Care Home: Sherborne House

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What the care home does well The home is well laid out, comfortable and homely. It is clean and fresh smelling. The environment is being improved with redecoration and refurbishment.The home was well staffed in number on the day of inspection and on the rotas. Care plans have been updated and are person centred. The management style is open and the people, their relatives and staff feel they can approach the manager if they have any concerns. There is also good support from the company. What has improved since the last inspection? The maintenance and decoration of the premises continues to improve to home for those in residence. Care plans have received the managers attention and have improved in content and are more person centred. Staff supervision is now in progress. Staff training has improved. The statement of purpose and the service user guide have been updated to include the new managers details. What the care home could do better: Risk assessment for denture cleaning tablets where they are held in a persons en suite is required. These preparations are hazardous if accidentally ingested. Hand transcribed entries on MAR sheets should be signed by two members of staff. One identified person should have their fire training update when they next come into work. All staff must receive formal supervision. The feedback from relatives and staff indicated that more could be possible with the development of social activities both at home and for excursions away from the home. CARE HOMES FOR OLDER PEOPLE Sherborne House 131 Sherborne Road Yeovil Somerset BA21 4HF Lead Inspector Barbara Ludlow Unannounced Inspection 11th January 2008 10:40 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 Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sherborne House Address 131 Sherborne Road Yeovil Somerset BA21 4HF 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) 01935 423210 01935 433702 caroline@sherbornecarehome.co.uk www.altogethercare.co.uk Altogether Care LLP Mrs Caroline Sharp Care Home 32 Category(ies) of Dementia (32), Old age, not falling within any registration, with number other category (32) of places Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia (Code DE) Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 32. 31/05/07 2. Date of last inspection Brief Description of the Service: Sherborne House is situated near Yeovil town centre within walking distance of local amenities. The home provides personal care and support for older people with dementia care needs. The house is arranged on two floors can accommodate up to 32 people. There is an enclosed garden area. The home was registered with CSCI under the ownership and management of Altogether Care Group in September 2007. The present Registered Manager Mrs Caroline Sharp was confirmed in post in November 2007. The home had previously been suitably adapted as a care home. The home is being upgraded and refurbished to improve the accommodation and facilities. Fees range from £351.00 to £600.00 per week. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. The Annual Quality Assurance Assessment (AQAA) was completed and returned to CSCI. Questionnaires were sent to the home to seek the views of people and their families using the service and staff employed at the home. Health and social care professionals were also contacted for their views on the service provision at Sherborne House. The inspection visit was made over a 8 hour period. The Registered Manager Mrs Caroline Sharp was on duty; 18 people who use the service and 5 members of staff were seen and spoken with during the day. No visitors were seen. A tour of the premises was made and time was spent in the communal areas of the home speaking with the people in residence and observing daily life at the home. Records were sampled, these included care plans, medication records, staff recruitment records and maintenance files. The registered provider was present at the start of the inspection. The company operations manager came to the home at lunchtime and remained for the inspection period, this was helpful and supportive for the homes manager. This was a very positive inspection visit. The inspector would like to thank all the people who live at the home and their relatives and the staff who contributed to the inspection process. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. What the service does well: The home is well laid out, comfortable and homely. It is clean and fresh smelling. The environment is being improved with redecoration and refurbishment. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 6 The home was well staffed in number on the day of inspection and on the rotas. Care plans have been updated and are person centred. The management style is open and the people, their relatives and staff feel they can approach the manager if they have any concerns. There is also good support from the company. What has improved since the last inspection? What they could do better: Risk assessment for denture cleaning tablets where they are held in a persons en suite is required. These preparations are hazardous if accidentally ingested. Hand transcribed entries on MAR sheets should be signed by two members of staff. One identified person should have their fire training update when they next come into work. All staff must receive formal supervision. The feedback from relatives and staff indicated that more could be possible with the development of social activities both at home and for excursions away from the home. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 7 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. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is good. Up to date information is available about the home for prospective people and their families looking for a care home. Pre admission assessment is carried out and information from health and social care professionals is gathered to ensure that care needs can be met at Sherborne House. Clear contracts are issued. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector was informed that the brochure is being updated but new admissions would be offered the brochure, copy of the newsletter, a statement of purpose, service user guide and they would also be given access to the inspection reports at the home. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 10 The latest statement of purpose and service user guide which have been updated by the manager Mrs C.Sharp following her approval by CSCI as the Registered Manager. Three and care plans were sampled for people more recently admitted to the home. The plans held a copy of the Single Assessment Process carried out by the community professional care manager which had been passed to the home. Those who received social services funding had a statement of terms and conditions of residency on their files these had been signed. The contract states that the trial period for settling into the home before making a decision to stay is six weeks, the national minimum standard recommended a four week trial period. Letters are sent out to confirm to the prospective resident their place and that their care needs can be met at Sherborne House. Comment cards sent to people at the home and their relatives and professional contacts were received by CSCI. This feedback included: Two people said that their place at the home had been chosen for them by their relatives. One person responded saying ‘I am quite settled here’. A relative commented that they ‘Visit daily and were completely satisfied with information provided.’ A visiting professional commented that the home is ‘Good at supporting people to live the life they choose’ and that the ‘family was happy’, with their choice of home. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. People are treated with respect and in a dignified manner. People looked well cared for and the care planning indicated that the health and well being of people is well managed. Medications are safely managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All people had access to information about the home with the service user guide and statement of purpose being readily available. All service users had care plans, three were sampled in detail for people whose care was case tracked as part of the inspection process. The care plans were written in a sensitive and person centred way. They included photographic identification of the person in residence. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 12 All care plans held information gathered from community health care professionals in their Single Assessment Process (SAP) documentation. All service users had contracts and terms of conditions of residency. The care plans had full assessment of care needs with regular monthly reviews, all were up to date with two reviewed in January 2008 and one in December 2007.For one person there was evidence that a family member had been involved with the review process. Risks had been assessed for safe moving and handling, falls, nutritional need pressure sore risk and dependency. Health needs were assessed and social history and care needs had been recorded. No one was reported to have any pressure sores. Toiletries such as denture cleansing tablets were seen in one person’s bathroom. Although access was not thought to be problematic in this instance it would be best practice to risk assess where such toxic substances are stored for an individual . This risk assessment and management of the denture cleaning agent on their behalf would be part of the individuals care plan for daily living and personal care. There was evidence of visits made to people by external professionals such as GP and the district nurse and those professionals allied to health such as the chiropodist coming into the home. The visiting nurse attending the home said that staff were always very helpful. Medication management was examined, the controlled drugs were stored correctly and the medication stock was accounted for. Storage was satisfactory and safe with the locked trolley fastened to the wall. Cool storage in the medications fridge was within the correct temperature range. The medication administration records were neatly completed and there were no gaps. Variable doses were accounted for. Hand transcribed medication on two sheets had only one signature, a second is required to confirm that the entry has been checked and is verified as accurate by a competent second person. There is a homely remedies policy. Bulk prescribing was discussed as an alternative to large numbers of lactulose bottles being all in use and open at one time. Advised to discuss with GP’s. People were seen throughout the inspection day and time was taken to sit in the lounges with the people in residence to observe their day and speak with them about life at the home. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 13 People were all tidily and warmly dressed. All people looked well groomed, one person had untidy fingernails and this was brought to the attention of the manager. There was freedom for people to move around unhindered other than by the redecoration of the conservatory. All staff interactions were friendly and helpful. Great care was being taken by staff and the contractors on site to make sure the people who spend time walking around the home were not accidentally knocked by the doors opening into the corridors, in particular where redecoration work and decorators were busy. This work had put the conservatory and a bedroom out of bounds for safety reasons. People who were asked and were able to comment said they were treated kindly and with respect. The written feedback to CSCI included comment ‘I am well looked after’ and I am quite settled here’. Relatives commented that they were ‘pleased with the support’ for their relative. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. Sherborne House is very homely and people are able to spend their time as they choose. For example there are activities to join if desired and there is a quiet communal lounge. Families are welcomed and can be as involved with the home as they wish or are able. The food looked appetising and meals are social occasions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People were observed throughout the day and time was spent in the communal areas of the home with the people in residence. During the morning personal care had been given and people met together in the lounges. A cup of tea was served at 11am. The inspector was informed that lunch was served from 12.15 onwards and activities for the afternoon would be allocated after lunch. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 15 The home has entertainers coming into the home and ‘the music man’ comes in regularly each Wednesday. One person in residence has a piano and played to the people in the quiet lounge who appreciated this and some people were seen to be tapping their feet and humming along to the music. Photographs of recent events such as the mayors visit, Christmas festivities and trips out were displayed on a notice board. Also on the notice board were details of the company employee of the month award and other information such as the hairdressers price list. There was a good level of social interaction between the people living at the home. Friendships were evident and people seemed to be content in each others company during the day. The bigger of the lounges was warm and comfortable, this room has a television, this was switched on during the morning and a few people were watching. Staff were attentive to the people in the lounge, one person complained of feeling cold and was assisted to move to sit somewhere warmer. ( The weather was particularly bleak, dark and stormy all day) The corridor felt cool on the day of the inspection. Care must be taken to ensure an warm ambient temperature is maintained. The dining room was locked before