Inspection on 10/12/07 for Sherwood View Care Home

This inspection was carried out on 10th December 2007.

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

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

Other inspections for this house

Sherwood View Care Home 12/11/08

Sherwood View Care Home 22/02/07

Sherwood View Care Home 02/02/06

Sherwood View Care Home 05/10/05

Sherwood View Care Home 12/01/05

Sherwood View Care Home 07/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Sherwood View Care Home 29 Village Street Derby Derbyshire DE23 8DF Lead Inspector Janet Morrow Unannounced Inspection 09:20 10 December 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sherwood View Care Home DS0000048929.V352294.R02.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 View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sherwood View Care Home Address 29 Village Street Derby Derbyshire DE23 8DF 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) 01332 271941 F/P 01332 271941 www.europeancare.co.uk European Care (SW) Ltd Vacant Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To allow Sherwood View Care Home to accommodate one individual named in the proposal notice dated 13/01/06, who is under the age of 65 years old. 22nd February 2007 Date of last inspection Brief Description of the Service: Sherwood View is a purpose built home providing nursing and personal care for up to 39 people aged 65 years and over. The home is located next door to another home owned by the same company. The home has 31 single and 4 double bedrooms located on the ground and first floor. All rooms except one have en-suite facilities. Access to the first floor is by stairs and a passenger lift. Sherwood View is approximately three miles from the Derby City Centre, and is close to local shops and facilities. Communal areas consist of a large lounge and dining area and a quiet room on the ground floor. Additionally there is a large conservatory and a garden area. The current range of weekly fees at the home is from £296 to £540. Previous inspection reports are located in the office at the home. Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over one day for a total of 7.5 hours. An ‘expert by experience’ assisted with the inspection process. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The ‘expert by experience’ was present for three hours and spoke with three service users, three relatives and several members of staff. Her findings are incorporated into the report. Care records, staff records, maintenance records and a sample of policies and procedures were examined. A partial tour of the building was made. The inspector spoke with three members of staff, the acting manager and programme manager. Seven of twenty-eight residents currently accommodated, one visiting professional and one relative were spoken with. One visiting professional was contacted by telephone following the inspection visit. Four residents’ surveys were returned to us at the Commission for Social Care Inspection. Written information in the form of an annual quality assurance assessment was supplied by the home prior to the inspection visit and informed the inspection process. What the service does well: The home continues to provide a relaxed and flexible routine. There is a stable staff team at the home who benefit from good managerial support. The acting manager is striving to improve the care and facilities at the home and to support staff in their work. The arrangements for managing medication at the home were satisfactory and records were in good order. Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 6 Residents and families were encouraged to personalise their rooms with their own possessions. Health services were called in when required and specialist help and advice was sought as necessary. Care needs were reviewed regularly with a health professional. What has improved since the last inspection? What they could do better: Care planning needs to improve to ensure that all care needs are identified at the point of admission and full and detailed care plans are available for all residents. Staff training needs to be more comprehensive to ensure all staff have the necessary skills to carry out their work. Training in relation to care as well as health and safety needs to take place. Assessment information at the point of admission should be comprehensive and identify any risks and the action needed to minimise risks. There must always be an assessment in place for risk of pressure sores and nutritional and continence assessments. The environment needs refurbishing to ensure all areas of the home are well decorated and comfortable. The recent award of a grant for refurbishment should assist in this; in particular bathrooms need updating, the conservatory needs heating, adjustable tables need replacing and armchairs and dining furniture need replacement. Wheelchairs must always have footrests and shower chairs should always be used when residents use the shower room. Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 7 A wider range of activities needs to be organised to take account of individual interests and preferences. Staffing hours should be reviewed to ensure there are sufficient staff available to promote residents’ independence. 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 View Care Home DS0000048929.V352294.R02.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 View Care Home DS0000048929.V352294.R02.