Inspection on 10/08/05 for Sue Ryder Care Centre

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sue Ryder Care Centre 17/08/07

Sue Ryder Care Centre 05/09/06

Sue Ryder Care Centre 27/01/06

Sue Ryder Care Centre 24/02/05

Sue Ryder Care Centre 04/08/04

Sue Ryder Care Centre 23/02/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Sue Ryder Care Centre Holme Hall Holme On Spalding Moor East Yorkshire YO43 4BS Lead Inspector David White Unannounced 10 August 2005 th 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 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 Stationary 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. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sue Ryder Care Centre Address Holme Hall, Holme On Spalding Moor, East Yorkshire, YO43 4BS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01430 860904 01430 869591 N/A Sue Ryder Care Mrs Linda Christine Chapman Care Home 40 Category(ies) of Physical disability (40), Physical disability over registration, with number 65 years of age (40) of places Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24/02/05 Brief Description of the Service: The premises, known as Sue Ryder Care Home, date approximately from 1742 and were previously used as a convent. It is a Grade II listed building set in extensive grounds and has a chapel in the grounds to which the local community attend. Accommodation is currently provided on three floors following a major building and refurbishment programme a few years ago. Bedrooms are provided on the first and second floors with lounges and other communal areas on the ground floor. The home is served by two passenger lifts. The home has achieved Practice Development Unit status accredited by the University of Leeds. The home no longer provides day care services. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 hours. The inspector looked around the premises and a number of records were inspected. The inspector spoke with four residents, one visitor, one nurse and the manager. The care records of four residents were looked at. What the service does well: Residents are encouraged to be independent. The management and staff team put the needs of residents first. A visitor feels that “I am so lucky that I am able to be so involved in my wife’s care” and said that the “home is run as a family type home”.. Residents feel that the staff team are always polite and respectful. A wide range of training is provided to enable staff to have the knowledge and skills to meet resident needs. Resident views are listened to and acted upon. Care planning documentation provides the staff with detailed information about the needs of the residents and how these are to be met. A wide range of modern aids, adaptations and equipment are available to promote the independence and safety of the residents. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 6 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. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 4. Residents are aware of the care, services and facilities provided by the home and feel confident that their needs will be understood and met by the home’s staff. EVIDENCE: Prospective residents and their relatives are given information about the home prior to admission. Residents said they were offered the chance to visit the home with their relatives prior to making a decision about moving into the home. The admission procedure is very thorough and this makes sure that residents are properly assessed and that staff are fully aware of their needs. Information is gathered from residents’ relatives and other care professionals such as care managers and doctors as part of the assessment process. Any risks are identified as part of the pre-admission process. Staff have a good understanding of the needs of the residents and receive a wide range of training specific to the needs of the residents in their care. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 and 10 Care planning documentation information to be able to care making decisions about the independence. The lack of a risk put the resident at risk of harm. EVIDENCE: The organisation is introducing new care planning documentation for all residents. The care plans inspected contained detailed information that specified the needs of each resident and how these were to be met. Risk assessments were in place regarding the prevention of pressure sores, nutrition and to reduce resident risk of falling. Other specific risk assessments had been carried out in relation to medication and smoking. One resident has bedrails but there was no record that a risk assessment had been carried out to reduce the risks from the use of bedrails. Care plans are reviewed regularly and encourage the involvement of the family and other health professionals in the review of care. Residents feel that their needs are met. One resident said “staff are very good” whilst another said “all the staff are friendly, helpful and caring”. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 10 is detailed and provides staff with the for the residents. Residents are involved in home with the aim of promoting their assessment for one resident could potentially There are staff handover periods so that information is passed on between shifts. The home also has a communication book and a diary to keep staff up to date about what has happened and reminders about what needs to be done. However both the communication book and the diary contained personal information about a number of different residents. This does not meet data protection standards. Residents feel that they are involved in the decision-making of the home and resident meetings are held and recorded. There are a number of notice boards throughout the home which provide information to residents about the running of the organisation. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 and 17 Residents enjoy social activities both in and outside the home. Flexible visiting times mean residents can maintain links with family and friends. The meals are good and offer choice and variety. EVIDENCE: The home has 2 recreational assistants who provide a number of activities to suit all resident needs. Residents have access to computers and can choose from a range of other activities. A party was recently held at the home for one of the residents and there are leaflets on notice boards advertising forthcoming events. Residents also enjoy outings in the home’s minibus. One recreational assistant works on each floor of the home and it is part of their role to provide social stimulation for those residents who are confined to bed. The personal interests and hobbies of each resident are recorded within their care records. Visitors are welcome in the home at any time. One visitor said he was always greeted by friendly staff and described the home as “wonderful”. This visitor spoke very highly of the staff and management at the home and feels that he is “very lucky to be so involved in my wife’s care” saying “the home’s approach Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 12 is very inclusive”. The visitor was able to confirm that he receives invites and attends relative meetings in the home. There is a choice of menu available at each mealtime. Alternative food is offered if a resident does not like the food options on the menu. The home caters for special dietary needs. Residents are assisted with eating where support is needed. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19 The personal and healthcare needs of residents are well met with good access available to specialist healthcare services when required. EVIDENCE: On the day of inspection staff could be seen trying to encourage residents’ independence. Individual care plans state clearly how needs have been assessed and the actions that need to be taken to meet identified needs. Daily routines are flexible and dependent on the preferences of the residents. The preferred routines of residents are recorded within the plans of care. Residents feel that they are “always treated with respect” and said that call bells are always responded to promptly. One resident who was spoken to has a pressure sore and specialist equipment was in use to meet this need. Residents have access to a GP and other healthcare services and there is a physiotherapy department on-site. A beauty therapist visits the home. Some residents have difficulty communicating their needs and the care plans pay attention to specific detail and individual actions required to make sure residents are comfortable. The home is considering other ways in which this information could be made easily accessible and specific for each resident so that all staff including those who are new and agency workers have a good understanding of what is needed to make sure each individuals comfort. