Inspection on 02/08/05 for Sherwood House

This inspection was carried out on 2nd August 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sherwood House 26/11/08

Sherwood House 13/02/07

Sherwood House 01/12/05

Sherwood House 15/10/04

Sherwood House 27/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sherwood House Severn Drive Walton on Thames Surrey KT12 3BQ Lead Inspector Miss Marianne Barham Announced Inspection 02 August 2005 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 House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sherwood House Address Severn Drive, Walton on Thames, Surrey. KT12 3BQ 01932 221170 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) Walton on Thames Charities To be confirmed CRH (PC) 31 Category(ies) of Old age, not falling within any other category registration, with number (OP) 31. of places Dementia - over 65 years of age (DE(E)) 4. Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) The age/age range of the persons to be acommodated will be: OVER 65 YEARS. Up to 4 Service Users may be within the category DE(E). Date of last inspection 15 October 2004 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 en-suite 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 H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out at 10.20am by Marianne Barham, lead inspector for the service. The inspection was undertaken over a period of five hours and ten minutes and was the first inspection in the Commission for Social care Inspection (CSCI) year April 2005 to March 2006. The housing manager, Nigel Lucas was present and a total of twelve service users, five members of staff, three visiting relatives, one visiting professional and three voluntary workers were spoken with, and records relating to care of service users and management of the home were examined during this inspection. Several comment cards were received from service users, relatives and involved professionals before this inspection, all of which were complimentary about the care and services provided in the home. What the service does well: What has improved since the last inspection? The home has developed a ‘whistle blowing’ policy that has been given to all members of staff so that they know how to go about raising any concerns they may have about the safety and protection of service users. All members of staff have now had a Criminal Records Bureau (CRB) check carried out on them, meeting a requirement made at the last inspection on 15th October 2004. Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 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 House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 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 House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 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) 2, 3 and 5 Each service user has a contract stating the terms and conditions of residence in the home. New service users and their families are able to visit the home before they move in. Service user’s needs are not assessed adequately before they move into the home. EVIDENCE: All service users are given a copy of the terms and conditions of residence in the home at the time they apply. They are then given another copy on admission to the home, which they sign, this is held at the head office of the charity. The home uses the Standex system for assessing and planning service users care. Pre-admission assessments were examined for several service users. The assessments cover all aspects of service users care needs, however they had not been completed correctly and therefore show little detail of the person’s care, social and emotional needs. Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 Page 9 The importance in carrying out thorough assessments on service users is to be sure that the home can meet their needs. This was discussed with the manager and a requirement has been made that this is done. The home encourages prospective service users to visit the home for dinner or supper initially, leading to an overnight stay. The manager stated that the majority of admissions to the home are for people who originally came for respite care, and that the home would not admit anyone unless their needs could be met. Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 10 Each service user has a care plan, however their individual needs are not fully addressed. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: Care plans for several service users were examined. As with the assessments detailed previously, the Standex system is in place but has not been used effectively. The care plans have little detail, have not consulted the service user or other involved people and have not been reviewed. It was also noted that the plans focused on the physical care needs of the service users, with little attention to their social and emotional needs. These issues were discussed with the manager and a requirement has been made to address them. Throughout the inspection staff members were observed to treat service users with respect and to support them in a dignified and caring manner. Service users and visitors spoken with were complimentary about the care and support received in the home. Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 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 and 13 Service users social and recreational needs are not being met by the home. Service users maintain contact with friends, family and the local community. EVIDENCE: The home has an entertainment diary with events held on a monthly basis. There is no daily or weekly programme of activities in place. There is no system in place for discovering the interests, hobbies, preferences and friendships of the service users. Service users spoken with stated that they enjoyed the monthly events. One service user stated that they would like to have more activities and entertainment. These issues were discussed with the manager and a requirement has been made to address them. All service users are admitted from the Walton on Thames area and many knew each other prior to living at the home. Strong links are maintained with local churches with services being held at the home regularly. A hairdresser and a mobile shop visit weekly. Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 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) 18 Service users are protected from abuse. EVIDENCE: All staff members have received training on adult protection through an independent training organisation and some have also attended the Surrey Multi-Agency training. The home has a newly developed whistle blowing policy that has been put into the staff handbook and given to all members of staff. The home has a copy of the Surrey Multi-Agency Procedures and this is made available to all staff members, who sign to show they have read them. Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 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, 24 and 26 The home is clean, safe and well maintained. Service users bedrooms are comfortable and have their own possessions in them. EVIDENCE: The home is purpose built and this is reflected in the wide walkways and spacious communal areas. The home is furnished and decorated to a good standard and is very clean and tidy throughout. Service users bedrooms are pleasantly decorated and comfortably furnished. They are able to have their own furniture if they wish and all bedrooms are personalised with photographs and ornaments. Service users and their relatives spoken with stated that they are happy with the size and décor of their bedrooms. Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 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 and 29 The numbers and skill mix of the staff team is sufficient to meet the needs of the service users and they are protected by the homes recruitment policy and practices. EVIDENCE: The home has a stable staff team, many of whom have worked at the home for a number of years, providing continuity of care to the service users. The home employs three deputy managers who are registered nurses, senior care workers and care workers as well as domestic and catering staff. The home has a procedure for recruitment and records relating to staff recruitment are kept in the home. A requirement was made at the last inspection that all staff members have a Criminal Records Bureau (CRB) check carried out on them, and that evidence of this is available to audit at the next inspection. CRB certificates were seen for all but two members of staff working at the home and the numbers recorded by the inspector. The two staff members not seen had been applied for but not yet returned, reference numbers were noted for these. Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 Page 15 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) 31, 35 and 38 Service users’ financial interests are safeguarded and their health, welfare and safety is promoted and protected by the home. The home is managed effectively and competently in the absence of a registered manager. EVIDENCE: The home is currently being overseen by the organisations Housing Manager, Nigel Lucas, with the day-to-day management carried out by the deputy managers. All three deputies have worked at the home for several years and are registered nurses. The home is in the process of recruiting a new manager. The home is not involved in service users finances, a small amount of cash for personal expenses is held for each person and robust procedures are in place for the accounting of this. The organisation employs a finance officer to deal with all invoicing of service users or their relatives. Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 Page 16 The home carries out regular health and safety audits and related risk assessments are in place. The staffs training programme incorporates training in all aspects of health and safety and equipment and appliances are tested and maintained regularly. A recommendation was made at the last inspection that a policy on safeguarding service users on contracting the MRSA virus should be developed and it was pleasing to see that this has been done. Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x 4 x 4 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 x x x 3 x x 3 Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 Page 18 NO 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 3 Regulation 14 (1) (2) Requirement All service users must have a full assessment of needs, carried out by a suitably trained person and covering those aspects stated in Standard 3.3 of the National Minimum Standards for Older People. All service users must have a plan of care generated a comprehensive assessment that sets out in detail the actions to be taken by care staff to ensure that all aspects of their health, personal and social needs are met. 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. All care plans are reviewed monthly and any changes recorded. The registered person must produce and carry out, in consultation with the service users, a timetable of regular activities taking into account of the age, abilities, interests and preferences of the service users living in the home. Timescale for action 02/11/05 2. 7.1, 7.2 15 (1) (2) 02/11/05 3. 7.4, 7.6 15 (1) (2) 02/11/05 4. 12 16 (2) (m) (n) 02/10/05 Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 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 Good Practice Recommendations Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 Page 20 Commission for Social Care Inspection 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 © 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 Sherwood House H58 H09 s13787 Sherwood House v227948 020805 Stage 4 ann.doc Version 1.30 Page 21 - 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. 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