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): 3 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was a lack of admission information in some cases that did not ensure needs could be fully met. EVIDENCE: Three residents’ care files were examined and all contained a pre-admission assessment of need, including information from the assessment and care management process. However, the information seen was variable. For example, two files had sufficient information and a range of risk assessments including nutritional assessments, tissue viability assessments and falls risk assessments but one had no nutritional assessment and no tissue viability Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 10 assessment, two had no social needs assessment and one had an out of date continence assessment dated 2006. None of the files indicated whether the resident or their representative had been involved in the process of developing care documentation. One visiting professional spoken with stated that the care was improving and that residents ‘appeared cared for’ and one relative spoken with stated that they were ‘very satisfied’ with the care. Sherwood View Care Home DS0000048929.V352294.R02.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): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were some omissions in care planning information and inadequate attention to mobility and continence that indicated some care needs were not being met. EVIDENCE: Three residents’ care files were examined and all had a care plan in place. However, the information contained in them was variable. For example, one file had a care plan for only two areas although discussion with staff indicated a significant number of needs and a daily entry recorded the resident concerned as ‘poorly’. None of the files had specific care plans for pressure sore prevention although the two that contained pressure sore risk assessments both identified the residents as high risk. Reference was made in other areas, such as mobility care plans, to use of pressure relieving Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 12 equipment and monitoring of skin condition. None of the care files had any care plans on social needs, including religious or spiritual needs. Two of the records indicated that routine monthly evaluations of the care plans and their effectiveness were taking place. Care staff recorded information on a daily basis, and this provided a clear picture of how the resident was progressing at the home. Formal care reviews took place with external professionals as required. Records confirmed that access to General Practitioners (GP), optician and chiropodist took place. There was regular recording of weight, blood pressure, temperature and pulse. Continence appeared to be an issue and residents and their relatives stated that they were sometimes told to wait when they asked for assistance to be taken to the toilet. One visitor stated that their relative had become doubly incontinent since being admitted to the home when they had been fully continent in their own home. Observation showed that members of staff did not ask if anyone wanted to go to the toilet. Warm relationships between staff and residents were observed and most residents spoken with confirmed that they were cared for in a respectful manner. Some staff were described as ‘dedicated, others less so’. They gave mostly positive comments about the staff and how they did their best in difficult circumstances. However, one resident stated ‘you are a number here – not an individual’. Assistance with showers was being given using inappropriate equipment, i.e. in a wheelchair as opposed to a proper shower chair. This information came to light during discussion with two residents and their relatives and was later confirmed by staff. This practice must stop and appropriate equipment must be used. Discussion with staff revealed that most residents were unable to walk but there was a lack encouragement to walk. There were no visible activities to encourage independence and no specific encouraging of individuals to move at all from their chairs during the morning. It was observed that most residents continued to sit in the same chair, including wheelchairs, for extended periods, including lunchtime. Feedback from three residents during the inspection visit stated that there was sometimes a wait for the toilet and one survey received stated that ‘at certain times care has been lacking in full attention’. Feedback on other surveys was mixed; for example one residents’ survey responded that they ‘sometimes’ received the care and support they needed, Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 13 one responded that they ‘usually’ did and another stated they ‘always’ did. One responded that staff were ‘always’ available when needed and acted on what the resident said and another stated they ‘sometimes’ did. A visiting professional spoken with after the inspection visit stated that they ‘couldn’t fault’ the nursing care provided. Two residents’ surveys responded that they ‘always’ received the medical support they needed and one responded that they ‘usually’ did. Ten medication administration record (MAR) charts were examined for accuracy of recording. This showed that these were accurate with no unexplained gaps on the charts. Allergies were detailed at the front of each resident’s record, where appropriate. Handwritten charts were being signed by two people to check for accuracy. Three medication administration record (MAR) charts were then examined in more detail and were completed accurately with no errors noted. The record of controlled drugs was examined. A random check of three medicines showed that the record corresponded with the amount of medicine held in stock. The medication refrigerator temperatures were being recorded on a daily basis and were within safe limits. Eye drops were labelled with date of opening and all seen were within expiry dates. Sherwood View Care Home DS0000048929.V352294.R02.