of the required records to the commission, but these have never been received. An immediate requirement was issued at the end of the inspection regarding the registered provider completing the required checks on the fire system in line with guidance issued by the fire authority. There is no record that health and safety risk assessments have been completed. The registered provider has now been notified on three consecutive occasions regarding this matter. Failure to comply with the requirement within the timescale set could result in enforcement action. 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. There is no evidence that the bath lift has been serviced. Records show the stair lift was last serviced on 9/4/2003. This should be serviced at frequencies according to Health and Safety Executive and the manufacturer’s guidelines (usually annually). The registered provider said a new boiler had recently been installed as part of the recent building upgrade. However the last gas certificate available for inspection stated gas appliances had last been checked as safe on 28.11.01. This equipment needs to be serviced annually. There is no record of that portable electrical appliances have been tested, or that the electrical hardwire circuit has been checked as safe. No records are kept regarding checking bath temperatures. Records should be maintained, and the temperature checked before residents have a bath (if for example individuals cannot bathe independently or lack full capacity which may Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 25 put them at a risk of scalding). Otherwise thermostatic temperature valves need to be fitted to baths. The Environmental Health Officer has previously visited the home regarding food hygiene and said, at the time, that procedures were satisfactory. The kitchen appeared clean. The senior carer has attended training regarding the Food Standards Agency ‘Safer Food, Better Business’ standards. The guidelines appeared to have been partly implemented by the previous senior carer, although the system does appear to have lapsed in recent months. This needs to be reintroduced. 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.V345262.R01.S.doc Version 5.2 Page 26 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 1 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X 1 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 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.V345262.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 4, 6 Requirement Timescale for action 01/04/08 2 OP2 5, 6 3. OP2 OP29 OP30 OP31 5, 18, 19 The registered provider must have an accurate statement of purpose for the service. This needs to contain information required by regulation. Such information ensures there is a clear statement of what services the registered person provides. A copy of this information must be forwarded to the commission within the timescale set. 01/04/08 The registered provider must have a suitable service user guide. A copy of this needs to be issued to all people who use the service, and where appropriate their next of kin. 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. A copy of this information must be forwarded to the commission within the timescale set. The registered person must 01/02/08 ensure all records, as required by the regulations, are maintained in the care home. DS0000009163.V345262.R01.S.doc Version 5.2 Sherwell Page 28 For example: • Service user contracts / statement of terms and conditions of residency • Staff recruitment and personnel records • Staff training records This will ensure these records are available for inspection at any time. All people who use the service 01/04/08 must have a comprehensive care plan. This needs to also include a moving and handling assessment, and records of any medical interventions. Care plans need to be reviewed regularly (e.g. preferably monthly), and this review comprehensively documented. Comprehensive care plans, which are regularly reviewed, help to ensure people who use the service receive appropriate care according to their needs. (Previous timescales of 30/11/06 and 30/12/06 not met. Second Notification.) All medication must be kept in a 01/02/08 locked cupboard. Keys must be kept securely. This will ensure the medication of people who use the service is kept safely. A written response of action taken is required to the commission within one week of the inspection. Immediate Requirement (Immediate requirement dated 17/12/07 not fully complied with. Second Notification) Medication held on behalf of 01/02/08 people who use the service needs to be managed appropriately (e.g. according to Royal Pharmaceutical Society DS0000009163.V345262.R01.S.doc Version 5.2 Page 29 4 OP7 15 5 OP9 13(2) 6. OP9 13(2) Sherwell 7. OP9 13(2) 8. OP9 13(2), 18, 19 9. OP12 OP27 9, 16(2)(m)( n), 18 Guidelines.) Issues outlined in the report need to be addressed. This will ensure people who use the service can feel their medication is looked after appropriately. The registered provider must have a suitable medication policy. This will ensure there is a clear framework how the medication system will operate and assure people who use the service that there medication is looked after appropriately. A copy of the policy must be forwarded to the commission within the timescale. Staff must receive suitable training, for example as outlined in the CSCI guidelines provided, regarding the management and administration of medication. This will ensure staff are suitably skilled and knowledgeable to handle and administer medication of people who use the service. 