Care Home: The Sharmway

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What the care home does well This home provides a very clean, comfortable well maintained environment which is homely. People are pleased with their environment and one told us, `It`s a home from home.....I`m very comfortable here`. People are consulted so that their needs and preferences are known and care plans provide staff with relevant information so that they can provide the right support to each person and meet their cultural and well as their physical needs. One social worker told us that she was particularly pleased with the way in which the home meets the cultural needs of the person she had helped to place there. People are supported to receive appropriate health care and to follow a healthy lifestyle. The staff communicate well with health professionals. One visiting professional told us, `There is very good communication with me`. People are The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 protected by the home`s arrangements for the storage and administration of medication. People choose how they spend their days. There are suitable activities and a choice of where to sit. Visitors are welcomed to the home. There is a good variety of food and menus suit the people in the home. One person who lives in the home told us, `I look forward to my meals, there is always plenty to eat`. There are good arrangements for handling complaints and comments and for protecting people who live in the home. There is a staff team made up of people who receive ongoing training so that they are competent. The manager is committed to maintaining high standards and making improvements where possible. One relative told us that there are, `very high standards`. Another told us, `They look after the people in their care, make sure they are happy`. The system for assuring the quality of the care takes account of people`s comments about the service they receive and the manager is constantly looking for ways to improve the home. What has improved since the last inspection? The care plans are now more detailed and individual, so that staff are better informed about how to meet each person`s needs in the way they need and prefer. Staff have received further training in the safe handling of medication so that people are better protected by the home`s practice in this area. The risk assessments are more detailed so that people using the building are better protected. The range of activities has been increased and activities are rotated so that people do not get bored. There are more opportunities for people to go out of the home. The menus have been changed as a result of listening to people in the home, so that people receive the food which they prefer to eat.The SharmwayDS0000017027.V376604.R01.S.docVersion 5.2 What the care home could do better: The manager has identified the need to try to involve people more in planning their own care and to help them to have better access to information. This would ensure that people`s needs continue to be met in a way which meets their individual needs. The daily reports of what people have done vary in quality. The manager has identified the need for these to be more consistent and plans to provide some staff with more guidance in this area. Key inspection report CARE HOMES FOR OLDER PEOPLE The Sharmway 113 Handsworth Wood Road Handsworth Birmingham West Midlands B20 2PH Lead Inspector Chris Lancashire Key Unannounced Inspection 6th July 2009 10:00 DS0000017027.V376604.R01.S.do c Version 5.2 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. The Sharmway DS0000017027.V376604.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 The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Sharmway Address 113 Handsworth Wood Road Handsworth Birmingham West Midlands B20 2PH 0121 554 6061 F/P 0121 554 6061 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Winnie Purcell Provider in day to day control Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places The Sharmway DS0000017027.V376604.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. Old age, not falling within any other category (OP) 11 The maximum number of service users who can be accommodated is: 11 5th June 2007 Date of last inspection Brief Description of the Service: The Sharmway is a three storey detached property located on Handsworth Wood Road. It accommodates up to 11 older adults, and is within access of public transport links to Birmingham City Centre. The home is close to local facilities including shops and places of worship. There is a double bedroom on the ground floor and a WC with wash hand basin by the front entrance. A shower facility, laundry and kitchen are located along the hall. Adjacent to these are two communal areas to the front and rear of the property. The front room is mainly used as a dining room and the rear room is a lounge. There is a stair lift, which provides access to the first floor. This has four single bedrooms and one double, a shower facility and bathroom with bath hoist chair. There are two further WCs on this floor. The second floor is accessed by means of stairs, and has two single and one double bedroom, with bathroom and WC facilities. All bedrooms are lockable and have a hand wash basin, covered radiators, window restrictors and an emergency call system. There is ramped access to the side of the property and parallel handrails either side of the front passageway. There is a large well-maintained garden to the rear, and car parking at the front of the building. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 5 The fees for this home are available on application to the home. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We visited this home on a weekday without telling anyone that we would be arriving. The purpose of the visit was to see how the home is meeting key National Minimum Standards and to make sure that the requirements made in previous reports have been addressed. Before the visit we had received information from the manager in an Annual Quality Assurance Assessment (AQAA). This told us about the running of the home during the past year and the plans for development. This information arrived when we asked for it and it contained good detail. At the inspection we spoke to the manager, several members of the staff team and several people who live at the home. We looked round the building and into several bedrooms. We chose three people who live in the home and looked at the records which the home is required to keep about them. These include records about people’s needs and preferences, safety, menus, staff rotas, medication and complaints. We spoke