Care Home: Sherdley Court

What the care home does well `Sherdley Court` presented as a warm, homely and caring place in which to live. The manager and staff on duty were observed to interact with residents in a positive manner and people spoken with confirmed staff were attentive and responsive to their needs. All areas viewed appeared well maintained and were clean and hygienic. Systems had been developed to identify and respond to the health, personal and social care needs of prospective and current residents. Likewise, policies and procedures had been established to ensure an appropiate response to complaints and suspicion or evidence of abuse. Feedback received from residents and / or their representatives confirmed they were appropriately cared for and satisfied with all aspects of the service provided. Examples of some of the comments received from residents included: "Hayley [Registered Manager] and the staff are very nice." "I am looked after very well." "The food is good and the chef is very nice." "Sherdley Court is one of the best places I have ever lived." "I`m happy with all aspects of the service." "The staff are very caring and assist with any daily needs I have." "Everything at Sherdley Court works very well." "The home is kept clean and tidy. We have good food." The service "Provides good care and ensures good wellbeing." What the care home could do better: Care plans should be updated to describe in more detail the support residents require from staff to meet identified needs. This will help to safeguard the welfare of serviceusers. The date that medication is received into Sherdley Court should be recorded on Medication Administration Records to provide a clear audit trail. Staff should be reminded of how they can refer safeguarding incidents to external agencies to ensure best practice. Random inspection report Care homes for older people Name: Address: Sherdley Court 91 Rainhill Road Rainhill Merseyside L35 4PD three star excellent service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Daniel Hamilton Date: 1 4 0 5 2 0 1 0 Information about the care home Name of care home: Address: Sherdley Court 91 Rainhill Road Rainhill Merseyside L35 4PD 01514263096 01514939382 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Hayley Rowson de Vares Type of registration: Number of places registered: Conditions of registration: Category(ies) : Making Space care home 25 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Conditions of registration: 25 MD - Mental Disorder excluding learning disability or dementia (6) MD(E) - Mental Disorder excluding learning disability or dementia - over 65 years of age (19) Registered for a maximum of 25 service users The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 25 Date of last inspection Care Homes for Older People Page 2 of 10 Brief description of the care home Sherdley Court is a 25-bedded care home for people with a mental disorder. The building is owned by a Arena Housing and managed by a charity named Making Space. The Manager is Mrs Haley Rowson de Vares. It is a purpose-built facility on one floor. It is divided into three units, each with its own lounge and dining area as well as bedroom space. Each bedroom is for single occupancy. The care home also has a large communal lounge area as well as a conservatory, which is used as a smoking room. There is a rehabilitation kitchen, which has been refurbished to the highest standards. Sherdley Court has two rooms for management purposes and a wellappointed kitchen and laundry. It is not registered to provide nursing care but when necessary calls on nursing services, via the district nursing and community psychiatric nursing services. The care home is fully equipped with grab rails and other aids to assist disabled service users manage the premises. It has a call system located throughout the building. The care home integrates easily into the local environment being of a pleasant appearance with accessible garden areas. Sherdley Court is located in an established Residential area of St Helens with easy access to local facilities. The Manager advised that the weekly fees range from £394.00 to £435.96 Care Homes for Older People Page 3 of 10 What we found: This Random Inspection of Sherdley Court was undertaken on 14th May 2010 and lasted approximately 4.5 hours. The purpose of the Random Inspection was to undertake a review of the service, which was rated as excellent at the last inspection on 2nd July 2007. A site visit was undertaken which focused on two outcome areas only i.e. Health and Personal Care and Complaints and Protection. During the visit two of the residents care files were case tracked and the registered manager, deputy manager, assistant manager, one residential support worker, two relatives and seven residents were spoken with. Reference was also made to surveys received from residents and staff and an Annual Quality Assurance Assessment (AQAA), which was completed by the Registered Manager before the visit. This document enables a registered person to undertaken an assessment of their service, prior to an inspection. Comments included in the report are taken from survey forms and from feedback received from residents and their representatives during the site visit. Outcome Area - Health and Personal Care. The Annual Quality Assurance Assessment (AQAA) for Sherdley Court confirmed that policies and procedures had been developed for Individual Planning and Review, the Control Storage, Disposal, Recording and Administration of Medicines and the value base of social care. Two residents files were viewed during the visit. Each file was found to contain a preadmission assessment, effective care coordination information and care plan documentation. Assessment and care plan systems identified the health, personal and social care needs of the people using the service and included brief information on the action required by staff in response to assessed needs. Systems had also been established to ensure the the content of care plans was reviewed on a monthly basis in consultation with residents or their representatives. A range of supporting documentation including; personal information, risk