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): 12. 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A lack of activities for some residents and mixed feedback about meals indicated that quality of life for some residents was compromised. EVIDENCE: There was little activity taking place during the day of the inspection apart from a game of bingo in the afternoon. The manager stated that a member of the care staff had responsibility for activities and time was designated for activities on three afternoons per week. Three residents’ surveys received responded that there were ‘sometimes’ activities arranged and another stated that there ‘usually’ were. Residents spoken with stated that they spent most of the time watching television, although it was observed that the sound was turned down during part of the inspection visit. One resident stated that this was regular practice. Another stated that evening times were ‘as dead as a dodo’ and another stated that ‘not much goes on’. Most residents appeared to be dozing or just sitting doing nothing. Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 15 The manager stated that social events booked over the festive period included a carol service, a pantomime, a Christmas Party and also an external entertainer. A newsletter detailing planned activities was also available. Relatives and friends were encouraged to visit at any time and were encouraged to continue with caring activities if they wished. The majority of residents and staff spoken to felt that the standard of meals provided were satisfactory, and that they were provided with a good choice and variety at the main meals. Specialist meat (halal) was provided for those residents who wanted it and there was always a vegetarian option available. There was mixed feedback on the surveys received about the food; one stated that they ‘always’ enjoyed the meals, two that they ‘usually’ did and one that they ‘sometimes’ did. Part of a meal was sampled and although cooked adequately was found to be bland. One resident stated that the food was overcooked. Observation of the lunchtime meal showed that those residents who were unable to eat without help were given assistance in a sensitive manner. Those with reduced appetites were encouraged to eat. However, it was also observed that some residents left substantial portions on their plates and biscuits were put directly onto trays – not on a plate provided for this. Food stocks in the kitchen were viewed and were good and most of the recommendations issued by the Environmental Health officer in July 2007 had been addressed. The acting manager stated that one resident currently had an advocate and she knew which organisation to contact for an advocacy service, if required. Sherwood View Care Home DS0000048929.V352294.R02.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clear complaints procedure and comprehensive safeguarding policies ensured residents were safe from abuse. EVIDENCE: A copy of the complaints procedure was on display in the foyer and included all the required information and stated that complaints would be responded to in twenty-eight days. Contact details for the Commission for Social Care Inspection were available. The written information supplied by the home stated that six complaints had been received in the previous twelve months, of which two had been upheld. The records of these complaints were examined and it was clear from the records what action had been taken to address the issues, including whether or not the complainant was satisfied. All four residents’ surveys received stated that they knew how to make a complaint and who to speak to if they were not happy. Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 17 There had been no complaints received by the Commission for Social Care inspection since the last inspection in February 2007 but one concern raised by the Local Authority had been fully investigated by them and the home. The home had comprehensive information on safeguarding adults, including the company’s own policies and procedures, the Local Authority procedures, department of Health Guidance ‘No Secrets’ and how to refer to the Protection of Vulnerable Adults (POVA) list. Although staff spoken with confirmed that training had been undertaken in safeguarding adults, this had not been recent and one staff member stated that they had not undertaken any training in this area. The acting manager stated that the Local Authority course in safeguarding had been arranged but had been cancelled and new dates were awaited. The last recorded date for safeguarding training seen on the home’s training matrix was April 2006. Sherwood View Care Home DS0000048929.V352294.R02.