to these people and looked at how they spend their time. This helps us to know how well the home is meeting their needs. We also looked at records of staff recruitment and training, minutes of meetings and the systems which the home has for monitoring its performance. We sent questionnaire to people who live in the home, their relatives and visiting professionals and we received ten responses from people in the home, two from relatives and four from professionals. We also spoke with one social worker on the telephone. We this information from all these sources to write this report. What the service does well: This home provides a very clean, comfortable well maintained environment which is homely. People are pleased with their environment and one told us, ‘It’s a home from home…..I’m very comfortable here’. People are consulted so that their needs and preferences are known and care plans provide staff with relevant information so that they can provide the right support to each person and meet their cultural and well as their physical needs. One social worker told us that she was particularly pleased with the way in which the home meets the cultural needs of the person she had helped to place there. People are supported to receive appropriate health care and to follow a healthy lifestyle. The staff communicate well with health professionals. One visiting professional told us, ‘There is very good communication with me’. People are The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 7 protected by the homes arrangements for the storage and administration of medication. People choose how they spend their days. There are suitable activities and a choice of where to sit. Visitors are welcomed to the home. There is a good variety of food and menus suit the people in the home. One person who lives in the home told us, ‘I look forward to my meals, there is always plenty to eat’. There are good arrangements for handling complaints and comments and for protecting people who live in the home. There is a staff team made up of people who receive ongoing training so that they are competent. The manager is committed to maintaining high standards and making improvements where possible. One relative told us that there are, ‘very high standards’. Another told us, ‘They look after the people in their care, make sure they are happy’. The system for assuring the quality of the care takes account of peoples comments about the service they receive and the manager is constantly looking for ways to improve the home. What has improved since the last inspection? The care plans are now more detailed and individual, so that staff are better informed about how to meet each person’s needs in the way they need and prefer. Staff have received further training in the safe handling of medication so that people are better protected by the home’s practice in this area. The risk assessments are more detailed so that people using the building are better protected. The range of activities has been increased and activities are rotated so that people do not get bored. There are more opportunities for people to go out of the home. The menus have been changed as a result of listening to people in the home, so that people receive the food which they prefer to eat. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 8 What they could do better: 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. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 10 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): 3. People who are considering moving into this home are provided with the necessary information to make an informed choice. Assessments and visits to the home ensure that people know, before they move in, that their needs can be met by the home. 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. EVIDENCE: The manager told us that new people are admitted on the basis of a full and comprehensive assessment that is carried out by the manager or the deputy manager and that the assessment is undertaken with the person and or their representative. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 11 We looked at the files for three of the people who live in the home, including those for people who had most recently been admitted. All the files included an assessment of the people’s needs. Areas covered by the assessments include personal details and needs in terms of physical care, communication, mobility, personal safety, religious, cultural and social needs. People’s preferences are also recorded and the assessments are detailed, providing useful information from which to draw up the care plan which informs staff about how to provide suitable care. The files which we sampled showed assessments were signed by the person concerned, suggesting that they had been involved with and agreed with the assessment. The Sharmway provides respite care on occasions, and the manager told us that when this happens, people are supported to maintain their independence skills so that they do not become more dependent during their stay at the home. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 12 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’s health, personal and social needs are set out in a care plan so that they can be met by staff. People are treated with respect and their privacy and dignity are maintained. They are protected by the home’s practices in relation to the storage and administration of medication. 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. EVIDENCE: We looked at the files of three people living in the home and saw that they all had care plans, which had been drawn up using the information in the original assessment of their needs. The care plans contained good details for staff to follow, explaining how each person needs and prefers to be supported. For example, in the plan of someone who is at risk of developing pressure sores, there are instructions to observe the vulnerable areas whenever possible and to encourage the person to move around. Peoples needs and preferences in The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 13 terms of personal care such as bathing are recorded. For example, the instruction on one person’s plan is, The bath hoist will need to be operated by staff although x is quite capable of washing herself. These plans make sure that people receive suitable care from staff. The staff keep records of what people have done each day and this helps to provide evidence that the care plans have been followed. We found these records to be of an acceptable quality and to provide useful detail, but some were more detailed than others. The manager said that there has been