Inspection on 14/03/06 for Sue Ryder Care Centre

This inspection was carried out on 14th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sue Ryder Care Centre 29/08/07

Sue Ryder Care Centre 09/08/06

Sue Ryder Care Centre 29/11/05

Sue Ryder Care Centre 22/02/05

Sue Ryder Care Centre 10/08/04

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 Hickleton Hall Hickleton Doncaster South Yorkshire DN5 7BB Lead Inspector Mr Rob Curr Unannounced Inspection 14th March 2006 09:00 Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sue Ryder Care Centre Address Hickleton Hall Hickleton Doncaster South Yorkshire DN5 7BB 01709 892070 01709 890140 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) Sue Ryder Care Ann Marie Wood Care Home 48 Category(ies) of Physical disability (48), Physical disability over registration, with number 65 years of age (35) of places Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: Hickleton Hall was built in the 1740’s and has been the home of Sue Ryder Care since it was first opened in 1961. It is a large country house, with historical interest, located in the village of Hickleton on the outskirts of Doncaster. It is set in its own grounds and there are some buildings, which are not used by the home and remain empty. The home has three floors, which are accessible to residents by a shaft lift. The majority of the communal space is situated on the ground floor with large areas available for activities. There is a smoker’s lounge, a dining room, hairdressing facility and visitor’s room along with lounge and reception rooms available to residents. There are separate day care facilities and a chapel for residents use. Service users currently residing at the home fall into two category’s, elderly and young adults, with various permutations in evidence. The home provides care with nursing and those who are under 65 predominantly have neurological conditions, and ceased admitting older people in 2002. The home has been awarded Preferred Provider Status by the Multiple Sclerosis Society for its respite care facilities. Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 1.45 p.m. and lasted 2 hours. A second inspector – Janis Robinson was present during the inspection, which lessened the time on site. All but five of the key standards were met during the last inspection therefore progress of requirements and recommendations were made during this visit. The main inspection method was observation of routines and the quality of interaction between staff and residents. The manager was present during the inspection and the inspectors also discussed practice at the home with her. The residents were very helpful during the inspection process, offering an opportunity to talk about what life was like at the home. In all – 3 residents and 3 staff members were spoken to. The Manager and staff were helpful and assisted the inspectors throughout the visit. What the service does well: What has improved since the last inspection? The team as a whole have worked hard to maintain and enhance the service delivery. There have been further improvements to the environment and facilities. The refurbishment and decorating plan was on target and a variety of improvements had been completed. Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 6 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 DS0000015874.V288392.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5 Residents had individual terms and conditions of residence. EVIDENCE: The above key standard was not fully assessed, as this was checked and met during the last inspection. The varied needs of the resident group were discussed with the manager. It was stated that the organisation was in discussions with the CSCI with regard to the issue of registering to care for the most appropriate service user group. Contracts of care were seen in the files checked. However in three of the files checked, the residents or a representative had not signed the contracts. Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 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 the following standard(s): 6, 7, 8, 9 and 10 The information within the care plans was not clear Not all residents were involved in making decisions about their own lives. EVIDENCE: Four residents files were checked. These did not contain all of the relevant information in order to minimise risks to residents. Some risk assessments need to be reviewed with residents or an advocate. One resident’s bedroom door still had an alarm fitted to the door. This system needs a comprehensive risk assessment in place and where possible the agreement of the resident or their representative. Staff were unclear as to the use of this alarm. One resident said that they could see their files with staff support. Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 16 The staff did not always show respect for the people; in the way they spoke about them. The service users were observed to be offered choices and were supported to make everyday decisions. EVIDENCE: Staff were overheard discussing a resident that was being ‘vocal’ in the privacy of her room. Staff described this as “she’s still kicking off.” This is not a dignified manner in which to refer to resident’s behaviour. Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 18 and 19 Care plans need further clarity to indicate the support residents require. EVIDENCE: One care plan stated that a resident was ‘no longer able to feed himself without assistance and needs prompting to eat’. The inspectors noted that this resident’s meal was left in his room. The meal was cold and the resident had left the room. There were no staff in the vicinity to assist him with his meal. The inspector discussed this with the nurse and this was remedied this immediately. This same resident should be having his weight checked monthly. This had not been carried out since October 2005. It was noted in one care plan that a resident was ‘put on a behaviour modification programme’. This plan needs to be more comprehensive. There was no clear guidance for staff on what approaches and behaviours they need to adopt within the programme, or who was authorised to impose sanctions and restraints. Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 12 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 the following standard(s): None EVIDENCE: The above key standards were not fully assessed, as these were checked and met during the last inspection. Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 25 and 25 The home was clean and in the main well maintained. Communal areas were homely, and were well decorated. EVIDENCE: There was a shower unit that was able to dispense water at above 60ºC. The manager assured the inspectors that this had been actioned since the last inspection. She instructed the maintenance team to action this immediately. One resident’s bedroom door still had an alarm fitted to the door. The records said that this alarm was no longer in use. One member of the nursing staff said that the alarm was still in use. If this alarm is not in use it should be removed to prevent confusion and inappropriate restrictions on the residents lifestyle. Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 36 Staff need to have the necessary skills to deal with challenging behaviour. EVIDENCE: The staff that were over heard describing a resident as “kicking off” should be reminded that they need to understand that physical and verbal aggression can be a way of communicating needs, preferences and frustrations. Staff spoken to said that they received regular support and supervision. Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 41 and 42 The organisation constantly monitors the service. EVIDENCE: The manager is currently undertaking the Registered Managers Award and is on target to complete this by summer 2006. Residents and staff confirmed that monthly monitoring visits took place Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 X X 3 3 X X 2 2 X Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 17 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 YA1 Regulation 4, 16 Requirement The organisation must register their service within the most appropriate service user group. Residents must have a copy of their contract signed by them and the registered manager. A comprehensive risk assessment must be produced with the service user that has an alarm fitted to his bedroom door and understood by all staff. Timescale for action 02/05/06 2 YA41 , YA2 5 (c) 02/05/06 3 YA9 13 02/05/06 4 5 YA16 , YA9 YA10, YA32 13 6 7 8 YA18 , YA19 YA1 , YA18 YA17 If the alarm mentioned above is not in use – it should be removed. 12 The manager must monitor the conduct of staff in relation to inappropriate statements when discussing residents. 16, 12, 13 Staff must offer support and assistance as outlined in care planning documents. 12, 13 The identified resident must be weighed monthly as outlined in his care plan. 16 The identified resident must be supported during meal times as outlined in his care plan. DS0000015874.V288392.R01.S.doc 02/05/06 02/05/06 02/05/06 02/05/06 14/03/06 Sue Ryder Care Centre Version 5.2 Page 18 9 YA23 , YA18 , YA19 Sch 3 The identified ‘behaviour modification programme’ must be more comprehensive, indicating: • Who is authorised to carry out the sanctions. • What behaviours and approaches should the carer adopt? Staff must be reminded that residents challenging behaviour can be an indication of them communicating their needs. The shower outlet should dispense water at or around 43ºC 14/03/06 10 YA32 12 14/03/06 11 YA42 13 14/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA37 Good Practice Recommendations The registered manager should complete her on-going Registered Managers Award qualification. Sue Ryder Care Centre DS0000015874.V288392.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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