Care Home: Sherwood House

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What the care home does well All people that wish to use service benefit from a pre-admission assessment and the care plans are then generated from this initial assessment. People who use the service who spoke to us on the day were complimentary about the quality of the food provided. Completed surveys returned to us also made good comments about the food.Sherwood HouseDS0000013787.V378586.R01.S.docVersion 5.2The staff spoken to on the day were knowledgeable about the care needs of the people using the service. They were observed to be interacting and speaking appropriately to the people in a calm manner. Regular training takes place and this includes the NVQ (National Vocational Qualification) which all staff have access to. The registered manager and staff have a clear understanding of safeguarding policies and procedures and regular training takes place. Major refurbishment of the home will take place next year but the home still had a homely atmosphere when we visited. People using the service were pleased to show us their bedrooms and these had been personalised by them. What has improved since the last inspection? Four requirements were made following the key inspection in November 2008 and these have now been met. The five requirements made following a pharmacy inspection in October 2009 were not followed up during this key inspection as some of the timescales had not expired but the manager told us that these have been met. The manager told us that they are waiting for the delivery of their new controlled drugs cupboard. Risk assessments have been written for people using the service regarding their activities of daily living to include falls, manual handling and nutrition. The home now has a policy and procedure on safeguarding adults which has been reviewed. There is one paragraph that still refers to internal investigation which needs to be reviewed again and removed. All staff recruitment folders have been reviewed to ensure they contain all of the necessary information to allow the home to employ people safely. What the care home could do better: Three requirements were made as a result of this inspection. The statement of purpose should be reviewed and expanded to ensure that it contains all of the information required.Sherwood HouseDS0000013787.V378586.R01.S.docVersion 5.2A service user guide needs to be written and then supplied to all of the people who use the service. The care plans in use need to reviewed and updated to ensure they contain all the necessary information and that all people who use the service have access to them and have also agreed them. Key inspection report CARE HOMES FOR OLDER PEOPLE Sherwood House Sherwood House Severn Drive Walton-on-Thames Surrey KT12 3BQ Lead Inspector Lesley Garrett Key Unannounced Inspection 19th November 2009 10:20 DS0000013787.V378586.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought 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. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Sherwood House DS0000013787.V378586.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sherwood House Address Sherwood House Severn Drive Walton-on-Thames Surrey KT12 3BQ 01932 221170 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) sherwoodhouse@waltoncharity.org.uk Walton-on-Thames Charities Mrs Kathleen Mary White Mrs Catherine Mary Yandell Care Home 31 Category(ies) of Dementia (4), Old age, not falling within any registration, with number other category (0) of places Sherwood House DS0000013787.V378586.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia (DE) The maximum number of service users to be accommodated is 31. Date of last inspection 26th November 2008 Brief Description of the Service: Sherwood House is a purpose built home providing accommodation and care for up to 31 older people, 4 of who may also have dementia. The home is located in Walton on Thames and is close to shops and other facilities in the local community. Walton-On-Thames Charity owns the home and all service users come from the Walton on Thames area. The accommodation is arranged over two floors, with the first floor being reached by stairs or two passenger lifts. All bedrooms are single occupancy and all have a kitchenette and en-suite facilities. There are ample communal bathrooms and toilets throughout the home with most having adapted facilities. There are several sitting areas throughout the home and a large dining room. There is a well-maintained garden to the rear of the property that is accessible to service users and parking for several cars. The home has access to a mini bus for service users activities and appointments. The home has a hairdressing salon on site and a hairdresser visits the home regularly. A mobile shopping service also visits the home weekly. Sherwood House DS0000013787.V378586.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 1 Star. This means the people who use the service experience adequate quality outcomes. This inspection of the care home was an unannounced Key Inspection. Mrs Lesley Garrett, Regulation Inspector, carried out the inspection and the registered manager represented the service. We arrived at the service at 10:20 and were in the home for six hours. It was a thorough look at how well the home is performing. It took into account information provided by the home and any information that CQC has received about the service. The manager for the service supplied CQC with an AQAA (Annual Quality Assurance Assessment) and this document was used to assist with the inspection. We spent time talking and observing some of the people using the service and speaking with some staff members. Surveys were sent to the home and we received completed ones from the people who use the service, staff members and health care professionals. The information contained within some of the surveys has also been used in the report. We looked at how well the service was meeting the key national minimum standards and complying with the regulations and have in this report made judgements about the standard of the service. Documents sampled during the inspection included the home’s care plans, daily records and risk assessments, staff files, training records and the home’s safeguarding and complaints policies and procedures. From the evidence seen by us and comments received, we consider that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. What the service does well: All people that wish to use service benefit from a pre-admission assessment and the care plans are then generated from this initial assessment. People who use the service who spoke to us on the day were complimentary about the quality of the food provided. Completed surveys returned to us also made good comments about the food. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.2 Page 6 The staff spoken to on the day were knowledgeable about the care needs of the people using the service. They were observed to be interacting and speaking appropriately to the people in a calm manner. Regular training takes place and this includes the NVQ (National Vocational Qualification) which all staff have access to. The registered manager and staff have a clear understanding of safeguarding policies and procedures and regular training takes place. Major refurbishment of the home will take place next year but the home still had a homely atmosphere when we visited. People using the service were pleased to show us their bedrooms and these had been personalised by them. What has improved since the last inspection? What they could do better: Three requirements were made as a result of this inspection. The statement of purpose should be reviewed and expanded to ensure that it contains all of the information required. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.2 Page 7 A service user guide needs to be written and then supplied to all of the people who use the service. The care plans in use need to reviewed and updated to ensure they contain all the necessary information and that all people who use the service have access to them and have also agreed them. 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 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 Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 123&6 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who wish to use the service benefit from a pre-admission assessment from a suitably trained person but do not have access to enough information to assist with their decision to move into the home. EVIDENCE: We sampled the home’s statement of purpose. This document was very brief and did not contain all the information required. The home does not currently have a service user guide. Requirements will be made concerning these documents at the end of the report. It was also observed that no person using the service has a contract in place. The charity have recently issued a letter stating that new contracts are being Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 10 written and in the meantime the people using the service signed the letter agreeing to having accommodation provided. The signed letters have been placed in their administration folder. The manager told us that all people that are admitted to the home have a preadmission assessment which she carries out along with her deputy. The assessments that we observed were detailed and contained enough information for the manager to make a decision about the care needs of the individual. The care plans are then generated from this document. The home does not offer intermediate care. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plan documentation needs to be kept under review and updated by the staff to ensure all the necessary information is available. EVIDENCE: We looked at three care plans during this inspection. Since the last inspection in November 2008 the manager has changed the format and style of the care plans. The manager told us that during the past year she has worked hard reviewing all the documentation regarding each person using the service but in the main she has done this on her own. Care staff have all received training in care planning but the practice is still not embedded. For example we spoke to one person using the service who told us his preferred going to bed time and some of this information was not documented. He also had a bed rail in place but there was no risk assessment in for this. The care plans were not written Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 12 in a person centred style only giving instructions to staff and there was no evidence that the people using the service had agreed to these plans. There were some risk assessments in place but these again need to be further developed to ensure all people using the service have nutritional, bed rails, moving and handling and skin integrity risk assessments in place. The manager told us that she is now seeking advice from the Surrey Care Association to help to improve the documentation in the home further. We spoke to some staff during the day. They all told us that they understood care plans and how to write them. Further improvement is needed in writing the care plans to ensure they contain all the information required to allow all staff to care for the people in their care. From discussions with staff and people who use the service, and from viewing records, it was clear that individuals have access to all health care professionals as required. These include a General Practitioner, District Nurse, Dentist, Optician and Chiropodist. The manager told us that there are four GP surgeries that visit the home. As all people who use the service come from the Walton area many continue to be registered with their previous GP if the wish. In October 2009 the home had a pharmacy inspection following concerns that were bought to the attention of the Commission. Five requirements were made following this inspection. The manager advised us that these requirements have now all been met. The timescales for some of these requirements have not expired. The one still outstanding is the new controlled drugs cupboard which is on order and will be delivered soon. The medication procedures therefore were not tested on this occasion. Staff informed us that they respect the privacy and dignity of the people using the service through knocking on bedroom doors, calling individuals by their preferred names and providing personal care in the privacy of their bedrooms and bathrooms. Evidence of these practices was observed during this site visit. People who use the service told us:‘I have found the staff helpful and kind and usually available when you need them’. ‘Staff are very pleasant and cooperative and happy to help when asked’. In a returned survey one person told us ‘Staff could announce their name each time they address me so that I know who they are. This would enable me to engage in conversation and get to know them’. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to take part in limited social activities but are able to exercise choice in their daily lives. The quality of the meals is good which means nutritional needs should be met. EVIDENCE: The home employs an activity co-ordinator who organises activities from Monday to Friday. This person currently works fifteen hours per week and due to the lack of hours available is unable to provide one to one support for those people who are unable or too unwell to leave their bedroom. The manager told us that she would like to increase the hours of activities available if possible within the budget. An outside activity provider visits the home for chair based exercises twice a month. On the day on the inspection we observed that a number of people using the service were playing bingo upstairs. During the day we observed an activity list which was clearly displayed on the notice boards. The home is a member of the National Association for the Provision of Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 14 Activities (NAPA) and receives newsletters from them. Activities were recorded in residents care plans sampled during