Inspection on 20/12/05 for The Sharmway

This inspection was carried out on 20th December 2005.

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

The Sharmway 05/06/07

The Sharmway 25/07/05

The Sharmway 04/02/05

The Sharmway 01/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE The Sharmway 113 Handsworth Wood Road Handsworth Birmingham West Midlands B20 2PH Lead Inspector Monica Heaselgrave Unannounced Inspection 20th December 2005 11:20a 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 The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Sharmway Address 113 Handsworth Wood Road Handsworth Birmingham West Midlands B20 2PH 0121 554 6061 0121 554 6061 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) Mrs Winnie Purcell Mrs Winnie Purcell Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2005 Brief Description of the Service: The Sharmway is a three storey detached property located along Handsworth Wood Road. It accommodates up to 11 older adults, and is within access of public transport links to Birmingham City Centre. The home is close to local facilities including shops and places of worship. The property comprises of a double bedroom on the ground floor, with screens and wash hand basin. There is a WC with wash hand basin by the front entrance. A shower facility, laundry and kitchen are located along the hall. Adjacent to these are two lounge areas to the front and rear of the property, the front one is utilised as a dining room and seats eleven service users. The first floor is accessed via a stair lift, and has four single bedrooms and one double, a shower facility and bathroom with bath hoist chair. Two further WCs are sited on this floor. The second floor is accessed via stairs, and has two single and one double bedroom, with bathroom and WC facilities. All bedrooms are lockable and have a hand wash basin, covered radiators, window restrictors and an emergency call system. Sited around the home is ramped access to the side of the property, and parallel handrails either side of the front passageway. There is a large wellmaintained garden to the rear, and front car parking. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place between 11:20am and 2:00pm on a weekday, just prior to Christmas. The inspector met with the proprietor who is also the Registered Manager, two seniors and one member of care staff was spoken with. A friend of a service user was also spoken to. The inspector met visitors from the local church. One service user was in hospital and 10 service users were in the home at the time of inspection. The inspector met all ten service users six of whom were able to contribute to the inspection process. A number of records were inspected to include care plans, risk assessments, staff rotas, medication and staff training records. The lunchtime meal was observed. This is the second of two inspection visits made this year. Both reports should be read in conjunction in order to have a fuller picture of the service provided. What the service does well: The Sharmway has a consistently good record of maintaining a personalised service to its service users. Good communication, consistency of care, and wholesome portions of food, were observed. Service users commented upon these favourable features of the home. Good routines within the home, which allow service users a good degree of choice in choosing when to get up, go to bed, or even when to eat their meals, are evident. There are no set meal times, those who require assistance due to Dementia are encouraged to eat at regular times, but a great deal of consideration is given to what works best for them, and so the care is individualised and very flexible and supportive. The management of health care needs is very good. There are good systems for monitoring, and acting upon any concerns noted. Service users receive their medication in a safe and proper manner, and were seen to have access to the G.P and other health professionals, as they required. Service users who contributed to the inspection spoke fondly and highly of the manager and staff team. They described them as “kind and helpful.” The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 6 The Sharmway offers a small group living experience, within which, the routines are relaxed, and staff were observed to be tactile and gentle in their interactions with service users. What has improved since the last inspection? 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. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4, 6 A detailed assessment of service users current needs, gives assurance that care needs will be met, and risks diminished. Staff training does not adequately reflect that they can deliver the services and care that the home offers to provide. EVIDENCE: Standards 1 and 3 were assessed and met at the last inspection. Assessment of service users current needs has been addressed. Each has an up to date assessment, care plan and risk assessment. Assessments include advice from other specialist services, which ensure service users have appropriate aids suited to their needs. Records are available which demonstrate that needs are identified, acted upon and recorded. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 9 The needs and preferences of people from minority ethnic groups, particularly those of West Indian and Irish culture, are well understood and met. There are positive role models on the staff team from similar ethnic origins who have a good understanding of the service users needs. This understanding is utilised well in promoting access to food, social activities, music and skin care, that meets service users needs in a preferred manner. A training matrix was seen and a variety of training is undertaken. At the previous inspection standard 30 was assessed and a requirement was made that training and induction must follow the ‘Skills for Care’ targets. This requirement remains outstanding, and must be met in order to ensure that staff do have the skills and knowledge to meet the assessed needs of service users. The Sharmway does not provide intermediate care. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Procedures for the receipt, recording and storage of medication were good. Staff had been trained in this aspect of their work to ensure the well being of service users. EVIDENCE: Standards 7,8 and 10 were inspected and met at the last inspection visit. During the inspection the lunchtime medication round was observed, and medication records and storage examined. Staff had a good understanding of the residents medication needs. Training records indicated that staff had received accredited training in medicine safety. Medication records were in good order, signed and up to date. A record of medication ordered and received was maintained, which enabled staff to monitor that correct medication was received prior to dispensing it to service users. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 11 Medication was seen to be stored securely. Procedures for the storage and administration of controlled medicines were well maintained, with separate storage and double staff signatures. Service users care files showed that staff monitor the well being of service users on medication, and call the G.P. if concerns are evident. The review of medication was evident. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 12 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): 13 An impressive level of consultation with the families of service users ensures contact arrangements are respected, encouraged and supported. EVIDENCE: Standards 12, 14, and 15 were inspected and met at the last inspection. There is positive consideration of service users who may have limited capacity to exercise choice in their lives, they benefit from the support offered by a caring staff team. A few service users were spoken to and some were able to describe visits from their family members. A visiting friend described positive relations with the manager and staff team, and stated that she was always invited to join in social events. During the inspection members of the community church came to visit the service users, and stated this is a regular feature. A planned visit from the church leader and choir was to take place later that evening. It was especially commendable to note the efforts of the manager and her staff team in supporting individuals and their families, in maintaining some element The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 13 of control over their lives, particularly where individual’s capacity to do this, may have been limited. Care plans showed that the manager and the family explore on the service users behalf, the type of choices he would wish to make, and the events and activities that had been important to him. It was evident that staff try very hard to ‘mirror’ previous lifestyle choices where they can. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Complaints are handled properly and provide service users with confidence that their concerns are listened to and acted upon. Adult protection procedures and training for staff, ensures people living at the home are protected from abuse. However, the reporting of incidents that affect the well being of service users is not consistent, and the lack of awareness of the implications of POVA 1st checks, compromises this area. EVIDENCE: There is a complaints procedure, and service users and their families have access to this at the point of admission. Some service users spoken to indicated that they know how to make a complaint, but had not needed to. They were confident that staff would listen to them. No complaints have been received by the CSCI. Service Users also said that there are lots of other platforms available to them to air their views, and so there rarely was a need to complain. These included service user meetings. These were sampled and showed that comments made were followed up. A quality assurance system has also been implemented which enables service users to comment on aspects of the care and service they receive. This enables the manager to improve, where necessary, any aspects of care delivery, whilst The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 15 giving service users the confidence that their feedback is important and will be acted upon. Information available confirmed that the legal rights of service users are protected. Where service users lack capacity the manager has ensured that access to other advocacy or protection services is available. Currently Social Services are being utilised in order to explore and protect the interests of one individual. The manager stated that service users have the opportunity to vote in elections, and would provide support to access polling stations. Care staff has access to adult protection procedures. Staff training records indicates that staff receive training in relation to protection and abuse. The manager stated that re-fresher training in this area is planned. A staff member spoken to had a good knowledge of the indicators of abuse, and how they should act on this. Accident records were sampled. There have been incidents, which have not been reported to CSCI, as required by regulation 37. For instance, where an incident occurs which may affect the well being of the service user. Staff would benefit from training in this area, so that they are aware of the importance of regulations such as regulation 37, and how this affects their practice. The recruitment procedures were robust. However one staff member did not have all had the required information. There was no Police Check or POVA 1st, (Protection Of Vulnerable Adults) checks. Evidence that this has been undertaken, will need to be forwarded to the Commission. This was discussed with the manager who was not aware of the requirements around seeking POVA 1st checks, for all new staff, or referring unsuitable staff for inclusion on the Vulnerable Adults register, in accordance with the Care Standards Act. More vigilance in this area is required to ensure the proper protection of service users. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 16 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): EVIDENCE: Standards 19, 21,22,25 and 26 were inspected and met at the last inspection. At this inspection none of the remaining standards were assessed. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 17 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): 28 Staff are competent in carrying out their role as carers, but require foundation training to equip them to meet the needs of service users. EVIDENCE: Standards 27,and 29, and were assessed and met at the last inspection. Staff training records show that some are currently undertaking NVQ level 2. A minimum of 50 of trained staff (NVQ level 2 or equivalent) was required by 2005. The manager must demonstrate how this standard is now to be met. There is good awareness of the needs of service users. A training matrix was seen and a variety of training is undertaken. At the previous inspection standard 30 was assessed and a requirement was made that training and induction must follow the ‘Skills for Care’ targets. This requirement remains outstanding, and must be met in order to ensure that staff do have the skills and knowledge to meet the assessed needs of service users. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 18 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): 31, 38 The home is managed properly, with guidance to staff; ensuring service users receive consistent good quality care. The health, safety and welfare of service users and staff is good, ensuring risks are identified and acted upon. EVIDENCE: At the previous inspection standards 31, 32, 33, and 38 were assessed. Standard 32 was met. One requirement was made to implement a quality assurance system, which seeks to obtain the views of service users and their families. This has now been introduced. At the previous inspection the manager who is also the proprietor had commenced her NVQ Level 4 in Care and Management. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 19 This training has been interrupted for health reasons, the training and the standard remains outstanding. The Assistant Manager is a qualified RGN and has worked in the community as a District Nurse with older adults. Both have a wide range of experience, skill and expertise in meeting the needs of older persons. Service users and staff speak positively about the ethos of the home. There are good examples of written communication to ensure consistency of care. Since the last inspection the proprietor has implemented a Quality Audit, based upon seeking the views of service users and families. This is still in the early stages, and the results of this are yet to be produced. The proprietor stated the homes equipment, and heating systems are maintained properly. However the manager was unable to locate maintenance certificates to demonstrate this. Copies of the Landlords Gas Safety certificate, stair lift and hoist equipment must be submitted to the Commission to verify these have been maintained. The Heath and Safety of service users is promoted via the use of individual risk assessments, and risk assessment for the premises. Where requirements have been made with regard to the home’s physical environment, these have met. Staff have received a variety of training pertinent to their role as Care Assistants, this has included First Aid, Fire prevention, Manual Handling, Health and Safety, COSHH and Food and Hygiene. ‘Falls Awareness’ training also took place in September 2005. The training matrix showed that care staff had received training in the safe administration of medication. The manager was unable to clarify if this training was accredited. Confirmation of accredited training must be submitted to the Commission. The management of incidents and accidents in the home meets with requirements. The notification of these to the Commission via regulation 37 has not been consistent and needs to improve. . The management of safe working practices within the home is good. There are platforms for the monitoring and review of all practice areas, and this ensures that the well being of both service users and staff working within the home is promoted. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 20 The proprietor has purchased the TOPSS Induction package. This has not yet been implemented. When implemented, this will further ensure that staff receive training to meet ‘Skills For Care’ targets, on all safe working practices. The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 21 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 X 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 22 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 OP4 Regulation 18(1)(a) Requirement Timescale for action 01/03/06 2 OP18 10(3) 3 OP28 18(1)(a) 4 OP30 18 (a)(c) The Registered Manager must ensure that staff receive foundation training, and training specific to the service users needs, such as Dementia to ensure staff can meet the specific needs of service users. A training plan should be submitted to the Commission to demonstrate how this is to be addressed. 01/03/06 The Registered Manager must undertake training to ensure that she is familiar with the requirements of the POVA 1st requirements, necessary for managing the care home. A minimum of 50 of staff 01/03/06 trained to NVQ Level 2 by 2005 remains outstanding. The Registered Manager must demonstrate how this standard is to be met. Staff Induction and training 01/03/06 needs to be developed further to bring it in line with the Skills for Care requirements. This is an outstanding requirement. The Registered Manager must submit DS0000017027.V270602.R01.S.doc Version 5.0 The Sharmway Page 23 5 OP31 10(1)(3) 6 OP38 37(1)(e) 7 OP38 23(1)(c) 8 OP38 18(1)(a) an action plan to demonstrate how this is to be implemented. The Registered Manager has not completed NVQ level 4 training in care and management. An action plan outlining how this standard is to be met should be submitted to the Commission. The Registered Manager must ensure that any event that adversely affects the well being of a service user is reported to the Commission via regulation 37requirements. The Registered Manager must forward copies of the Landlords Gas Safety certificate, electric PAT tests, (portable appliances) and certificates to verify the maintenance and service of the stair lift and hoist equipment. The Registered Manager must ensure that staff induction and foundation training meets with the Skills for Care training targets. This is an outstanding requirement. An action plan specifying how this is to be achieved should be forwarded to the Commission. 01/03/06 21/12/05 01/03/06 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 The Sharmway DS0000017027.V270602.R01.S.doc Version 5.0 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!