Inspection on 26/11/08 for Sherwood House

This inspection was carried out on 26th November 2008.

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

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 13/02/07

Sherwood House 01/12/05

Sherwood House 02/08/05

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 06/02/2009.

CARE HOMES FOR OLDER PEOPLE Sherwood House Sherwood House Severn Drive Walton-on-Thames Surrey KT12 3BQ Lead Inspector Joseph Croft Unannounced Inspection 26th November 2008 10:00 26/11/08 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sherwood House DS0000013787.V373299.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. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 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) sherwoodhouse@waltoncharity.org.uk Walton-on-Thames Charities Mrs Kathleen Mary White Care Home 31 Category(ies) of Dementia (4), Old age, not falling within any registration, with number other category (0) of places Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia (DE) The maximum number of service users to be accommodated is 31. Date of last inspection 13th February 2007 Brief Description of the Service: Sherwood House is a purpose built home providing accommodation and care for up to 31 older people, 4 of who may also have dementia. The home is located in Walton on Thames and is close to shops and other facilities in the local community. Walton-On-Thames Charity owns the home 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. The weekly fees at the home are £600. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 Star. This means the people who use the service experience adequate quality outcomes. The Commission For Social Care Inspection (CSCI) (we, us) undertook an unannounced site visit to the service on the 26th November 2008 using the Inspecting for Better Lives (IBL) process. This site visit was undertaken by Mr Joe Croft and took over seven hours commencing at 10:00 and concluding at 17:30. The last key inspection for the service was on the 13th February 2007. People living at the home prefer to be known as residents, therefore this term of reference is used throughout this report. The key Standards for Older People were assessed. The inspection process included a tour of the premises, sampling of residents’ care plans and risk assessments, the viewing of the menu, training records, staff recruitment files, some policies and procedures and health and safety records. The Inspector had discussions with the manager, four members of staff, activity organiser, the cook, five residents and the housing manager who was present from the afternoon onwards. Residents informed the Inspector that they were happy living at the home, and were complimentary about the care they receive from staff, stating that the staff are excellent and they look after them well. Residents informed the Inspector that the food was very good, and they are offered a choice of foods. During observations staff and residents were interacting in an appropriate manner, and residents were being addressed by their preferred names. The Annual Quality Assurance Assessment (AQAA) completed by the manager of the care home has been used as a source of evidence in this report. At the time of writing this report the Inspector had only received one completed survey from a resident. No issues were identified in this survey. The inspector would like to thank the manager, members of staff and residents for their cooperation during this visit. Feedback was provided to the registered manager and the housing officer at the end of this site visit. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Risk assessments must be in place for all residents in regard to daily living, and must include manual handling, falls and nutrition. The registered person must ensure that a local Safeguarding Policy and procedure that is in line with Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 7 the Surrey Multi – Agency procedures is provided for the home. All staff files must include two written references, a full employment history, reasons for gaps in employment and a statement about their mental and physical health. The manager must obtain, from the supplying agency, evidence that all the recruitment checks as stated in Schedule 2 of The Care Home Regulations have been undertaken. A robust recruitment policy and procedure must be produced and adhered to when recruiting staff. Structured induction training must be provided for new staff that is in line with the Skills For Care. Staff must receive the entire mandatory training as required. 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. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 8 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.V373299.R01.S.doc Version 5.2 Page 9 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): Standards 1, 3 and 6 were assessed. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information about the home is provided to people who use the service, however, these documents were not available during the site visit. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: The manager was asked for a copy of the homes Statement of Purpose and Service User Guide during the site visit. The manager told us that she could not locate copies of these and they would have to be sent to the Commission For Social Care Inspection from the head office. At the time of writing this report these documents had not been received, therefore it was not possible to ascertain if they complied with The Care Home Regulations 2001, as amended. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 10 The manager and organisation must ensure that copies of the Statement of Purpose and Service User Guide are available at the care home. A recommendation has been made that copies of these documents should be available at the home for inspection purposes and for residents and visitors to see. Two residents care files were sampled during the site visit. These provided evidence that prospective residents had a pre admission assessment undertaken prior to admission to the home, which included personal, health and social care needs. The manager told us that she undertakes the pre-admission assessments to ensure that only residents whose needs can be met are admitted to the home. All prospective residents are encouraged to visit the home to meet other residents and staff. The home has a referral and admission policy that was last reviewed in June 2008. During discussions some residents told us that they remember visiting the home before deciding to move in and that a meeting took place with the manager. One resident stated that they remember having an assessment undertaken. The manager told us that the home does not offer intermediate care. The Annual Quality Assurance Assessment (AQAA) informs that residents are admitted following a full assessment to ensure a positive placement. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have care plans in place, however, these require further developing to ensure their physical and health care needs are met, and risk assessments in regard to daily living must be developed. Residents are protected by the home’s storage and administration of medication procedures, however, some issues require addressing. EVIDENCE: Two care plans were viewed during the site visit. The home uses the Standex system and included information in regard to the next of kin, GP, diagnosis, life story, activities, personal history, personal hygiene and dressing. Information provided in the care plans was limited. Only one care plan had information in regard to their dietary needs. There was no information in regard to the personal preferences of residents, their sight, hearing, communication, medication, mental state, sleeping patterns or nutrition, although monthly weights were being recorded. Discussions took place with the manager in Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 12 regard to the lack of information. The manager was advised that the care plans need to be more person centred, and provide as much information as possible about the resident to clearly inform the reader how the identified needs are to be met. A recommendation in regard to this has been made. Care plans had been signed by residents and had been reviewed on a monthly basis. This was in line with a requirement made in the last inspection report. However, review notes only state No changes. These require more information to evidence they are being appropriately reviewed. Daily notes were being recorded in the two care plans viewed. During discussions all but one resident told us that they were not aware of the care plan. This was discussed with the manager who told us that this is due to their age and memory loss, however, relatives are aware of the care plans. One resident told us they knew they had a care plan but could not remember what was in it. There was a lack of risk assessments in the care plans viewed. Care plans had identified mobility issues but there were no risk assessments in regard to this. It was noted that one resident used a bed rail, walking frame and a wheel chair but there were no risk assessments in place for these. Further discussions took place with the manager in regard to this, and that risk assessments for the ageing population of the home must be developed. A requirement has been made that risk assessments must be in place for all residents in regard to daily living, and must include manual handling, falls and nutrition. During the site visit one resident had gone missing. Staff immediately notified the manager and a search commenced. The police were also notified. The resident was found safe and well and returned to the care home. Discussions took place with the manager in regard to this resident and the need for a risk assessment to be produced, as this was not the first time this person had wandered off. During a telephone conversation on the following day of the site visit, the housing manager was reminded that a Regulation 37 Notification must be completed and forwarded to the CSCI in regard to this incident. From discussions with staff and residents, and from viewing records, it was clear that residents have access to all health care professionals as required. These include a General Practitioner, District Nurse, Dentist, Optician and Chiropodist. Staff informed the Inspector that records of monthly weights for residents are maintained. During discussions residents told us that the GP visits the home, and sees them in the privacy of their bedrooms. They can go to the surgery if they wish to and access all other health care professionals when they need to. Residents told us that they always receive their medication on time. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 13 The home follows the organisation’s medication policy and procedure that was last reviewed in June 2008. During the site visit the local pharmacist arrived to undertake an inspection of the storage of medication, therefore we did not assess Standard 9. However, we did receive feedback from the pharmacist at the end of their inspection who told us that the storage of medication is good, and the Medication Administration Record sheets (MARs) were being appropriate maintained, however, there had been an omission on the MAR sheet. Staff at the home had received training in regard to medication, and the pharmacist was recommending further training in regard to the care of medications. Controlled Drugs (CD) are being appropriately stored and a CD register is maintained and being signed by two members of staff. The home will receive a copy of the pharmacist report with their recommendations that must be addressed by the home. The home maintains records of medicines received and returned to the Pharmacist. This was viewed during the site visit. Staff informed the Inspector that they respect residents’ privacy and dignity through knocking on bedroom doors, calling residents by their preferred names and providing personal care in the privacy of their bedrooms and bathrooms. Evidence of these practices was observed during this site visit. Residents stated that the staff look after them well, and that they are always treated with respect. The AQAA informs that they ensure residents are treated with respect and dignity, only trained senior staff control medication and that professional advice is sought if required in regard to the health needs of residents. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 14 and 15 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with opportunities to improve their lifestyle, and where possible they are able to maintain contact with family. Special dietary needs are catered for. Meals are varied and choices are offered ensuring that residents receive an appealing and balanced diet. EVIDENCE: The home employs an activity co-ordinator who organises activities from Monday to Friday. This person currently works fifteen hours per week, but during discussion we were told that the manager could increase this if they thought there was a need to do so. The activity coordinator told us that activities provided include skittles, bowling, magnetic darts, quoits, scrabble and reminiscence sessions with a local University. The home owns its own transport therefore trips outside of the home take place. During the site visit an activity list was clearly displayed on the notice boards. The home has regular visits from external entertainers that residents enjoy. The home has Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 15 joined the National Association for the Provision of Activities (NAPA) and receives newsletters from them. Activities were recorded in residents care plans sampled during the site visit. During discussions residents and staff told us that activities are provided every day, and residents can choose whether or not they wish to take part. Photographs were displayed on the notice boards of activities that have taken place, and included the recent 100th birthday celebrations of one of the residents. A local church leader visits the home on the third Saturday of each month and provides a communion service. During discussions, staff and residents told us that there are no restrictions on visitors to the home, although visits during meal times are discouraged. This was confirmed during discussions with residents who told us that they see their visitors in private and go out with them if they wish to. Residents receive their own mail and most bedrooms visited had a land line telephone. The home has a four-week rolling menu that includes meat, fish, pasta, rice, vegetables and desserts. Each meal provides a choice for residents. During discussions the cook told us that there is always a choice of meal offered, and special diets are catered for. Two surveys have been undertaken to ascertain the residents views in regard to the meals provided, and if there were any concerns the care staff would report to the cook immediately. Lunch was observed and this was a relaxed unhurried occasion with residents sitting at tables conversing with each other. Staff were available in the dining room, but could be more proactive ensuring that any resident requiring support received this. This was discussed with the manager. Residents told us that the food is very good and that drinks and snacks are available throughout the day. There were water dispensers throughout the home and residents were provided with drinks and biscuits during the site visit. The AQAA informs that social activities have been increased since the employment of an activity coordinator, visiting times are open throughout the day although visits at meal times are discouraged, and a choice of meals is provided. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a complaints system that enables residents and their families to raise concerns, however, this requires reviewing. Staff having training and an understanding of adult protection issues protects residents, but the recruitment procedures of the home do not fully protect people using the service. EVIDENCE: The Commission For Social Care Inspection has not received any complaints in regard to the care home during the last twelve months. The home has a complaints procedure in place that includes the timescale for responding to complainants. A copy of this was displayed on the notice board outside the office. It was noted that this was the only place in the home that the complaints procedure was on display. This document requires reviewing as the contact details for the CSCI were out of date and the procedure needs to be clear that complainants can go directly to the manager of the home. A recommendation has been made in regard to this. Some residents stated they would talk to the manager if they wanted to make a complaint, and they had seen the complaints policy. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 17 The manager has recently purchased a complaints book for the home that records the date and nature of the complaint, actions taken, the outcome and the date feedback was provided to the complainant. The AQAA informs that one complaint had been received during the last twelve months, but the manager could not locate the paperwork for this. The manager told us this was dealt with before the complaint book was purchased, and this was the reason for obtaining the book. The one survey received from a resident informs that they know how to make a complaint. The Commission For Social Care Inspection has not received any Safeguarding issues in regard to the home since the last inspection. The home had a copy of the Surrey Multi – Agency Safeguarding procedures of January 2008 that were available for staff to read. However, the home did not have a local policy and procedure for staff to follow. This was discussed with the manager and housing manager, and a requirement has been made that a local Safeguarding Policy that is in line with the Surrey Multi – Agency procedures must be provided for the home. Scenarios in respect of abusive situations were discussed with four members of staff and the manager. They were able to demonstrate an understanding of Safeguarding Adults issues, and care staff stated they had read the whistle blowing policy but could not recall reading a local Safeguarding policy. The manager provided written evidence that ten care staff had attended training in regard to Safeguarding Adults in October 2008. Evidence of certificates for these were viewed in three staff training files sampled during the site visit. Eight staff had last received this training in 2005. The managers file was not available during the site visit therefore it was not possible to evidence training undertaken in regard to Safeguarding Adults. The manager told us she could not remember the exact date of this training. A recommendation has been made that all staff, including the manager, should be provided with regular refresher training in regard to Safeguarding Adults. The current recruitment procedures of the home do not ensure that residents are safeguarded from abuse. Requirements have been made in regard to this under the Staffing section of this report. The AQAA informs that all staff are being updated in training on abuse, and that each resident has a copy of the complaints procedure. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible with a pleasant and homely atmosphere. EVIDENCE: A tour of the premises and the sampling of residents’ bedrooms were undertaken during the site visit. Sherwood House is a purpose built home providing accommodation and care for up to 31 older people. 