lunch to allow the tables to be prepared for use. Food is passed directly from the kitchen via a serving hatch. This room provides a large spacious room that can accommodate everyone at lunchtime. The tables were nicely laid ready for lunch. The mealtime was a social event and the food looked appetising. Assistance was given as required. Some of the dining chairs are stained and some were quite low against the dining tables. People did seem to be very unsettled during the late afternoon. Whether this was due to the altered environment was unclear. (The reduction in communal space was due to the conservatory being out of bounds for decorating and the dining room being kept locked between meals.) Staff were present to assist the people who were using the corridors at the front of the house for walking up and down at this time. Relatives and resident meetings are held. Three people living at the home responded to CSCI questionnaire, saying there are usually activities to join in with and adding that ‘there is enough to keep me occupied’ and another said ‘if it appeals to me I’ll join in any activity’. One relative commented that there could me ‘more recreational activity’ including ‘more frequent excursions’ available for the people in residence to go outside the home. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 16 Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 17 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): 16,18 Quality in this outcome area is good. There is a complaints policy and procedure. No complaints have been reported since the last inspection. Staff are safely recruited and have received training in the protection of vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure. There have been no complaints made to the home or to CSCI. Recruitment practice was examined and was through. Seven staff files were seen. Two references had been taken up for new staff and their Criminal Record Bureau (CRB) checks had been made. Staff had received induction training and there was documentary evidence of protection of vulnerable adults training. Staff responded to CSCI in writing by completing comment cards, 10 responses were received. One said ‘I could not start work until all the checks were received’, another said ‘I couldn’t start until I had CRB and references’. All responded that they knew what to do if a concern is raised about the home. Most qualified this stating they would speak to the ‘manager’ or a ‘senior carer’. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 18 People who live at the service said they would ‘probably ask to see someone in charge’. Another said ‘no’ they did not know how to make a complaint. Relatives commented that they would ‘go straight to the manager’. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 19 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): 19,26 Quality in this outcome area is good. The home is well maintained and was safely managed. The home was clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was made. Building work was in progress to upgrade the bedrooms in one wing in the ground floor corridor close to the conservatory. The conservatory that is normally well used, was out of bounds as it was being decorated. The contractors and decorators were extremely vigilant about health and safety within the care home and along with staff maintained a watchful eye when entering and exiting areas of working from the corridor. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 20 The home was found to be clean and comfortable. Bedrooms were personalised and made homely. The home refurbishment is being completed to a high standard creating attractive and comfortable accommodation. The home has a fire alarm system and fire safety equipment. There is a nurse call system throughout home. Communal rooms were tidy and had sufficient comfortable seating. The dining room was kept locked between meals, this found people congregating in the front hall a tea time. Infection control is well managed. There are gloves and aprons for staff to use and there are staff hand washing facilities. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. There was a sufficient staff number and skill mix on duty to care for the number of people in residence. Staff receive appropriate training and supervision. Personnel files were generally complete and recruitment practice was to a good standard to protect people living at the home from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection there was the manager in charge, one senior and three carers to care for the 18 people in residence, 2 people were reported to be in hospital. There was also the cook, and kitchen assistant and a domestic cleaner on duty. This was a sufficient number and skill mix. The home had 27 staff in total at the time of completing the AQAA and one bank / agency staff had been used at the home. The AQAA stated that 8 or 57 of staff were working towards their National Vocational Qualification in care. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 22 Over the past year there had been only three new staff recruited. Staff recruitment files were examined for a total of seven staff, of these three were examined in detail. Staff had completed application forms and made a declaration about their health. Photographic identification and diversity monitoring was in place in the three files scanned for detail. All seven staff had Criminal Record Bureau checks in place, PoVA list checks and two references had been taken up prior to their employment. One interview record was not dated or signed, the manager confirmed that dating and signing a records of interview is her usual practice. Staff had received induction training, annual appraisal and five had undergone supervision, two did not have a supervision record on file. There was good evidence of staff training which included dementia care, food hygiene, abuse awareness training and manual handling. The manager stated that first aid and health and safety training were planned for January. Fire training records were sampled and one person did not have up to date evidence of having received fire training, this is recommended for urgent attention. Regular staff meeting are held for senior carers and carers. A senior carer meeting was held during the inspection day. People who live at Sherborne House commented that staff were kind and helpful. All interactions between staff and people living at the home and observed during the day were respectful, polite and kind in manner. Ten comment cards were sent to staff and all were completed and returned to CSCI. The inspector would like to thank the staff for taking time to complete these and also for the written comments made to support their tick box responses. Positive responses were made to all questions. Staff confirmed having CRB checks and references before they started working at the home. Care staffs said they update the care plans ‘every day’ , ‘regularly’ and ‘read the care plans of people we take care of and it makes us understand their needs as individuals’. Staff confirmed having induction training 8 people said it covered what they need to know about the job ‘very well’. 