Inspection on 02/02/06 for Sherwood View Care Home

This inspection was carried out on 2nd February 2006.

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 10/12/07

Sherwood View Care Home 22/02/07

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 Jo Wright Unannounced Inspection 2nd February 2006 01:30 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.V281622.R01.S.doc Version 5.1 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.V281622.R01.S.doc Version 5.1 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 01332 271941 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.V281622.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 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 ensuite 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. The home has a smoking area, and a garden area. Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced inspection and the duration of the visit was approximately 3 ½ hours. The purpose of this inspection was to check compliance with the requirements made in the last inspection report that had time expired. A number of records were examined, including care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual service users), medication charts and staff files. The manager was present at the inspection, and the findings the inspection were discussed with her. The findings of this inspection showed that the home has met a number of the requirements made in the previous inspection report. However, some key areas such as a structured activity programme and safe administration of medication had not been met. What the service does well: What has improved since the last inspection? The files demonstrated that staff had fully assessed residents’ needs on admission, and developed care plans for any areas where residents required help. Although the amount of detail contained in the care plans varied, all plans were detailed enough to enable staff to meet residents needs. Although some of the requirements relating to administration of medication have been addressed, a number of other issues were identified during this inspection. Residents need to receive their medication as prescribed in order for their health care needs to be fully met. Hand written entries need to be checked by another member of staff to check for accuracy and prevent an omission as identified during this inspection occurring. Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 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 View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 The information recorded within the assessments was sufficient to ensure that individuals’ needs were fully identified and planned for. EVIDENCE: The manager reported that an updated Statement of Purpose and Service User Guide were not available in the home. The files of four residents were looked at during this inspection. Efforts have been made to improve the quality of information recorded on the assessments. The standard of information generally was more detailed, although there was still room for improvement, as some assessments did not provide supporting information, for example type of continence products required, length of time for indwelling catheter. Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 11 The care planning system provided staff with the information they need to satisfactorily meet residents’ needs. Inconsistent staff practice for administration of medication potentially placed residents at risk. EVIDENCE: The care plans of four residents were examined in detail as part of the case tracking process, which is used to help determine how the home meets the needs of individuals. Improvements have been made to the standard care planning. However, the detail within the care plans varied depending on which member of staff had written them. Some care plans were detailed, specific and clearly set out how to meet individuals’ needs, whilst others lacked this level of detail. However, all care plans provided sufficient information to enable staff to meet the residents’ needs. Not all files supported that residents and/or relatives had been involved in all aspects of planning and reviewing their care. The monthly statements reviewed the effectiveness or appropriateness of the care and treatment being delivered. Care staff continue to record information about residents day to day lives, and this provided a clearer picture of how the resident had been. Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 Page 10 Not all of the files examined contained details the personal wishes of the residents at the time of severe illness or post death. A review of medication was carried out to assess progress towards compliance with the requirements made in the previous inspection report. It was reported that qualified staff had recently received medication training provided by Boots The Chemist. Since the last inspection, a new medication refrigerator has been purchased, and temperature was being recorded daily. It was noted that on several occasions for two different residents, the medication chart had been signed as administered but the medication remained in the monitored dosage system. Night time medication for one resident was to be given ‘as required’, 9 doses had been signed as administered, yet 11 doses had been removed from the monitored dosage system. In addition, the days of the doses removed did not correspond with the days signed for. The medication for one resident had been discontinued for a week following instruction by the GP. It was not clearly recorded on the chart when this medication had been stopped or when it was due to recommence. One resident’s medication chart that had been hand written had not been checked and countered signed by a second member of staff. The number of doses to be given for one medication differed from the information recorded on the dispensing label. Consequently this resident had only received one dose a day instead of the two prescribed doses. The member of staff who wrote the chart acknowledged that they had written this entry up incorrectly, and the error would be rectified. In addition, the full instructions as recorded on the dispensing label had not been transferred to the medication chart. Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 The home does not provide a range of social and leisure activities, and therefore the social needs of residents were not fully met. EVIDENCE: The manager reported that the activities coordinator had decided not to return to her post following maternity leave. There were no arrangements in place for regular social and leisure activities for residents. Files did not clearly demonstrate how individual social needs would be met. Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 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 the following standard(s): These standards were not fully assessed during this inspection. EVIDENCE: The up to date complaints procedure was on display in the home. The Commission has received one complaint since the last inspection. This complaint was referred to the provider for investigation, and was not substantiated. Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 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 the following standard(s): These standards were not fully assessed during this inspection. EVIDENCE: Although some heating was been provided in the conservatory area, residents commented that the level of heating was not adequate. This was partly due to the lack of ventilation, which meant that the window had to be left open whilst residents were smoking. The manager was aware of this and reported that additional heating had been purchased but not installed, and there were plans to install an extractor fan. Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Staff received appropriate training to assist them to do their jobs. Although the procedures for the recruitment of staff had been strengthened to offer protection to people living in the home, additional information was required to fully safeguard residents. EVIDENCE: An audit of a number of staff files supported that action had been taken to provide the required information. Discussion took place with the manager about the need to obtain a full employment history and explore and record the reasons for gaps in employment. Reference letters did not request the reason for leaving previous employment. There was a commitment to providing all care staff with training towards NVQ’s. The manager reported that 14 out of the 20 care staff employed at the home had achieved NVQ Level 2 or equivalent. Therefore, the 50 target of trained care staff has been achieved. A more structured and detailed induction programme was available. The manager reported that she planned to introduce this for newly appointed staff. Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during this inspection. EVIDENCE: Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 Page 16 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 2 X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X 2 X X X X X X STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 X 2 Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 Page 17 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4&5 Requirement The Statement of Purpose and Service User Guide must be reviewed and amended to include up to date and essential information. (Previous timescale of 31/12/05 not met) All staff must individually and collectively have the skills and experience to deliver the services and care that the home offers to provide. Care plans must demonstrate resident/relative involvement. (Previous timescales of 30/09/04 and 31/12/05 not met) All medication must be administered according to the Prescribers instructions as stated on the dispensing label or prescription and recorded accordingly. (Previous timescale of 07/11/05 not met) Any change in dosage of medication must be clearly stated on the medication record, with details of who authorised the change and the date of commencement and finish (if appropriate). DS0000048929.V281622.R01.S.doc Timescale for action 31/03/06 2 OP4 12(1)(a) (b) 18(1)(a) 15(1) 30/04/06 3 OP7 31/03/06 4 OP9 13(2) 31/03/06 5 OP9 13(2) 31/03/06 Sherwood View Care Home Version 5.1 Page 18 6 OP9 13(2) 7 OP9 13(2) 17(1)(a) Sch3 8 OP11 12(3) 9 OP12 16(2)(m) & (n) 10 OP20 23(2)(p) 11 OP29 19 Sch 2 12 13 14 OP30 OP36 OP38 18(1)(a) (b)(c) 18(2) 18(1)(a) & (c)(i) The person completing hand written medication records must sign and date these, and the records must be checked for accuracy and countered signed by another person. All hand written entries on the medication records must include the name, strength and dose of the medication and administration instructions, as detailed on the dispensing label. Residents’ wishes concerning terminal care and arrangements after death must be discussed and recorded (Previous timescales of 30/09/05 and 31/12/05 not met). A structured programme of activities must be put in place and up to date information circulated to residents (Previous timescales of 31/03/05 and 31/12/05 not met). Adequate heating must be provided in the conservatory area (Previous timescales of 28/02/05 and 31/10/05 not met) Full employment histories must be obtained for all newly appointed staff, and any gaps in employment must be explored and the reasons recorded. Reference letters must request the reason for leaving previous employment. All staff must receive training appropriate to the work they are to perform. All staff must receive informal and formal supervision All staff must have received training in mandatory safe working practices (Previous timescale of 30/11/04 not met) 31/03/06 31/03/06 31/03/06 30/04/06 31/03/06 31/03/06 30/04/06 30/04/06 30/04/06 Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 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 2 3 4 5 6 7 8 9 10 11 12 Refer to Standard OP9 OP9 OP9 OP11 OP15 OP15 OP16 OP16 OP19 OP22 OP30 OP35 Good Practice Recommendations A copy should be obtained of nurses signatures who have read and agreed to abide by the homes medication handling policies. Medication profiles of current medication with dosages are to be maintained in the service users care plans. The management of the home frequently documents and carries out medication audits at the home. All staff should receive training in care of the dying. The provision of dining tables and chairs should be reviewed to meet the needs of current and future residents. Residents should be further consulted about the presentation and quality of meals provided. A copy of all complaint investigations, including those referred to the company for investigation, should be available in the home. The manager should take appropriate action to ensure that residents and relatives feel confident that all staff will listen to and act on their complaints. A written plan for redecoration and refurbishment of the building should be put in place. A review of the range of moving and handling aids available to staff should be undertaken. An annual training and development plan and individual training records for all staff should be developed. Receipt books for money and valuables should be available in both homes, and all entries and withdrawals should be witnessed and countersigned, as stated in the homes policy. Sherwood View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 View Care Home DS0000048929.V281622.R01.S.doc Version 5.1 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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