CARE HOMES FOR OLDER PEOPLE
Sherwood Clifton Street Rishton Nr Blackburn Lancashire. BB1 4DW Lead Inspector
Susan Hargreaves Unannounced 17 August 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Sherwood Address Clifton Street Rishton Nr Blackburn Lancashire BB1 4DW 01254 829816 01254 829816 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Geoffrey Timmins Mrs Maria Goretti Timmins Ms Michaela Anne Marie Hancock Care Home Only Personal Care (PC) 6 Category(ies) of Physical Disability (PD) 2 registration, with number of places Physical Disability over 65 years of age (PD)(E) 6 Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1 The service should, at all times, employ a suitably qualified and experienced manager who is registered with CSCI. 2 A max of 6 service users requiring personal care who fall into the category of PD(E). 3 Within th etotal number of 6, a max of 2 service users requirning personal care who fall into the category of PD. 4 It is recommended that the registered manager have a job description that clearly outlines their responsibilities and areas of authority in line with the requirements of the Care Homes Regulations 2001. Date of last inspection 08 February 2005 Brief Description of the Service: Sherwood House is a large 2 storey terraced property situated in the small town of Rishton and close to shops and local amenities. The home offers 24 hour personal care for up to 6 people who have a physical disability and require intermediate care. Staff at Sherwood House work in partnership with Lancashire Council Social Services and the National Health Service to provide a rehabilitation programme for the residents. Accommodation is provided in single en-suite rooms on both floors of the home. Access to the first floor is via a stair lift. Communal rooms consist of a lounge, dining room and kitchen. Residents usually stay at the home for about 6 weeks. During this time independence is promoted and progress reviewed weekly. Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four and a half hours. No additional visits have been made since the last unannounced inspection. A tour of the premises took place and staff files and care records were inspected. Members of staff on duty and residents were spoken to. Discussions also took place with the manager regarding issues raised during the inspection. What the service does well: What has improved since the last inspection?
Care planning has improved considerably. A care plan, including a risk assessment relating to nutrition had been written for each resident. The care plans also included details of how any identified risks were to be addressed. This ensures that the care needs of all residents are identified and met. To promote the safe handling of medication appropriate policies and procedures have been developed. Records of the receipt and disposal of medication were kept. Variable doses of medication were recorded on the medicine administration records. An up to date copy of a suitable reference book had been obtained.
Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 6 Admission procedures were thorough. A detailed pre-admission assessment was completed for each resident prior to admission. The rehabilitation programme was well-organised promoting independence for the residents. EVIDENCE: Individual records of two residents were inspected. Both files contained a detailed pre-admission assessment, which had been completed by the social worker and other healthcare professionals. This assessment provided useful information for the care plan. A senior member of staff also visited prospective residents prior to admission. The rehabilitation programme lasted for about 6 weeks and was delivered by the multidisciplinary team. This involved frequent visits from healthcare professionals including physiotherapists and occupational therapists. The multidisciplinary team met weekly with members of staff and the resident. At this meeting progress with the rehabilitation programme was discussed and new goals were set. The multidisciplinary team provided any necessary equipment. Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The health and personal care needs of the residents were identified and met. Care was given in a manner, which promoted the privacy, dignity and independence of all residents. Care staff had not received training in the management of medication potentially putting residents at risk. EVIDENCE: The individual care plans of two residents were inspected. These identified the needs of each resident and explained how these needs were met. Risk assessments relating to nutrition, moving and handling, falls and pressure sores had been carried out. However, neither the risk assessments nor the care plans were signed or dated. Information about how any identified risks were addressed was written in the care plan. This included the use of pressure relieving equipment. A written report about the care and condition of individual residents was completed during each shift. Care plans were reviewed weekly at a meeting involving members of the multidisciplinary team and the resident. At this meeting progress with the rehabilitation programme was discussed and if appropriate new goals set. At the time of the inspection none of the residents were self-medicating. Care staff administered all medication. Although members of staff had received
Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 10 some guidance on the administration of medication from the manager they had not been given formal training. Records for the management of medication were seen to be up to date. Medication was stored in a locked drawer in the office. Controlled drugs were stored in a locked box within this drawer. A controlled drugs register was available and a stock check was satisfactory. The temperature of this area should be checked and recorded daily. Members of staff were observed attending to residents in a patient and friendly manner. One resident said, “The staff are sensitive and respectful.” Assistance with personal care was carried out in the privacy of the bathroom or the resident’s own room. A senior care assistant described in detail how she promoted privacy and dignity for all residents. Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Social activities were well managed and visitors were welcomed into the home at any reasonable time. The daily routine was flexible in order to meet the needs and preferences of residents. Residents were involved in planning the meals. EVIDENCE: Leisure activities included; dominoes, scrabble, cards, watching TV and visits to local amenities. One resident said, “They will take you to the shops.” The daily routine was flexible in order to meet the needs and preferences of residents. One resident said, “ I get up and go to bed when I want.” Visitors were welcomed into the home at any reasonable time. Residents were encouraged to receive visitors in their own room. All the residents said the meals were very good. Menus were planned on a daily basis when the residents had been asked what they wanted to eat. The meal served at lunchtime was wholesome and looked appetising. Residents were encouraged to make drinks and snacks in between meals as part of the rehabilitation programme. Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Complaints would be taken seriously and investigated. Members of staff had a clear understanding of adult protection issues, which protects residents from abuse. EVIDENCE: A copy of the complaints procedure was displayed in the home and included in the service user guide. No complaints have been made to the home or the Commission since the last inspection. Policies and procedures relating to the protection of vulnerable adults were in place. This issue was discussed with one member of staff. She was aware of the procedure and said she would report any concerns immediately. Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home was clean, comfortable and well maintained. A number of internal doors were wedged open potentially putting residents at risk in the event of a fire. Laundry facilities were appropriate for the size of the home. EVIDENCE: At the time of the inspection the home was clean, tidy and well maintained. This provided a safe and comfortable environment for the residents. A planned programme for the routine redecoration and refurbishment of the premises was in place in order to maintain and improve the environment at the home. However, several internal doors were wedged open. This could potentially put residents at risk in the event of a fire. The manager was advised to consult the fire service for advice on obtaining appropriate self-closing devices for these doors. Laundry facilities were located in the kitchen. These were suitable for the size of the home and the needs of the residents. Red alginate bags, which dissolve in the washing machine, were used when necessary to prevent any cross infection from soiled linen. An infection control policy was available. One member of staff was currently on a training course for infection control.
Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Staffing levels were appropriate to meet the assessed needs of the residents. Recruitment procedures were thorough. More than 50 of care assistants had NVQ qualifications. Records of induction training for new members of staff were not kept EVIDENCE: Examination of the duty rota confirmed that a sufficient number of staff were on duty for all shifts in order to meet the assessed needs of the residents. During the night when one carer was on duty a senior member of staff was on call for emergencies. The file of a recently appointed care assistant was inspected. This indicated that all the required pre-employment checks to ensure protection of the residents had been completed. However, a recent photograph had not been obtained and the manager was advised to get one. It was evident that NVQ training was actively encouraged. In addition to the 6 care assistants who had achieved NVQ qualifications one care assistant was working towards level 2. This meant that 78 of care assistants were NVQ qualified. Two care assistants who had achieved NVQ level 2 were working towards level 3. Members of staff also received training in moving and handling and first aid. A fire safety training video had been obtained to enable all members of staff to receive appropriate fire safety training.
Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 15 New employees worked alongside an experienced member of staff for a minimum of three shifts. The manager explained that although an induction programme was in place detailed records of this training were not kept. The manager was advised to check that induction training met the required standard and detailed records were kept. . Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 Systems to effectively monitor the quality of the care given were in place. Not all members of staff involved in preparing meals had received appropriate training. Policies and procedures relating to safe working practices were available. EVIDENCE: The home had achieved the nationally accredited Investors in People award. Feedback from residents was actively encouraged at their individual weekly review meetings. Satisfaction questionnaires were available in each bedroom for residents to complete. This questionnaire had also been translated into Urdu. In addition to this questionnaires were sent to residents from social services. Policies and procedures relating to safe working practices were in place. To ensure the safety of residents fire alarms and emergency lighting was tested weekly. The manager was in the process of completing a fire risk assessment and said it would be finished by September 2005. Although fire drills were held regularly the names of staff present when these took place
Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 17 were not recorded. A fire training video had been obtained to ensure all members of staff understood the principles of fire safety. Records of the routine servicing of equipment were seen. An electrical installation certificate dated 3/7/03 was seen. However, a gas safety certificate was not available. Records maintained in the kitchen included fridge and freezer temperatures. Although the manager explained that food temperatures were also checked records to support this were not available. Members of staff were responsible for preparing and cooking food but only the manager and one care assistant had obtained the basic food hygiene certificate. A member of staff qualified to administer first aid was not on duty for all shifts. Safety procedures were displayed throughout the home. Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 2 Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13(2) Timescale for action The registered person shall make 30 Dec arrangements for the, recording, 2005 handling, safe keeping, safe administration and disposal of medicines received into the care home. All members of staff responsible for the administration of medication must be given appropriate training. The registered person shall after 28 Oct consultation with the fire 2005 authority (c ) make adequate arrangements (i) for detecting, containing and extinguishing fires. Door wedges must not be used. Appropriate self-closing devices should be fitted. Timescale of 27 May not met All staff files must include a 28 Oct recent photograph 2005 The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users (c ) ensure that the persons employed by the registered person to work at the care home 30 Dec 2005 Requirement 2. 19 23(4) (c )(i) 3. 4. 29 30 19(b) Schedule 2 18(1) (c )(i) Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 20 5. 38 13(3) 6. 7. 38 38 13(4) 18(1) (c )(i)(ii) 8. 38 14(4)(a) receive (i) training appropriate to the work they are to perform. Induction training must be fully documented and meet the required TOPSS standard. The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection in the care home. The temperature of cooked meat must be checked and recorded. The registered person shall make suitable arrangements for the training of staff in first aid. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users (c ) ensure that persons employed by the registered person to work at the care home receive (i) training appropriate to the work they are to perform and (ii) suitable assistance, including time off, for the purpose of obtaining further qualifications appropriate to such work. All members of staff involved in the preparation and cooking of food must receive appropriate training in basic food hygiene. Timescale of 31 December 2004 and 27 May 2005 not met. The registered person shall ensure that (a) all parts of the home to which service users have assess are so far as reasonably practicable free from hazards to their safety. A gas safety certificate must be obtained. Timescale of 26 November 2004 and 27 May 2005 not met. 17 Aug 2005 28 Oct 2005 30 Dec 2005 28 Oct 2005 Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 21 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. 2. 3. Refer to Standard 7 9 38 Good Practice Recommendations All care plans and risk assessments should be signed and dated. The temperature of the of the drug storage area should be checked and recorded daily. Records should be kept of all members of staff attending fire drills. Sherwood F57 F07 S52306 Sherwood V240543 160805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 1st Floor, Unit 4 Petre Road, Clayton-Le-Moors Accrington Lancashire. BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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