2 said ‘mostly’. Staff confirmed having Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 23 on going training and staff meetings. One person said theat ‘most of us are doing NVQ’s’. Staff responding in writing confirmed having 1:1 supervision on a monthly basis. All staff said they would know what to do if someone raised a concern about the home. Five people described their action as referring to a senior carer or manager. Staff commented that there are usually enough staff to meet the needs of people at the home. Staff sickness and absence being covered by staff ‘working extra shifts’. Staff commented on some of the staff being of ‘different race’ or ‘from overseas’, but that staff work together and help each other to be understood and ‘everybody tries to explain things in a way they can understand’. One person commented that all the people in residence are English. When asked what Sherborne House does well staff commented that they have training to meet the needs of the people in residence. That they always do their best, are friendly and patient. Staff also felt that the activities, birthday celebrations and trips out are well done. This was also an area where staff thought they could do better by providing more social activities. No staff indicated that they would wish to speak with the inspector. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 24 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): 31,33,35,36,38 Quality in this outcome area is good. The home has an experienced registered manager who has good support for the company. Service users interests are safeguarded by the management practice and procedures at the home. The home is well maintained and is being refurbished to a high standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an experienced registered manager who is a trained nurse and holds the Registered Managers Award. The manager has introduced staff Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 25 supervision which was evident on some of the staff personnel files seen. Not all were in place but this had been progressed very well. There is input into the management of the home by the owner, who was seen and was spoken with at the start of the inspection visit. Time was given to discuss the service and the company aspirations for the development of the service and the refurbishment of the premises. The company operations manager visits the home regularly and completes the regulation 26 visit report each month, these are copied to CSCI. The operations manager was seen at the inspection, arriving at lunchtime, again time was given by them to the inspection process and to explain the redevelopment of the home and service offered. Peoples views are sought at the residents and relatives meetings. The last meeting was held in September 2007. Regular staff group and full staff team meetings are held. The AQAA stated that there are plans to introduce a Quality Assurance scheme in line with the other homes in the company group. Further meetings are planned once the building work outside commences to ensure people remain satisfied with the service during what could be an unsettling period with contractors and noise on site during the daytime. The AQAA reports under what we could do better, that there are plans to launch a website, have a shortened version of the statement of purpose and have quality assurance surveys in 2008. Plus the ongoing development of the physical environment. The company publishes an informative newsletter , a copy of this was seen. News from across the homes is reported including management news from Sherborne House. It was confirmed by manager after the inspection, that the company head office does not act as appointee for anyone using the service. Any personal monies held for people who live at the home are recorded on computer and on paper. The small amounts of money held are in separate wallets and receipts are retained for all purchases. Access to the wallets is restricted. All invoicing for fees is handled centrally by the company head office. Chemicals were generally securely stored. Toiletries such as denture cleansing tablets were seen in one persons bathroom. Although access was not thought to be problematic in this instance it would be best practice to risk assess where such toxic substances are stored for an individual . This risk assessment and management of the denture cleaning agent on their behalf would be part of the individuals care plan for daily living and personal care. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 26 Maintenance records were sampled, the home has a maintenance person who completes all in house checks records all findings: Fire safety, all records were well organised. The fire alarm is checked on a weekly basis and was last tested on 4/01/08. The emergency lighting and fire door releases were also checked at this time. A visual inspection was made of the fire extinguishers. A fire audit of the premises was carried out 10/11/07. Staff fire drills were recorded for March and October 2007. Fire training was held in August, October and November 2007 and only one person was identified as not having attended. This training is strongly recommended prior to this person returning to work. Gas Safety: Landlords gas safety certificate issued 3.07 Portable Appliance Testing: 5/01/07, Electrical Installation 15/10/07. Legionella testing : 22/08/07 Patient Lifting: Bath hoists: 27/09/07 Passenger Lift: 27/09/07 Patient hoists: 21/12/07 Hot water calibration of failsafe valves and flushing: 11/12/07 Nurse call testing: 18/12/07, each room checked in the room check log. All records were retained securely and access is restricted where required. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 27 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 X 3 Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 13(4)(a) and (c) Requirement Risk assessments must be completed for the individual where a decision has been made to have denture cleaning tablets in their en-suite bathroom. All staff must receive formal supervision. Formal Quality Assurance must be implemented. Timescale for action 08/03/08 2 3 OP36 OP33 18(2) 24 08/03/08 08/04/08 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 Refer to Standard OP38 OP9 Good Practice Recommendations Fire training, outstanding for one person should be completed on their next shift on their return to work. Hand transcribed entries on the Medication administration records should be countersigned to demonstrate checking and verification of the entry by a competent second person. Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Sherborne House DS0000070483.V357420.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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