Care Home: Sherrick House

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What the care home does well Good, individual care is provided to people using the service. Staff know the people using the service well and they have created a welcoming, attractive and homely environment for people to come to for regular visits. Relatives appreciate the care provided and the work of staff. A typical comment from relatives was that the home is, "A home from home", and that the staff are, "very nice people and very caring". One relative described the service. "Sherrick is so welcoming. Once we`ve pressed the door bell we know we`ll be greeted with a beautiful warm smile and that warmth remains." Many other similar complimentary responses were provided by relatives. The service is also good at providing people with a pleasant stay through the use of activities including trips out. The fact that many of the staff have lots of work experience at the home assists as does the fact that staff clearly see their role as to provide an individual service for people.The service is well managed and organised resulting in staff who are well trained and supervised and motivated for their work. Similarly, quality assurance initiatives are good which ensure that people are involved in the work of the home. Competent arrangements have been made to make sure that the home is well maintained and kept safe. What has improved since the last inspection? Previous requirements in the area of risk assessments and care planning have been complied with. This has involved making sure that care planning documentation makes clear any specific requirements people may have for personal care provision. The good standards identified at the last inspection of 16 February 2007 have been maintained. What the care home could do better: Overall, an excellent standard of care has been achieved. An increased frequency of the review of risk assessments would benefit people using the service and a recommendation has been given about this. The recruitment process needs to be adjusted so that it is clear that all the staff verification checks have been carried out. Currently, the documentation relating to some of the verification checks for staff are kept at the organisation`s head office whilst other documentation is kept at the home. This practice must be reviewed with a uniform system adopted. CARE HOME ADULTS 18-65 Sherrick House 30 Church End Hendon London NW4 4JX Lead Inspector Duncan Paterson Key Unannounced Inspection 11th January 2008 3:00 Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 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 Sherrick House DS0000010464.V354789.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 Adults 18-65. 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. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sherrick House Address 30 Church End Hendon London NW4 4JX 020 8203 4860 020 8202 6603 sherrickhouse@barnetmencap.org.uk 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) Barnet Mencap Ademola Timothy Adedoyin Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Sherrick House DS0000010464.V354789.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 the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 4 16th February 2007 Date of last inspection Brief Description of the Service: Sherrick House is a small care home run by Barnet Mencap. It provides, at any one time, a respite service for up to four younger adults who have a learning disability. Usually only three people are accommodated with the fourth bedroom kept for emergencies. There are 37 people registered to receive the service at times throughout the year. The majority of people using the service live with their parents and some with other relatives. It offers them a chance to learn what it is like to live away from the family home as well as providing a break from caring for family members. There are four bedrooms at Sherrick House. On the ground floor there is a large lounge, a kitchen/dining room, one bedroom, a shower room and toilet. There is a patio area and garden to the rear. On the first floor there are three bedrooms and a bathroom as well as the office. The home is close to the shops, transport links and services in Hendon. The cost of overnight respite at Sherrick House is £196.00. The people using the service meet a percentage of this cost. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent outcomes. This key inspection took place on 11 January 2008. The inspection involved speaking with the people using the service, the staff on duty and the manager. A standard form, the Annual Quality Assurance Assessment (AQAA), was returned to CSCI by the manager. This was taken into consideration. The inspection also involved the case tracking of three people’s care, the assessment of a range of the home’s records, procedures and forms as well as observation and a tour of the premises. 14 questionnaires were received from relatives and four from staff. Three relatives were also spoken with on the telephone. Many of the relatives in their returned questionnaires made reference to the fact that there is uncertainty about the future of the home. During 2007 there had been fears that the home would close. Although that did not happen relatives expressed concern about the future and worry about what would happen to their relatives. The manager advised that there have been discussions with Barnet Council, who fund the service, and that these discussions are ongoing. What the service does well: Good, individual care is provided to people using the service. Staff know the people using the service well and they have created a welcoming, attractive and homely environment for people to come to for regular visits. Relatives appreciate the care provided and the work of staff. A typical comment from relatives was that the home is, “A home from home”, and that the staff are, “very nice people and very caring”. One relative described the service. “Sherrick is so welcoming. Once we’ve pressed the door bell we know we’ll be greeted with a beautiful warm smile and that warmth remains.” Many other similar complimentary responses were provided by relatives. The service is also good at providing people with a pleasant stay through the use of activities including trips out. The fact that many of the staff have lots of work experience at the home assists as does the fact that staff clearly see their role as to provide an individual service for people. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 6 The service is well managed and organised resulting in staff who are well trained and supervised and motivated for their work. Similarly, quality assurance initiatives are good which ensure that people are involved in the work of the home. Competent arrangements have been made to make sure that the home is well maintained and kept safe. 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 summary of this inspection report can be made available in other formats on request. