CARE HOMES FOR OLDER PEOPLE
Sherwood House Sherwood House Severn Drive Walton-on-Thames Surrey KT12 3BQ Lead Inspector
Marianne Barham Unannounced Inspection 1st December 2005 09:50 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 Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 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. Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Sherwood House Address Sherwood House Severn Drive Walton-on-Thames Surrey KT12 3BQ 01932 221170 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) sherwood@waltoncharity.org.uk Walton-on-Thames Charities Mrs Catherine Mary Yandell Care Home 31 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (31) of places Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The age/age range of the persons to be accommodated will be: OVER 65 YEARS. Up to 4 Service Users may be within the category DE(E). 15th October 2004 Date of last inspection Brief Description of the Service: Sherwood House is a purpose built home providing accommodation and care for up to 31 older people, 4 of whom may also have dementia. The home is located in Walton on Thames and is close to shops and other facilities in the local community. The home is owned by Walton-On-Thames Charity and all service users come from the Walton on Thames area. The accommodation is arranged over two floors, with the first floor being reached by stairs or two passenger lifts. All bedrooms are single occupancy and all have a kitchenette and ensuite facilities. There are ample communal bathrooms and toilets throughout the home with most having adapted facilities. There are several sitting areas throughout the home and a large dining room. There is a well maintained garden to the rear of the property that is accessible to service users and parking for several cars. The home has access to a mini bus for service users activities and appointments. The home has a hairdressing salon on site and a hairdresser visits the home regularly. A mobile shopping service also visits the home weekly. Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out at 09.50am by Marianne Barham, lead inspector for the service. The inspection was undertaken over a period of four hours and was the second inspection in the Commission for Social care Inspection (CSCI) year April 2005 to March 2006. The deputy manager, Margaret Endicott was present and a total of fifteen service users and five members of staff were spoken with, and records relating to care of service users and management of the home were examined during this inspection. The deputy manager had only recently returned to work following a family bereavement and a member of the staff team had also died suddenly since the last inspection. The inspector would like to offer her condolences and thank the deputy and the staff team for the professional and courteous manner in which they approached this inspection. What the service does well: What has improved since the last inspection?
The home has introduced a timetable of leisure activities based on the needs, abilities and preferences of the service users. Those service users spoken with were happy with the choices on offer and said they enjoyed taking part in them. This meets a requirement made at the last inspection on 2nd August 2005. Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 6 All service users have had their care needs assessed by the home and more detail recorded in their care plans on the support each person needs and these are reviewed monthly. This helps the home to make sure that they are providing the right level of care and support to the service users and meets a requirement made at the last inspection on 2nd August 2005. 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 House DS0000013787.V261390.R01.S.doc Version 5.0 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 Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 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 the following standard(s): 3 All service users have their needs assessed when they move into the home. EVIDENCE: A requirement was made at the last inspection on 2nd August 2005 that the home must ensure that all service users have a full needs assessment undertaken. It was pleasing to see that this has been done. The home uses the Standex system for assessing and planning service users care. Assessments were examined for several service users and found to be detailed and cover all aspects of the individual’s needs. Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 and 9 Each service user has an individual care plan detailing their health, personal and social needs, however there is no evidence to show their involvement in them. Service users’ health care needs are met by the home and the home’s policies and procedures for dealing with medicines protect them, however the receipt of medication needs to be recorded. EVIDENCE: A requirement was made at the last inspection that all service users must have a written care plan generated from the initial assessment and that service users are involved in their care. It was pleasing to see that some work has been done to meet this requirement. Several care plans were examined. There is improvement in the content of the plans, with more detailed instructions to care staff on how to meet needs and there is evidence of ongoing review. It was disappointing to see that the care plans had not been signed by the service user or a representative. A further requirement has been made to address this.
Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 10 It was also of concern to note that a service user who has had increasing and frequent falls in recent months has not had a falls risk assessment carried out. The deputy manager stated that despite input from the GP and the physiotherapist the home is finding it difficult to meet the service users needs owing to the level of supervision this person now requires. A requirement and a recommendation has been made to address these issues. All service users are registered with a local GP practice and specialist healthcare professionals are accessed through these. The district nurses attached to the GP practices visit the home regularly as needed. A domiciliary NHS dentist and NHS optician visit the home every six months or as needed and a private chiropodist visits every six weeks. The home has a policy and procedure in place for dealing with medicines that is in line with the guidance issued by the Royal Pharmaceutical Society. Medication is delivered mainly in dossette packs by a local pharmacy. Medication is administered by, registered nurses, who attend update training regularly. Audits are carried out annually by, the Primary Care team. All medications were seen to be stored securely and appropriately and medication administration charts are maintained accurately. The medication administration records were examined. These are maintained in good order, with no gaps or errors apparent, however the charts are not signed or dated to show when medication is received. A requirement has been made to address this. Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 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 the following standard(s): 12, 14 and 15 Service users experience a lifestyle in the home that takes account of their individual preferences and needs and they are supported to exercise choice and control over their lives. Service users receive a wholesome, balanced diet according their needs and preferences. EVIDENCE: A requirement was made at the last inspection on 2nd August 2005 to produce a timetable of activities appropriate to the needs and preferences of the service users. It was pleasing to see that this has been done. There are now a good variety of activities on offer, with at least one activity offered each day outside of the home as well as those in house. Service users spoken with expressed their satisfaction with the activities on offer. Service users are encouraged and supported to make choices in their everyday lives by the home. Service user meetings are held every six weeks and these are recorded, with actions to be taken followed up at the next meeting. Service users get up and go to bed when they please and choose what to wear and what to do each day. Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 12 The home employs a cook, an assistant cook and a kitchen assistant. The kitchen was viewed and seen to be very clean with a good range of professional standard equipment. The storage areas for food were seen to be appropriate and a good variety of high quality fresh produce was found to stored, with meat purchased from a local butcher and fruit and vegetables from the greengrocer. Members of the kitchen staff have undergone food hygiene and other relevant training and records are maintained for food, fridge/freezer temperatures and cleaning schedules. The menus are planned weekly in consultation with the service users and there is always a choice of two main meals on offer. Service users are asked their meal preferences daily. Service users spoken with were all complimentary about the food they receive, with comments made such as I cant fault it, the foods lovely, I can have what I like, I can choose each day, I really enjoy the food, its always good etc. The home is to be commended for its’ commitment to providing the service users with good quality, nutritious food of their choosing. Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 16 The home listens to and acts upon complaints made by service users, their relatives and friends, however a record of all complaints needs to be kept. EVIDENCE: The home has a complaints procedure in place and this included in the service users guide given to all service users prior to admission. A comments and suggestions box is located in the lobby area for service users and visitors to raise issues or concerns, this is checked weekly and any issues raised are recorded in the persons care plan. The home does not have a dedicated complaints book and therefore has no system for recording complaints made anonymously or from persons not using the suggestion box. A requirement has been made to address this. Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 14 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 the following standard(s): N/A These standards were not assessed at this inspection. Please see report dated 2nd August 2005 for detail on these standards. EVIDENCE: Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The staff team are trained and competent to do their jobs. EVIDENCE: The home has a programme of planned training in place. This is put together in February/March for the coming year. Training needs are identified at induction and through the appraisal process. An external training provider carries training sessions at the home. Individual training records are kept for each member of staff and copies of training certificates are retained as proof of training. Members of staff spoken with confirmed that they receive regular training sessions and told the inspector they had attended courses on first aid, adult protection and food hygiene since the last inspection. Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 The home is run in the best interests of the service users. EVIDENCE: The Trustees of the charity meet once a year with all service users and their relatives to obtain feedback on the service provided. The meetings are recorded along with any actions needed in response to issues raised and sent out to service users and their families. Senior managers carry out quality audits every month, copies of which are kept in the home. As stated previously in this report, service users meetings are held six weekly and recorded. Coffee mornings are held weekly and service users are encouraged to raise any concerns at these. The home also recently carried out a survey regarding the quality of the food provided to them, responses to this were seen to be very complimentary.
Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 17 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 18 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 7 Regulation 15 (1) (2) Requirement Timescale for action 31/12/05 2 7 38 3 9 4 16 All service users are involved as fully as possible in formulating their individual care plan and the plan is signed by them or a representative. 13(4)(b-c) The registered person must carry 31/12/05 15(2)(b) out a falls risk assessment for the named service user and review and update that service user’s care plan as necessary to include detail of how the risk is to be reduced. 13 (2) The registered person must 31/12/05 ensure that all medication received into the home is signed for on the medication chart by the person receiving it and the date recorded. 17(2)Sch The registered person must 31/12/05 4(11) ensure that a record is kept along with actions taken of all complaints received by the home. Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 19 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 7 Good Practice Recommendations It is strongly recommended that the home contacts the Care Manager of the named service user in order to arrange an urgent review of that service user’s assessed needs and of the home’s ability to meet the service user’s needs. Sherwood House DS0000013787.V261390.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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