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. The Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 19 manager told us that due to the changing needs of the ageing population, the kitchen areas of the bedrooms will be removed as and when they become vacant. There are communal bathrooms and toilets throughout the home. There are some assisted baths and walk in showers, however, the manager and housing manager told us there is a refurbishment programme that is due to commence in 2009. This includes ensuring that all other bathrooms have assisted baths. Communal baths/showers and toilets had liquid soap dispensers and paper towels. There are several sitting areas, known as bays, throughout the home that were furnished with sofas and armchairs. These are also to be redeveloped as part of the refurbishment of the home. There is a large dining room, hairdressing salon, laundry and a garden to the rear of the property. Bedrooms viewed during the site visit were appropriately decorated and furnished. Bedrooms contained the personal possessions of residents including their own furniture and family photographs. Residents told us they like their bedrooms and have all they need. One resident stated, It is better than a hotel. It was noted that one bed requires attention due to the creaking noise it was making. This was discussed with the manager who told us this would be attended to, and that all beds in the home are being replaced. The home now has a locked cupboard for the safe storage of Control Of Substances Hazardous to Health (COSHH). This was in compliance with a requirement made at the previous inspection. Further discussions took place in regard to the refurbishment plans for the home. We were told that a meeting is being held on the 5th December to finalise the plans with the architects, and that work is to commence in 2009. The plans are to include the refurbishment of three bathrooms, all communal areas, extend the dining room to include a more comfortable separate seating area, and have small units fitted into the bays for visitors to be able to make drinks. The housing manager was advised to keep the Commission For Social Care Inspection informed of the progress. During the sampling of training records it was noted that staff last undertook training in regard to Infection Control in 2004. Requirements have been made in regard to this under the Management and Administration section of this report. The home has a team of two domestic staff who are responsible for the cleanliness of the home. On the day of the site visit the home was very clean, tidy and free from offensive odours. The AQAA informs that each bedroom has en suite facilities, and residents are allowed to bring their own furniture. Under what we could do better the Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 20 organisation has identified that the lighting in communal areas needs to be improved. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were assessed. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory. Staff training requires further attention to ensure staff are able to continue meeting the needs of residents. Recruitment procedures must ensure that people who use the service are fully protected. EVIDENCE: The home has a multi-cultural staff team. The manager told us that the home works a two-shift system of early and late shifts. Staffing on the early shifts consists of four care staff and a senior carer. The late shift includes three staff and a senior carer. The duty rota for the week of the site visit was viewed. This confirmed the staffing arrangements for each shift. It was noted that the duty rota had changes made to it and Tippex had been used to change some shifts due to staff illness. The manager was advised that this was bad practise and that the duty rota should not be changed in this way. The manager told us that the staffing levels for the home have been reviewed due to the changing needs of the current residents. There will be an increase of staff on the shifts, allowing the manager more time to attend to her managerial responsibilities of the home. The housing manager had informed Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 22 the Commission For Social Care Inspection that the staffing levels were being reviewed. The home employs two waking staff, two cooks, two kitchen assistants, two domestic cleaners and one housekeeper. The manager told us that of the twenty care staff working at the home, ten hold the minimum of an NVQ level two and above, therefore complying with the National Minimum Standards of 50 of care staff working at the home holding this qualification. Four staff recruitment files were sampled, however, three of these had been working at the home for many years. The fourth file was that of one member of staff recently recruited. All staff files included a photograph that was in compliance with the requirement made at the last inspection. The most recent staff file had an application form, but did not request a full employment history. Only one written reference was in this file, but the housing manager told us that the second may be at the head office. Discussions took place with the manager and housing manager in regard to all recruitment files and the information required must be kept at the care home for inspection purposes, including the managers recruitment file. On the day following the site visit the housing manager told us by telephone that the second reference for the identified member of staff could not be located. Other issues identified included the lack of a health questionnaire and reasons for gaps in employment. The manager told us that they use agency workers to cover staff shortages. However, the manager is not seeking clarification from the employment agency that all the recruitment procedures had been fully undertaken on staff supplied. A requirement in regard to the recruitment practise of the home has been made. Discussions took place in regard to the induction for new staff. The manager and the housing manager told us that staff receive induction to the organisation and the charitable work it undertakes, however, staff are not receiving induction that is in line with the Skills For Council. A requirement in regard to this has been made. During discussions staff informed the Inspector that they receive regular training that has included dementia, deafness, behaviours and training in the Control Of Substances Hazardous to Health (COSHH). The AQAA informs that the organisation aim to maintain their long-term staff. The restructuring of staffing is in place, and they have recently employed a senior member of staff with an NVQ level 3 and an activity coordinator. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35, 36 and 38 were assessed. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of residents, however, the manager must attend to the identified issues in regard to risk assessments, safeguarding, recruitment and staff induction to ensure people who use the service continue to be safe and protected from harm. EVIDENCE: The manager told us that she has been working at the home for three years and registered with the Commission For Social Care Inspection in 2005. The Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 24 manager has thirty years experience as a nurse and has recently completed the Registered Managers Award (RMA). The managers file was not available at the home during the site visit as this is maintained at the head office, and some of the training information had been part of the RMA training and has yet to be returned to the manager, therefore none of this could be evidenced. Annual quality assurance surveys are undertaken by the Trustees of the charity every year to seek the views of residents. This was taking place on the day of the site visit. The manager told us that a report would be produced as a result of todays meeting. The manager told us that questionnaires are sent out on a quarterly basis, however, reports for these were not viewed. Meetings are held with residents at the home. The manager stated that meetings would be held every three months, the next meeting being due in January 2009. The organisation conducts monthly Regulation 26 visits, two of which were sampled during the site visit. The organisation has a development plan for the home that currently focuses on the refurbishment and staffing structure for the home. Residents and their families are responsible for their finances. The manager told us that they hold small amounts of money for some residents. Three of these were viewed and were appropriately maintained. Supervision is taking place, and the manager told us she has set dates for all staff to ensure they receive the minimum of six supervisions per year. The manager told us that a copy of these would be forwarded to the Commission For Social Care Inspection. Three staff training files were sampled during the site visit. These provided evidence that staff had received training in regard to first aid in 2006, two staff had received training in manual handling and health and safety in 2008, one received food hygiene and handling training in 2008 and all three had received fire training in 2008. There was a lack of training in regard to Infection Control, last delivered in 2004. One of three files did not have evidence of training in regard to first aid, and manual handling, and one had no evidence of training in regard to health and safety. A requirement has been made that all staff must receive the mandatory training as required. The AQAA informs that all the maintenance equipment used at the home has been serviced as per the manufacturers recommendations. Evidence was viewed that the passenger lifts, portable electric appliances (PAT) and the assisted baths had been serviced during the last twelve months. Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 25 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 13 (4) (b) (c) Requirement The registered person shall ensure that any activities in which a resident participates are so far as reasonably practicable free from avoidable risk, and unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. Timescale for action 02/01/09 2. OP18 13 (6) Risk assessments must be in place for all residents pertaining to daily living, and must include manual handling, falls and nutrition. The registered person shall make 26/12/08 arrangements, by training or by other measures, to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person must ensure that a Safeguarding Policy and procedure that is in line with the Surrey Multi – Agency procedures is provided for the home. This will ensure that people who Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 27 3. OP29 19 Schedule 2 use the service are protected from abuse. The registered person shall not employ a person to work at the home unless the person is fit to work at the care home. All staff files must include two written references, a full employment history, reasons for gaps in employment and a statement about their mental and physical health. The manager must obtain from the supplying agency evidence that all the recruitment checks as stated in Schedule 2 of The Care Home Regulations have been undertaken. A robust recruitment policy and procedure must be produced and adhered to when recruiting staff. 26/12/08 4. OP30 OP38 This will ensure that people who use the service are protected by the homes recruitment policy and procedures. 18 (1) (c) The registered person shall, having regard to the size of the care home, the statement of purpose and number and needs of residents, ensure that persons employed by the registered person to work at the care home, receive training appropriate to the work they are to perform, including structured induction training. Staff must receive the entire mandatory training as required. This will ensure that staff are trained and competent to do their jobs. 25/02/09 Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 28 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 OP1 Good Practice Recommendations The Statement Of Purpose and Service User Guide should be available at the home for inspection purposes and any resident or visitor making a request to view these documents. Care plans should be further developed to ensure they are person centred, and provide as much information about the resident and their likes and dislikes, and how their identified needs are to be met. The complaints policy should be reviewed to include the correct contact details for the Commission For Social Care Inspection, and state that complainants can go directly to the manager of the home. All staff, including the manager, should be provided with regular refresher training in regard to Safeguarding Adults. 2. OP7 3. OP16 4. OP18 Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Sherwood House DS0000013787.V373299.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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