some improvement in the quality of recording recently, but she has recognised the need for recording to be more consistent and plans to provide more guidance for some staff in this area. The care plans contain good details of peoples health needs and the medication which they need to take. We saw details of appointments with a variety of health professionals such as GPs, dentists, hospital specialists, audiologists and chiropodists on peoples files. The manager told us that people are encouraged to maintain a healthy lifestyle and are encouraged to remain as mobile as independent as possible. We saw reminders to people to drink plenty of fluids during the hot weather. The inspection took place during a time of high risk for people contracting swine flu. We saw a notice on the door asking visitors not to enter the home if they had any symptoms. We looked at the arrangements for storage, administration and recording of medication for people in the home. All staff have received training in the safe handling of medicines. We saw that there are suitable facilities for storing medication and the doses which people have been given are clearly recorded. The medication which each person needs to take is recorded on their files in addition to the medication records. We saw notes for staff in care plans, advising them to look up the medication in the relevant book to become familiar with the effects and possible side effects. These measures help to make sure that people are protected by the homes practices in relation to medication. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Peoples lifestyles in the home match their preferences and suitable activities are arranged. They are encouraged to maintain significant relationships with people in the community and they receive a choice of nutritious meals which meet their needs and take account of their preferences. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager told us that people take part in a variety of activities including exercises, meals out, games and barbecues. We saw the records of activities which people had undertaken and these included bingo, listening to music and watching videos, skittles, story telling, knitting and Birthday celebrations. Some people had also attended prayers and church. In response to our questionnaires, people told us that they were pleased with the number and range of activities on offer. We spoke with several people who live in the home and they told us that they do not get bored as there is always something to do or someone to talk to. One visiting professional told us that she was pleased with the home because it was able to meet the cultural needs of the person The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 15 whom she had placed there. We saw that the home is particularly good at meeting the needs of people with an Irish cultural heritage. However, the staff team is varied in terms of ethnic and cultural background and we saw that people from other cultures are also well catered for. A professional visitor told us, ‘they are not judgemental’. This shows that people have the choice of a range of activities which meet their needs and expectations and their cultural needs are met. We saw instructions for staff about how to assist people with their appearance. We saw records of visits by the hairdresser, foot massages and nail care. People look well groomed. The WC and bathing facilities are large enough for people to be provided with assistance in privacy. This shows that people are helped to maintain their dignity. We saw nutritional assessments on peoples files and details of what they preferred and did not like to eat in their care plans. We also saw that the care plans contain details of peoples specific needs when they have medical or cultural reasons for needing to follow a particular diet. The menus show that people are offered a varied diet, with a choice at each mealtime. Staff record the choices made at each meal time and these records show that sometimes people ask for something which is not on the menu and they are provided with it. We saw details of times when people had been taken out for meals such as a carvery, and food nights, such as a Caribbean night, a Chinese and a country Kentucky night when people had been encouraged to try food from a variety of different cultures. The inspector ate a meal on the day of the inspection. It was well presented, appeared to be well balanced in terms of nutrition and was tasty. Several people told us that they had enjoyed their meal and they said that the food us usually very good. This shows that people receive meals which meet their needs and preferences and promote good health. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 16 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. There are good arrangements to ensure that people are protected, including the arrangements for handling complaints. 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. EVIDENCE: The manager told us that there is a clear procedure for handling complaints and details of how to complain are provided in the Statement of Purpose and service user guide to the home, in addition to the individual contracts. This makes sure that people know how to complain. In addition to the formal procedure, there is also a niggles book for recording minor events and comments. There is also a procedure for protecting people from abuse. We spoke to three people who live in the home and they confirmed that they would know how to complain, but they all said that they were very pleased with the home. One said, there is nothing to complain about. The records show that during the past year, there have been no incidents which required the adult protection procedures to be followed and no formal complaints about the home. The procedure for staff recruitments includes taking up references and checks through the Criminal Records Bureau and we sampled three staff files. These showed that the process had been followed. The records show that staff are The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 17 trained in whistleblowing and adult protection. Three people told us that they feel safe in the home. This means that staff are made aware of the need to protect people in the home and people are well protected by the homes procedures and practice in this area. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 18 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 live in a very clean, homely and safe environment which meets their needs. 