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 123&5 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff know the people using the service well and are able to provide well considered, individual care which is much appreciated by relatives. There is good quality written information informing people about the service and for planning people’s care. EVIDENCE: I used the CSCI case tracking method throughout this inspection to assess the quality of the service. Sherrick House provides a respite service with people staying at the home for a set number of days each year. I carried out my case tracking by looking in detail at the three people who were staying at the home on the day of the inspection. I looked at the care plans, discussed the care arrangements with staff, made observations on the day and spoke with three relatives after the inspection. I also took into consideration comments made in the 14 returned questionnaires I received from relatives. This allowed me to reach an overall judgement about the quality of the service provided. I was shown the home’s statement of purpose which had been updated during the last year when the registration certificate was changed. The home is now registered to care for four people. The manager told me that the fourth person was only accommodated at short notice in emergency situations. These arrangements are covered in the statement of purpose. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 9 Many of the people have been using the service for a long time. One of the people staying on the day of the inspection had been going to the home for 20 years. Sherrick House is not people’s main home and therefore their needs for care revolve around respite provision rather than continuous day-to-day care provision. The needs assessments are consequently different to that which would be expected in care homes providing permanent 24 hour care. I looked through the care plans for each of the people using the service on the day I was there. I could see that the care plans were detailed and focused on how the Sherrick House staff were to work with people for their stay. The people’s files also contained risk assessments as well as notes of other professionals, such as psychologists, who may be involved in contributing to the people’s care needs. I noted that, in line with a requirement given at the last inspection of 16 February 2007, the care plans now noted people preferences about personal care provision. For example, it was noted whether people wished gender specific care. I was also shown a communications file for one person containing some good quality photographs used to assist with interactions. In addition to many of the people having attended the home for a long time some of the staff have equally long service. This provides a very useful foundation for care provision. Staff and people using the service know each other well and a good understanding and rapport between them has developed. I received some very positive feedback from relatives. For example, one relative said that she had, “peace of mind knowing that our daughter is being well cared for”. Another relative said that, “I trust their care 100 ”. I identified a number of positive equality and diversity initiatives within the service. The manager advised, through the returned AQAA form, that within Barnet Mencap there was an Equalities Group which the manager was part of. There were relevant equalities and diversity polices and procedures and staff had organised care provision so that when people came to the home they had familiar things such as making sure that dietary preferences were considered. The home was equipped with a hoist and other adaptations to enable care to be provided for people with disabilities and the staff team was considered in its approach to people’s individual needs. I noted on the case files that I looked at that there were signed terms and conditions forms providing details about the service and what was to be provided. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 9 10 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans are detailed and provide staff with a range of relevant information. Staff have been successful in using that information, and their good knowledge of people using the service, to provide sensitive and positive care on an individual basis. EVIDENCE: As already described, I inspected the care plans of the three people staying at the home on the day of the inspection. The care plans were of a good standard. From my reading of them I could easily get a picture of each person, what his or her needs were and how the manager and staff were working to meet those needs. The care plans were all up to date and I could see that there were reviewed annually. Each care plan provided a great deal of detail about each person and included, where relevant, the input of external professionals. There were also details about individual needs, such as needs relating to manual handling, medication or continence care. I could see, from my observations of staff on the day and Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 11 discussions with relatives after the inspection, that staff were following these guidelines and working with people using the service in a proactive and life affirming way. For example, I could see that each person was being treated as an individual as well as with warmth. This was a feature of the feedback received from relatives. One relative said that, “The staff are superb. They really care about their clients and try to make their stay as much like home as possible. They take into consideration the needs of each person individually.” I noted that each case file also contained a risk assessment. The risk assessments were comprehensive and typically included assessments about accessing the community, moving around the home and manual handling matters. I noted that the risk assessments had not been updated at the same time as the care plans were reviewed. This was discussed with the manager and a recommendation is given that the risk assessments are reviewed annually at the same time the care plans are reviewed. From my observations during the inspection I could see that staff were actively involved in assisting people using the service to make decisions and to participate in the life of the home. For example, I saw a communication file for one of the people using the service along with photographs. I could see that staff were using these photographs as well as keeping up verbal interaction with the people using the service. I could also see that the home was geared to making sure that people coming to the home had an enjoyable as well as a fulfilling time. I was told of trips and outings that had taken place and I saw photographs of these events. I identified that there is a great variety in the needs of the people using the service. From people with the need for a great deal of personal care to those who live a more independent life. I could see that the staff had arranged things so that when people stayed they were compatible with each other. I identified that information about each person using the service was kept confidentially and securely in a locked section of the home. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 16 & 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using this service are provided with many opportunities to participate in enjoyable and stimulating activities. A welcoming home has been created where people can come on a regular basis to enjoy friendship, warmth and comfortable surroundings. Meal arrangements have been made taking into consideration people’s needs and wishes. EVIDENCE: The inspection took place on a Friday afternoon and evening. In that time I was able to observe the arrival of the people using the service, the settling in period, the serving of the evening meal and then relaxation after the meal. One of the aims of the service is to provide a social arena for visitors. I could see that this was achieved on the day of the inspection. People were greeted warmly on arrival, staff worked with people to settle them and gave them a drink and exchanged pleasantries. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 13 Some of the standards in this section do not fully apply as the service is not aiming to assist the people to take up employment or education. The people using the service all live in the community, usually with their families, and are already involved in a range of community based activities such as attending day centres or in some cases working. Staff at the home make sure that people using the service are able to attend these daily activities when they are staying at the service. They also assist to sustain relationships with significant others such as families. Feedback from relatives was very positive with many stressing the good relations that existed between them and the staff. One relative said that, “staff treat us with kindness, friendliness and respect. And they listen”. I was told by staff that activities were provided on a regular basis. For example, the previous weekend had seen a cinema trip organised. Other trips, depending on the people using the service at the time, were organised and often these were on a one-to-one basis. The matching of people using the service includes activities so that people with similar needs, or who are compatible together, usually stay at the same time. I was shown the “Visitors Activities” file which provided details of activities which had taken place each day. These records confirmed what staff had told me. During the inspection I observed the evening meal being served. All the people using the service ate together in the kitchen. A light meal was provided. I was told that day centres now provide a larger meal at lunch times and consequently the home provides lighter meals on weekdays. I could see that the people using the service were used to the arrangements and were sitting happily at the table. Staff interaction during the meal was positive with pleasant conversation going on and people being encouraged to eat. Menus are not kept but records of the food served are kept which were shown to me. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 & 20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal and health care needs have been considered in detail and relevant plans have been established which take into consideration individual needs. The arrangements to safeguard medication are sound. EVIDENCE: As already discussed, the care plans I saw were detailed about people’s individual needs and set out how people’s personal care should be provided by staff. Where relevant, risk assessments also covered these areas. However, staff at the home do not take the main role when it comes to organising and arranging health care as the service provides respite only. There is ample information obtained for the need of providing personal care but there is no need for the service to compile information, such as preventative health care visits, as the responsibility for these matters lies elsewhere. Having said that I saw evidence that specialists, such as health care professionals, had been involved in assessments and care planning arrangements for people. There are very good links with relatives and the care provided can be seen as a partnership between the staff and relatives. Feedback from relatives typically made positive comments about the caring work carried out by staff. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 15 I inspected the medication storage and administration arrangements. I noted that people using the service had medication profiles on their individual files. Medication is stored in a locked cabinet in the kitchen. A record is kept of medication brought into the home by people, the administration whilst people are there and then out of the home when the person leaves. The amount of medication at the home varies depending on the people currently attending. On the day of the inspection only a small amount of medication was being stored. The records were clear with signatures from two staff for each administration. A good standard was being maintained. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are effective Safeguarding Adults and complaints arrangements. There are good relations between the home, people using the service and relatives evidenced by the number of compliments made about the service. EVIDENCE: I was shown the home’s complaint record book in order to assess this standard. No complaints have been made since the last inspection of 16 February 2007. The manager showed me five compliments that had been received as well as a complimentary letter. Clearly, there are very good relations between the home, people using the service and relatives. There have been no Safeguarding Adults incidents or allegations since the last inspection. I was shown the home’s Safeguarding Adults policy. I noted that it was dated 2007 and that it covered the reporting arrangements to the local authority who have the lead role in responding to safeguarding matters. The policy was detailed. I also noted that staff had received recent Safeguarding Adults training. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 & 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. A pleasant, attractive and welcoming environment has been created for people using the service. Adaptations have been made to enable people with disabilities to use the service and individual bedrooms are comfortably furnished. EVIDENCE: Sherrick House is a large semi-detached house located in a pleasant part of Hendon close to community facilities. The home is attractive and inviting and on my arrival I found the atmosphere warm and homely. During the inspection I was shown round by the manager. I saw each bedroom, the bathrooms and toilet facilities and the communal areas. There is one bedroom on the ground floor which is used by people who may have a physical disability. The other three bedrooms are on the first floor. Each room was comfortably furnished and nicely decorated. As a respite service there is less scope for personalisation of the bedrooms as there is with a traditional care home. However, each room looked inviting and they are Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 18 roomy and well furnished. There were some new furnishings such as a special bed in the ground floor bedroom. There is a large lounge on the ground floor made up of two original rooms providing a variety of spaces for people to either watch television, relax or undertake other activities such as playing games. The kitchen is relatively large as well and easily accommodates the people using the service and staff for mealtimes. Overall, the home is well maintained and provides a pleasant place for people to come to. I could see that people arriving on the day of the inspection were clearly at home. They got on well with staff and looked relaxed and happy to be there. The manager told me that he was to attend forthcoming Barnet Council training on infection control. This will provide information on the Department of Health new care home guidance “Essential Steps.” Once completed, the manager should be able to introduce the “Essential Steps” initiative to work at the home. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 35 & 36 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service benefit from an experienced and skilled staff team who are lead by an able and organised manager. New staff have been introduced into a staff culture that is caring, supportive and person centred. Recruitment, training and supervision arrangements are overall good but require some adjustments to make sure that recruitment checks meet The Care Homes Regulations. EVIDENCE: When I arrived for the inspection there were two members of staff on duty. They were both scheduled to work until 9pm when one was to leave and the second was to continue providing night time cover. This is standard staff cover for the service and is adequate for the numbers and needs of people using the service. The manager then arrived at the home and assisted with the inspection. To enable me to assess the staffing arrangements the manager showed me staffing records that covered recruitment, training and supervision. The manager advised that recruitment was taking place at the moment, as additional permanent staff are required. Currently, the staff hours required Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 20 have been met through use of bank staff and some staff working additional hours. In terms of recruitment I identified that not all copies of CRB checks were being kept at the home. Two were not available. However, the manager provided me a copy of one of these after the inspection. He also advised that the second one had not been sent off for and that the person concerned would not work at the home until it had been obtained. A POVAFirst check would be acceptable in this case pending the return of the full CRB check. I also identified that the full range of verification checks were not available at the home for some of the staff. This may be allowed subject to the home completing relevant CSCI forms, retaining the information at the organisation’s head office and agreeing that the staff verification checks would be available to CSCI once given notice. The CSCI forms have been sent to the manager. I was able to see that staff had received a range of adequate training including NVQ training. Three of the staff had achieved NVQ Level 3 awards and one was currently studying for a NVQ Level 2 award. The manager has obtained the Registered Managers Award. I was shown staff supervision records and I could see that staff were receiving supervision on a regular basis. A number of the staff have been working at the home for many years and bring a considerable expertise and experience to their work. They clearly know their work well as well as the people using the service. Newer staff have been recruited and inducted into a strong, stable and supportive staff team. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 40 41 42 & 43 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Strong leadership is provided by the manager, which combined with the interest and wider support provided by Barnet Mencap, has meant that people using the service benefit from a well run and organised service. Quality assurance initiatives are good and encourage people to participate. The service is efficient at maintaining the environment and keeping it safe. EVIDENCE: The manager is qualified and competent for the role and has worked at the home for a number of years, first as the assistant manager and more recently as the manager. He is able to bring strong leadership and support to staff and he demonstrated a commitment and passion for the service during the inspection. The aims of the service are clear for staff and they benefit from the support provided from Barnet Mencap which runs the service. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 22 The manager showed me the analysis and questionnaires which had been returned by relatives and others during 2007. This is a major part of the organisation’s quality assurance work. The returned questionnaires were positive in the views expressed about the service. I could see that thought and consideration had been given to the overall design of the forms. They included pictures, were attractive and were easy to read and comment on. The manager had produced a report on the findings which demonstrated that the views expressed were being taken seriously. Regular monthly monitoring reports of the service from Barnet Mencap are sent through to CSCI. I was shown the home’s policies and procedures files which were extensive. I sampled some of the policies. I found that the policies were being reviewed regularly, that they were clearly set out and presented and that they were detailed in their coverage of the issues. I inspected the records for the maintenance of the home as well as the servicing of the home’s installations and equipment and the maintenance of health and safety. The records were generally well ordered. With some help from a long serving member of staff, I was shown all the relevant checks relating to fire safety and the maintenance of the home’s installations. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 4 3 3 3 3 3 Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 24 No 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 YA34 Regulation 19 Sch 2 Requirement The location for the retention of staff recruitment checks must be reviewed. A uniform system must be adopted. Timescale for action 01/04/08 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 Refer to Standard YA9 Good Practice Recommendations The risk assessments for people using the service should be reviewed each year at the same time as the review of care plans. Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Sherrick House DS0000010464.V354789.R01.S.doc Version 5.2 Page 26 - 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. 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