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. Staffing levels need to be reviewed by the registered provider-particularly in the afternoons to ensure this. A report outlining the review, and subsequent action taken, needs to be submitted to the commission by the date given. The registered provider must provide people who use the service with a satisfactory choice DS0000009163.V345262.R01.S.doc 01/04/08 01/04/08 01/04/08 10. OP15 16(2)(h)(i ) 01/04/08 Sherwell Version 5.2 Page 30 11. OP16 OP1 OP2 22 12. OP18 12,13(6) 13. OP18 12, 13(6) 14. OP29 OP18 7, 9, 19. Schedule 2 and variety of food at meal times. Food provided needs to be documented. A choice of lunch and tea must be provided so people who use the service have a more appealing diet. The menu must be reviewed, and a copy of the review forwarded to the commission by the date given. The registered provider must have a suitable complaints procedure, and this must be issued to people who use the service and where appropriate their representatives. This will ensure people know how they can make a complaint if they need to. A copy of the revised policy must be forwarded to the commission within the set timescale. The registered provider must have a clear and comprehensive adult protection procedure. This will ensure there are clear guidelines what staff should do if there is an allegation of abuse. A copy of the revised policy must be forwarded to the commission within the set timescale. All staff must have training regarding the prevention of abuse. This will help ensure staff know how to recognise abusive practice, and know what to do if they believe abuse is occurring. New staff members must not commence care duties until the registered person has received a satisfactory POVA First check (Previous Timescale of 30/10/2006 not met. Second Notification.) A second bathroom facility must be provided. This needs to be suitable to meet the needs of elderly people. The current DS0000009163.V345262.R01.S.doc 01/04/08 01/04/08 01/08/08 01/01/08 15. OP21 23(2)(j) 01/04/08 Sherwell Version 5.2 Page 31 upstairs bathroom needs to be locked so people are protected from harm until work is completed. This will ensure there are satisfactory bathing facilities in the home. (Previous timescale of 30/3/2007 not met Second Notification) The downstairs bathroom must 28/02/08 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. 01/01/08 The registered provider must ensure all staff have recruitment checks required by law. This must include: • Documentation outlined in Schedule 4 of the Care Homes Regulations 2001 such as two written references etc. • A Criminal Records Bureau check which must be obtained before the member of staff carries out unsupervised care of people who use the service. (Previous timescale of 30/12/06 not met. Second Notification) The registered provider must 28/02/08 submit, as part of the home’s Improvement Plan, a schedule of training required by regulation that will be delivered to all staff. This needs to include: • A list of staff employed and what training by law they require (e.g. as outlined in DS0000009163.V345262.R01.S.doc Version 5.2 Page 32 16. OP21 23(2)(j) 17. OP29 19 Schedule 2, Schedule 4 18. OP30 18. 19 Sherwell 19. OP30 18, 19 20. OP31 9 21. OP33 24 the report.) Specific dates when staff will attend this training, so it is all completed, in the next six months • Training regarding fire, manual handling and first aid must be prioritised and should be delivered no later than in the next three months i.e. 01/04/08. The action plan should be received by the commission by no later than the deadline in the next column. Suitable training will ensure people who use the service are supported by staff who are appropriately trained to meet their needs, according to legal requirements. The registered provider must develop a comprehensive induction checklist. This will verify staff have received appropriate basic training before they work on their own. A copy of the checklist must be forwarded to the commission within the timescale set. The registered provider must employ a registered manager to manage the home. An application for a registered manager must be submitted to the commission within three months of the date of this report. This should help improve the service provided to people who live there, and ensure management arrangements comply with the regulations. 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 • DS0000009163.V345262.R01.S.doc 01/04/08 01/04/08 01/04/08 Sherwell Version 5.2 Page 33 22. OP33 24 23. OP35 13, 20 24. OP38 9, 13, 23, 25. OP38 9, 13, 23, help ensure regulatory standards are met. (Previous timescale of 30/12/06 not met- Second Notification) The registered provider must submit its Annual Quality Assurance Assessment to the Commission for Social Care Inspection as required by the regulations. 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. The registered provider must test fire prevention equipment at intervals specified by the fire authority. The registered provider is advised to liaise with the fire authority regarding their requirements, and at what intervals equipment should be tested and by whom. This will help ensure that people who use the service live in a safe environment. Immediate Requirement The registered provider must ensure suitable preventative measures are taken to ensure the health and safety of staff and people who use the service: 1. Health and safety risk assessments (including the prevention of legionella) must be completed, and appropriate control measures introduced. (Previous timescale regarding risk assessments of 30/11/06 not met. Third Notification). 2. A gas certificate must be obtained annually to ensure all appliances are DS0000009163.V345262.R01.S.doc 28/02/08 01/02/08 17/12/07 01/04/08 Sherwell Version 5.2 Page 34 safe. 3. Portable electrical appliances must be tested (at least every two years) 4. The electrical hardwire circuit for the whole property must be tested and a certificate of compliance obtained from a registered and qualified electrician. (At least every five years.) 5. Manual handling equipment must be checked by qualified personnel in line with HSE requirements. Certificates of compliance must be obtained. 6. 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. 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. Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 35 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sherwell DS0000009163.V345262.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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.V345262.R01.S.doc Version 5.2 Page 37 - 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!