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. EVIDENCE: We looked around all the communal areas of the home and several bedrooms. All areas were very clean, well maintained and free from unpleasant odours. This home is a large, three storey house and has a homely feel, with plenty of ornaments and pictures. There seating is varied so that people have choice. The bedrooms have personal items. There have been no changes to the layout of the home since the last inspection. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 19 The exterior of the home remains well maintained with a garden to the front with flowers and shrubs. Ramped access to the side of the property, and parallel handrails either side of the front passageway allow for people to have easy access to the property. The lounge and dining area are spacious and well laid out enabling people to move around safely. These are comfortably furnished and decorated. The rear lounge has a large patio door to the garden providing good views of the garden. The rear garden is spacious, well maintained, and relatively level. The manager told us that good use is made of the garden in the warm weather. There is an adequate number of bathrooms, shower rooms and toilets throughout the home. These facilities allowed for assistance from staff, and are within reach of communal areas so that people who live in the home can access them without too much difficulty. There are some aids and adaptations throughout the home including a stair lift, emergency call system, and grab rails, which enabled some people to move around more independently. The bedrooms on the first floor can be reached by means of a stair lift, but people need to use a few stairs to reach the next floor. The records show that the people using these rooms have been assessed as fit enough to negotiate the stairs. The manager reviews these assessments on a regular basis. The laundry room has a sluice that is able to cater for soiled items .An industrial sluice washing machine with specific programmes to meet disinfection standards is used. We saw that a clinical waste contract is in place to ensure collection of clinical waste to comply with infection control procedures. The records show that all staff is trained in accordance with infection control and its prevention. There was a risk of infection with the swine flu virus at the time of the inspection and the manager had supplied all staff with kits so that they had antibacterial hand gel at all times. There were good instructions for staff and visitors about minimising the risk of infection. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 20 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. The people who live in this home are cared for by sufficient numbers of staff who are well trained and competent to do their jobs. They are protected by the home’s recruitment practices. 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. EVIDENCE: The rotas show that there are adequate numbers of staff on duty at all times, in addition to a manager. There were four members of staff in the home on the day of the inspection. The records show that the team is well balanced in terms of gender and ethnic background, to reflect and meet the needs of the people in the home. We sampled three staff files and found that there is a standard process of recruitment and selection, which includes taking up references and checks through the Criminal Records Bureau. The manager told us that all staff receive an induction and this is followed by additional training in areas relevant to meeting the needs of the people in the home. The records show that all members of the staff team have received training to NVQ level 2 or above. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 21 The manager supervises the staff on a regular basis and this includes supervising their practice as well as discussion and consideration of their training needs. For example, on one file we sampled, the record stated, ‘x has been observed during direct service user care and has safely carried out the high risk elements in preventing the spread of infection’. We observed staff in their interactions with people and they seemed to have a good relationship with the people in the home. People told us that staff are ‘caring’ and ‘lovely’. They confirmed that staff provide them with the care which they need and respect their choices. This shows that staff are well trained and competent in their role. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 22 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): 31,33,35,38. People live in a well managed home which is run in their best interests and where there are good systems for maintaining the quality of care. Their financial interests are safeguarded and their health, safety and welfare is promoted and protected. 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. EVIDENCE: The manager is well qualified and experienced in running the home. She has made sure that the requirements and recommendations made at the last inspection have been addressed. At this visit we saw evidence of progress The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 23 made in making sure that not only are people looked after well but the records demonstrate that their needs are met. The home has a system for monitoring the quality of the service provided. This includes seeking feedback from people living in the home, their relatives and visitors. There is an annual audit each July. The manager made the findings of the last audit available to us and this demonstrated that her assessment of the home matched our findings. The information in the AQAA shows that the manager identifies areas for improvement in the home, so that the high standards can be maintained and raised where possible. Where people are unable to manage their financial affairs, their relatives manage them. Where people require personal items there is a system in place to bill relatives; this includes retaining the receipts for spending undertaken on their behalf. The manager provided details of the dates for the servicing and checks on equipment in the home. We sampled the records and found that the dates were correct. We also saw risk assessments, including one for fire and guidance for staff about controlling risks. This means that there are good arrangements for making sure that people using the building and living in the home are kept safe. The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 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 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Sharmway DS0000017027.V376604.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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. 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