assessments, weight records, daily monitoring sheets, incident / accident reports, complaint information and miscellaneous records etc were also available on file for reference. Health care information was generally recorded and highlighted in diary sheets although some information was found to be stored in other locations. Records viewed confirmed residents had been supported to access appointments with a range of health care practitioners subject to individual need including; community psychiatric nurses, dentist appointments, chiropodists, hospital out-patient, general practitioner and opticians etc. The registered manager was recommended to update care plans to describe in more detail the action to be taken by staff in response to individual needs and to ensure health care records were stored in one location. Advice regarding outstanding equality and diversity information was also given to the manager to ensure best practice. Care Homes for Older People Page 4 of 10 Medication systems were checked with the registered manager and an assistant manager during the visit. The registered manager reported that all staff designated with responsibility for administering medication complete an external medication course and in-house training (which includes watching a video and completing an assessment). A medication policy was in place together with a service user identification system and a staff signature checklist. The registered manager was also advised to obtain a copy of guidance issued by the Royal Pharmaceutical Society of Great Britain to provide additional guidance for staff. Medication was found to be securely stored in three medication trolleys (one for each unit) within a locked room and a separate storage facility was in place for controlled drugs. Although no controlled drugs were being stored on the premises at the time of the visit advice was given regarding the correct fixing method to be used for the controlled drugs cabinet, to ensure compliance with the Misuse of Drugs (Safe Custody) Regulations 1973. A selection of Medication Administration Records (MAR) and medication was checked during the visit. MAR viewed had been correctly completed to account for medication administered, however the date that medication had been received into Sherdley Court had not been recorded to provide a clear audit trail. Action should be taken to address this issue. Feedback received from residents and /or their representatives via discussion or care home surveys confirmed they were happy with the overall standard of care provided. The manager and her staff team were observed to be responsive to the needs of the people they cared for and residents reported that they felt valued and were treated with respect and dignity. Outcome Area - Complaints and Protection. The Annual Quality Assurance Assessment (AQAA) for Sherdley Court confirmed a policy and procedure on Concerns and Complaints was in place, a copy of which was stored within the Statement of Purpose, Residents Guide and an information leaflet displayed in the reception area of the home. The AQAA highlighted that no complaints had been received by the service in the last 12 months and the Care Quality Commission has received no complaints, concerns or allegations about the service in the same period. Furthermore, no issues of concern were brought to the attention of the inspector during the random inspection. The homes complaint log was viewed during the visit. This revealed that the last complaint received by the service was in 2006. Policies and procedures were in place to ensure an appropriate response to suspicion or evidence of abuse. This included a copy of the local authoritys adult protection procedures, together with internal policies to ensure the protection of vulnerable adults and guidance on whistle blowing procedures. The registered manager reported that the Registered Provider (Making Space) had also developed a policy on Deprivation of Liberty which was awaiting ratification from the board of trustees. Care Homes for Older People Page 5 of 10 The AQAA detailed that there had been no safeguarding referrals or investigations in the past 12 months and the Care Quality Commission has received no safeguarding referrals in this period. Examination of the AQAA and discussion with the manager and staff confirmed staff had received training in the Protection of Vulnerable Adults as part of their ongoing training and development. The registered manager and staff spoken with demonstrated a sound understanding of the different types of abuse, internal reporting procedures and their duty of care to safeguard the welfare of vulnerable adults. Some staff appeared vague regarding external alerting procedures and this was discussed with the registered manager who agreed to review this issue to ensure best practice. What the care home does well: What they could do better: Care plans should be updated to describe in more detail the support residents require from staff to meet identified needs. This will help to safeguard the welfare of service Care Homes for Older People Page 6 of 10 users. The date that medication is received into Sherdley Court should be recorded on Medication Administration Records to provide a clear audit trail. Staff should be reminded of how they can refer safeguarding incidents to external agencies to ensure best practice. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 7 of 10 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 8 of 10 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 Care plans should be updated to describe in more detail the support residents require from staff to meet identified needs. This will help to safeguard the welfare of service users. The date that medication is received into Sherdley Court should be recorded on Medication Administration Records to provide a clear audit trail. Staff should be reminded of how they can refer safeguarding incidents to external agencies to ensure best practice. 2 9 3 18 Care Homes for Older People Page 9 of 10 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 10 of 10 - 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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