the site visit. The home has a mini bus and the manager told us that people who use the service have enjoyed visits to Bushey Park, a local garden centre and shopping trips. The manager told us that there are no restrictions on visitors to the home, although visits during meal times are discouraged. People who use the service told us that they can see their visitors in private and go out with them if they wish to. One person told us about an outing that he had the previous day and that he has a specially adapted car so that relatives can drive him without having to transfer out of the wheelchair. During the visit to the home we observed staff speaking to the people using the service and offering choices in their lives. This includes; where they would like to eat their meal and if they would like to join in an activity. People who use the service confirmed this in conversations with them. The manager told us that she has the benefit of a head chef who is supported by another two chefs. This ensures that the kitchen is covered seven days a week and they also cover for each other during holiday periods. A recent environmental health officer visit awarded the home four stars. There is a four week cycle of menus and people using the service are also offered choice. The manager told us that about seventy-five per cent of the people using the service come to the dining room for breakfast where a cooked breakfast can be available between eight and nine. People using the service told us:‘The home provides good quality and varied meals’. ‘I enjoy the food here there is plenty’. ‘I enjoy the food but I always eat in my room and that’s my choice’. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be confident that their complaints are listened to and that they should be protected from abuse as the staff team have received training in safeguarding adults. EVIDENCE: The manager told us that the complaints that are received by the home are mostly verbal and can be resolved quickly. A discussion took place about this and best practice would be to document these complaints and the outcome. Any complaint that the home does receive in the written format is kept in the administration file for the person using the service and the home’s investigation and outcome is documented. Since the last inspection the complaints policy has been reviewed and updated. The home does not have a service user guide available for people who use the service so the policy is not available in an individual form in their bedrooms. The manager showed us a copy of the local authority’s multi agency safeguarding procedures and all staff have access to this. During the last inspection it was observed that the home did not have a local safeguarding adults policy. This has now been written but it is not in line with the local Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 16 authority’s. This was discussed with the manager who will ensure that this policy is reviewed and updated. There have been six safeguarding referrals to the local authority since the last inspection and these have now all been resolved. Staff spoken to on the day all had knowledge of the procedures to follow and they all confirmed that they had received training. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The location and layout of the home is suitable for its stated purpose. It is accessible with a pleasant and homely atmosphere. EVIDENCE: Accommodation is arranged over two floors, with the first floor being reached by stairs or two passenger lifts. All bedrooms are single occupancy and all have en-suite facilities. The manager said that since the last inspection the small kitchenettes have gradually been removed as the room became vacant. They were removed as the people using the service could no longer manage to make hot drinks unaided. The bedrooms that we observed were light and spacious and where the kitchenette was has now become, in some bedrooms, Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 18 a small extra seating area. The manager told us that the bedrooms are unfurnished so that people moving into the home can bring with them their own furniture and personal items as long as they comply with the fire regulations. All bedrooms observed were personalised with a very homely appearance. The manager showed us the plans for the planned refurbishment of the home which is due to start next year. The people who use the service have been consulted as this will cause some disruption to the running of the home. During the tour of the building it was observed that in some communal areas lighting was dull and some decoration needed refreshing. It was also noted that there was only two assisted baths available for the people using the service. The other two bathrooms that were available were not able to be used as they were difficult to climb in and out of. The manager told us these were all things that would be addressed during the refurbishment. There was also to be some changes to the gardens giving some raised flower beds and a summer house. People who use the service told us:‘I would like the entry lounge to each group of five bedrooms to be brightened up’. ‘Window panes need replacing they’re blown’. ‘I would like more bathing facilities so we can have more than one bath a week’. The home has the benefit of a housekeeper who is responsible for the laundry Monday to Friday. The manager told us that the carers cover the laundry at weekends if they have time. The housekeeper confirmed that she had received regular training and this included infection control. It was observed that paper towels, liquid soap, gloves and aprons were all available to aid the staff with their infection control procedures. The home also has a team of two domestic staff who are responsible for the cleanliness of the home. On the day of the site visit the home was clean, tidy and free from offensive odours. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff numbers at the home on the day of inspection were sufficient to meet the assessed needs of the people using the service. NVQ training for the care staff continues to ensure a good skill mix of staff on duty. EVIDENCE: We sampled the staff rotas which showed us that the numbers were consistent. Since the last inspection staffing numbers have been increased due to the increasing dependency of the people using the service. We were told that Monday to Friday the manager and the deputy manager are supernumerary. They are supported in the morning shift by one or two senior carers and five carers. In the afternoon there are one to two seniors supported by four carers. The manager told us that although staffing levels had been increased for the day shifts staffing levels at night remained the same with just two carers. The manager did tell us that the afternoon staff are on duty until ten so many of the people who use the service are in bed. Due to the layout of the building and the dependency of the people who use the service some consideration should be given to increasing the number of staff at night. The manager told us that she was interviewing for more night staff currently. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 20 The manager told us that most staff have now achieved their National Vocational Qualification (NVQ) at level 2 and senior carers have either achieved level 3 or are currently enrolled on the course. The manager told us that this training is always on going and available through a local college. We sampled two staff folders for recently recruited members of staff. All the necessary documentation was in place to allow the manager to employ those members of staff safely. Since the last inspection we were told that the recruitment folders had been reviewed in order to comply with the requirement made at that time. All staff employed now receive an induction that is linked with Skills for Care following the requirement that was made at the last inspection. Supervision takes place every two months but the manager told us that the charity does not carry out yearly appraisals for the staff. The manager told us that since the last inspection she has now developed some documentation with regard to the training needs of the staff. This document identifies the training that staff have undertaken and when the mandatory and regular training needs updating. Mandatory training that is available at the home includes safeguarding adults, moving and handling, health and safety, first aid, infection control and the senior carers do medication procedures. We were told that other training is available if the need of the people using the service requires this for example dementia awareness. Staff that we spoke to on the day confirmed that they all had access to training. Staff that completed and returned surveys confirmed that they had received a variety of training to help with the work that they undertook. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management arrangements need to be strengthened to ensure the smooth and efficient running of the home. EVIDENCE: On the day of inspection the manager was a day off but came in at lunch time to assist us. Prior to this inspection an AQAA had been completed by her. This document was very brief and did not allow us to have a clear picture of the home and did not contain all of the information requested. The manager told us that she was about to go on annual leave so rushed to complete the document. It is the registered manager’s responsibility to ensure that the AQAA is fully completed and returned to us within the timescales. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 22 The manager has been in post for four years and registered with us since 2005. She has achieved her registered manager’s award and has a nursing qualification. The manager said that most of her time is taken up with paper work which keeps her in the office for the majority of the time. She has also been responsible for writing and reviewing some policies and procedures. Some surveys returned to us from carers were not complimentary about the management of the home. Some comments received included:‘Better communication would be good’. ‘The manager should have more time to come out of the office and talk to staff and service users’. ‘The charity has restructured Sherwood House and this has caused some problems and upset with the staff. Staff morale is low’. On the day of the inspection none of these concerns were raised with us. When we spoke with the staff they were knowledgeable about their roles and responsibilities and were very positive in their conversations with us. One health care professional that completed a survey told us ‘On arrival at Sherwood House you always get a warm, friendly welcome. I have noticed how caring and attentive the staff are’. It was also noted on the staff rota that many of the staff have been employed at the home for a long time with very few new staff members. The manager is supported at the home by a full time deputy manager and senior carers. The statement of purpose was very brief and there was no service user guide in place. The manager told us that these documents were the responsibility of the responsible individual however the manager should ensure that she has these in place for the people using the service. Requirements have been made. The manager has changed the care plan format so that these can be completed giving the reader more detail. She has sought guidance from the Surrey Care Association regarding care planning. Staff have received training in care plans but still these documents do not contain all of the information required and a requirement has been made. The manager told us that surveys are sent every year to the people using the service and their relatives to seek their views on the service provided. These surveys have just been completed for this year and the manager was in the process of collating the information. The manager does not seek the views of healthcare professionals and it was recommended that this be carried out. The manager also told us that they have held resident meetings but this is not a regular occurrence. The last meeting that took place was to discuss the refurbishment of the home during next year and relatives were invited to this meeting. Regulation 26 visits take place every month and the reports are available at the home. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 23 People who use the service are able to deposit some personal allowance with the service. The manager told us that this cash is audited every week by two members of staff. All receipts are kept to provide a clear audit trail. This system was not sampled during this inspection. The completed AQAA confirmed that the home has most of the necessary health and safety certificates in place. There was no certificate date for the homes electrical circuits or their gas appliances. Please advise CQC of these dates to ensure that these certificates are current. Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 1 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 N/A 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 2 X 3 X 3 X X 3 Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 25 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 OP1 Regulation 4 Requirement The statement of purpose should be reviewed to ensure that it contains all of the information required in the regulation and schedule 1 A service user guide needs to be written and then supplied to all of the people who use the service. The care plans in use need to reviewed and updated to ensure they contain all the necessary information and that all people who use the service have access to them and have also agreed them. Timescale for action 01/02/10 2. OP1 5 01/02/10 3. OP7 15 01/01/10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 26 Sherwood House DS0000013787.V378586.R01.S.doc Version 5.3 Page 27 Care Quality Commission South East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.southeast@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. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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