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): 19, 20, 22 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical layout of the home enables residents to live in a comfortable environment, which is clean and generally well maintained but poor quality of furniture and fittings may affect residents’ wellbeing. EVIDENCE: The home was generally clean and tidy at the time of the inspection visit but there were a number of areas that needed refurbishment: • • Bathrooms needed upgrading and had broken tiles in the shower areas Adjustable tables were damaged and one was mended with tape DS0000048929.V352294.R02.S.doc Version 5.2 Page 19 Sherwood View Care Home • • • Armchairs in the lounge and dining room furniture were worn and in need of replacement The lounge carpet was stained and in need of cleaning or replacement The conservatory was cold and unused Two residents were observed being moved around the home in wheelchairs without footrests and a further three wheelchairs were seen without footrests. All wheelchairs should have footrests and these must be used to maximise residents’ comfort and safety. The annual quality assurance assessment stated that the garden had been cleared and a gardener was now employed. It also stated that twenty bedrooms were due to be upgraded in the next twelve months and that bathroom upgrades were planned. The Programme Manager for the company stated that a grant had recently been awarded to the home and the company had identified some of the areas above as a priority for improvement. The laundry was viewed and had two washing machines with a sluice wash facility and two driers, all of which were in working order. Residents spoken with stated that their laundry was dealt with well. Staff spoken with were aware of infection control procedures and stated that there was a plentiful supply of gloves and aprons. However, not all had undertaken infection control training and the last recorded course in the training matrix provided was in 2005. However, the acting manager stated that training was planned with a local college over the next six months. There was no odour noted at the time of the visit, although there was a mixed response on the residents’ surveys seen that responded ‘always’, ‘usually’ and ‘sometimes’ when asked if the home was fresh and clean. Information on the Control of Substances Hazardous to Health (COSHH) was available in the office. Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were sometimes insufficient staff available to meet residents’ needs and inadequate training in key areas to ensure staff had the skills required. Recruitment procedures were thorough and safeguarded residents. EVIDENCE: The staff rota for 3rd –16th December 2007 was examined and showed that there were five care staff and one qualified nurse on the morning shift and four staff and one qualified nurse on the afternoon shift. The acting manager was available between 8.30am and 4.15pm each day. This was consistent with the number of staff on duty on the day of the inspection. There was one cook and one kitchen assistant on duty each day, one laundry worker and two domestic staff. A handyperson was employed for Sherwood view and the adjoining home, Forest View. Staff spoken with stated that there was sufficient time to undertake the necessary care tasks but they sometimes felt rushed if there were any staff Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 21 shortages due to sickness. However, they stated that this was occasional rather than a regular occurrence. Residents and their relatives felt there were sometimes insufficient staff and this resulted in not being taken to the toilet quickly enough. For example, it was noted during the visit that no-one was asked if they wanted to go to the toilet and incontinence had increased for some residents since their admission. One survey commented that there were ‘problems with staff shortages – are sometimes late getting down for breakfast and then do not want lunch as there is only a two hour gap between the meals’. The acting manager stated that there was a stable staff group and shortages of staff were rare and were covered from within the company. Agency staff were used very infrequently to cover absences. Three staff recruitment files were examined and showed thorough recruitment procedures. All files seen had evidence of identity information, two written references, a Criminal Record Bureau (CRB) check and evidence of qualification, where appropriate. Staff training was the main shortfall in this area. Although a programme was being devised for mandatory health and safety training and National Vocational Qualification (NVQ) training took place, there was little evidence of any other recent training in care related areas. For example, the training matrix devised by the home listed the only care courses as wound dressing, hearing loss, care of medicines and resuscitation and none of these had occurred in 2007. The annual quality assurance assessment stated that training had been undertaken in death and dying but there were no records to support this and staff spoken with stated that they had had no training this area. Although the acting manager stated that the home had access via the company to dementia training, there was no evidence seen of this, although there were several residents who had cognitive impairments. Staff spoken with had not undertaken training in dementia care. National Vocational Qualification training to level 2 was well established and all staff, except two, had now achieved this qualification or above. This meant the home was now exceeding the target of having 50 of staff qualified to level 2 or above and is therefore commended for the improvements made in this area. Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management systems had improved with a senior manager being in charge of the day to day running of the home and this ensured the home was run in residents’ best interests. EVIDENCE: The home did not have a registered manager and had been operating without one since February 2007. However, to introduce stability into the management arrangements, the operations manager of the company was managing the home on a day to day basis. The operations manager was experienced and Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 23 knowledgeable and was striving to make improvements in the home, which had improved some management functions such as the response to complaints and staff support. The company had comprehensive quality assurance processes and monitoring systems were in place that included visits from an external manager, as required by Regulation 26 of the Care Homes Regulations 2001. The written information supplied by the home stated that there was an annual development plan as well as a three monthly business plan and that future plans were for relatives to be more involved by encouraging them to join a residents’ committee. A satisfaction survey had been undertaken in June 2007 and the feedback received was generally good. For example, one stated that ‘everything is to my satisfaction’ and another gave the home ‘full marks’. One relative who had previous complaints stated that the home had ‘improved’ under the new management system. The home did not deal with any residents’ finances at the current time and this standard was therefore not applicable. Although staff spoken with confirmed that fire safety, moving and handling and food hygiene training had occurred in 2007, not all staff had received updated training in these areas. Infection control training had not occurred although the manager stated that this was due to be provided by a local college. The written information supplied by the home stated that maintenance checks were up to date. For example, the hoists and lift were checked in September 2007 and gas safety in June 2007. Portable electrical appliances were being checked on the day of the inspection visit. An external company had completed a fire risk assessment and the manager stated that the recommendations made were due to be carried out in the next two weeks. Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 24 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 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X 2 X X X 3 STAFFING Standard No Score 27 2 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A X X 2 Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1), 5(1) Requirement The Statement of Purpose and Service User Guide must be reviewed and amended to include up to date information to refer to the new management arrangements of the home. This requirement was not assessed on this occasion. Previous timescale of 31/5/07 extended. Timescale for action 31/01/08 2. OP3 13(4) 31/01/08 All hazards and risks in the lives of residents of the home, and steps taken to manage them, must be identified and documented in written form, particularly in relation to tissue viability, nutrition and continence. This is to ensure that all care needs are addressed and residents’ health is maintained. All residents must have a fully completed care plan to ensure that all care needs are met. Care practice in relation to continence promotion must be reviewed to ensure residents DS0000048929.V352294.R02.S.doc 3. OP7 15 (1) 31/01/08 4. OP8 12 (1) (a) 31/01/08 Sherwood View Care Home Version 5.2 Page 26 maintain as much independence as possible. 5. OP10 12 (4) (a) Greater efforts to maintain dignity must be made, including treating residents as individuals and using appropriate equipment in the shower rooms. A structured programme of activities, appropriate to the capabilities of residents must be put in place to improve residents’ quality of life. (Previous timescale of 31/08/07 not fully met although improvements made. Timescale extended). The conservatory area must be improved so that the majority of residents and their visitors can use it and improvements must be made to the room’s heating. Previous timescale of 31/05/07 not met. Timescale extended. Wheelchairs must have footrests in place to maximise residents’ comfort and safety. All staff must receive training appropriate to the work they are to perform. This must include training relevant to the care needs of residents in the home (e.g. in dementia) to ensure all care needs are met. (Previous timescale of 30/07/07 not met. Timescale extended) All staff must receive updated training in mandatory safe working practices to ensure the safety of residents and themselves. (Previous timescale of 30/06/07 not met. Timescale extended) DS0000048929.V352294.R02.S.doc 31/01/08 6. OP12 16(2) (n) 29/02/08 7. OP20 23(2) (e) & (p). 31/01/08 8. OP22 23 (2) (c) & 13 (4) (c) 18(1) 31/01/08 9. OP30 31/03/08 10. OP38 18(1)(a) & (c)(i) 31/03/08 Sherwood View Care Home Version 5.2 Page 27 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 OP3 OP7 OP11 Good Practice Recommendations Social needs assessments, including religious and spiritual needs, should be included in all residents’ assessment documentation. Care plans should demonstrate resident/relative involvement. Residents’ wishes concerning terminal care and arrangements after death should be discussed and recorded. All staff should receive training in care of the dying. Residents should be consulted about the presentation and quality of meals provided. All staff should receive updated safeguarding adults training. A written plan for redecoration and refurbishment of the building should be put in place. A review of staffing hours should be undertaken to ensure there are sufficient staff to enable independence to be promoted. A Criminal Record Bureau (CRB) check should always be available for inspection. 4. 5. 6. 7. 8. OP11 OP15 OP18 OP19 OP27 9. OP29 Sherwood View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 View Care Home DS0000048929.V352294.R02.S.doc Version 5.2 Page 29 - 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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