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 All complaints and concerns are dealt with appropriately and abuse policies and procedures safeguard resident wellbeing. EVIDENCE: The home has a complaints policies and procedure which residents, relatives and others have access to. The complaints records held by the home contain information about the nature of the complaint, investigations undertaken and actions taken. Residents are aware of who they would need to see if they had any concerns. Adult protection policies and procedures are in place and staff are given adult abuse training from the point of induction. A member of staff spoken to showed a good understanding of adult protection procedures. The home has recently been dealing with an incident of abuse and the correct authority had been informed of the incident. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 29 and 30 The standard of the environment is good and provides residents with a clean and homely place in which to live. Specialist aids and equipment are in place to support staff to meet the specific needs of the residents. EVIDENCE: Four residents rooms were looked at and these were clean, tidy and comfortable as was the home in general. Residents have access to all parts of the home and there are lifts to promote access for wheelchair users. One lift although still working is in need of repair and the manager has arranged for this work to take place. A contingency plan has been made so that the repair work does not cause too much disruption to residents. There are aids and adaptations throughout the home to promote the independence of residents and there are plans to extend the space in shower areas. Residents said that the home is always kept clean. Laundry assistants are employed to look after resident personal clothing and all the residents looked clean and tidy. Sluicing facilities help to reduce risks from the spread of infection and there were plentiful supplies of aprons, hand paper towels, soap dispensers and alcohol gel throughout the home. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 16 Call bell systems are located in bedrooms, toilets and all communal areas of the home and residents said these were responded to quickly. Random checks of hot water temperatures in the bathrooms were found to be within safe limits. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34, 35 and 36 The staff team work positively with residents to improve their whole quality of life. EVIDENCE: There were 2 qualified nurses and 8 carers on duty plus the manager to care for 34 residents. The residents looked well cared for and staff carried out their duties in an unhurried manner. The manager has recently recruited extra nursing staff and carers and so the need for agency staff is less frequent. Residents praised the attitudes and abilities of the staff. One visitor said that staff are “wonderful” and feels that the management of the home is “absolutely excellent”. Residents said agency staff were good although “not quite as efficient as the permanent staff”. The home has achieved Practice Development Unit status accredited by the University of Leeds. The manager has forged links with resource centres and a wide range of training is available to staff to improve their knowledge and skills of the resident group. A training officer is on-site to co-ordinate training programmes and this person was seen to be supporting a new member of staff with his induction at the time of inspection. A number of carers are doing the NVQ level 2 training. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 18 The inspector spoke to a recently employed member of staff. This member of staff said that he would be going on a neurological course at Leeds University to improve his knowledge of the resident group. Induction training is given to new members of staff and all staff have a job description. Supervision arrangements are now in place for all staff and a senior nurse has been given the lead clinical supervisor role. Staff meetings are held on a regular basis and records from these are available. The inspector looked at the staff files of three recently appointed members of staff. These contained information to show that thorough pre-employment checks are carried out before a new member of staff starts working at the home. Each member of staff has a personal performance file which contains information about their job descriptions and training and supervision records. The organisation has recently carried out a “harmonisation programme” which has lead to improved pay and terms and conditions for the staff. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40 and 42 The home is well run by the manager who puts the views of the residents first. The home reviews its performance through feedback from residents, relatives, staff and others. EVIDENCE: The registered manager is well experienced in running the home and leads others by example. She is supported by a Clinical Head of Services to carry out her management duties. The registered manager is doing the Registered Manager’s Award to develop her management skills. Residents, relatives and staff spoke well of the manager’s abilities. A visitor said she was “absolutely excellent” and residents said she was “approachable and efficient”. The organisation has a number of quality performance indicators and the home and individual staff aims and objectives are linked to these. Surveys have been sent out to residents to find out their views about the home but response to the surveys has been poor although some feedback has been provided via eSue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 20 mailing systems. Regular resident and relative meetings are held and a visitor said that comments from these meetings are acted upon. There is a book which enables visitors to make comments about the home. Care plans are reviewed regularly and encourage the involvement of the family and other health professionals in the review of care. A Performance Manager for the organisation makes unannounced monthly visits to the home and findings from these visits are sent to the Commission. Arrangements are in place for the protection of residents and a number of policies and procedures have been reviewed and updated recently. Individual and general risk assessments are carried out and recommendations from fire officer and environmental health inspections are acted upon. Aids, adaptations and equipment are all regularly serviced. All staff have health and safety training from the point of induction. Sue Ryder Care Centre J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 1 1 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score 3 2 x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sue Ryder Care Centre Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 2 x 3 3 x 3 x J53_J04_S955_Sue Ryder_V234674_190705_Stage 4.doc Version 1.30 Page 22 yes 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 9 Regulation 13 Requirement A risk assessment must be carried out on each resident who has bedrails. Personal information about residents must be individually held. Timescale for action As from 10/08/05 and thereafter As from 10/08/05 and thereafter 2. 10 17 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 32 37 Good Practice Recommendations 50 of care staff in the home should be trained to NVQ level 2 by 2005. The registered manager should be qualified to NVQ level 4 or equivalent by 2005. 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