Inspection on 22/06/07 for Sue Ryder Care Centre

This inspection was carried out on 22nd June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sue Ryder Care Centre 24/09/08

Sue Ryder Care Centre 13/12/05

Sue Ryder Care Centre 12/05/05

Sue Ryder Care Centre 30/11/04

Sue Ryder Care Centre 06/05/04

Sue Ryder Care Centre 21/01/04

Similar services:

Ruskin Lodge

Dystlegh Grange

The Good Companions

Springfield Cottage

Cuerden Grange Rest Home

Cornmill Nursing Home

Vitalise Sandpipers Centre

Sue Ryder Care Birchley Hall

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 Cuerden Hall Shady Lane Bamber Bridge Preston Lancashire PR5 6AZ Lead Inspector Mr Ajam Auckburally Unannounced Inspection 22nd June 2007 10:00 Sue Ryder Care Centre DS0000025555.V338540.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 DS0000025555.V338540.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 DS0000025555.V338540.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sue Ryder Care Centre Address 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) Cuerden Hall Shady Lane Bamber Bridge Preston Lancashire PR5 6AZ 01772 627374 01772 629290 anne-marie.potter@suerydercare.org None Sue Ryder Care Mrs Anne-Marie Potter Care Home 37 Category(ies) of Physical disability (37), Terminally ill (6) registration, with number of places Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. This home is registered for a maximum of 37 service users to include: Up to 37 service users in the category PD - Physical Disability Up to 6 service users in the category TI - Terminally Ill The Registered Provider should, at all times, employ a suitably qualified and experienced Manager who is registered with the National Care Standards Commission. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the National Care Standards Commission regarding staffing levels in care homes. 13th December 2005 5. Date of last inspection Brief Description of the Service: Sue Ryder Care Centre is situated in Bamber Bridge in a formerly stately home. The home is set in eleven acres of parklands with easy link to the motorway network. Local amenities are not within easy reach as the home is secluded within its own grounds. Sue Ryder Care Centre is a thirty-seven bedded care home, which provides residential, nursing and day care to young physically disabled people. Accommodation is provided on three floors in single or shared rooms. There is wheelchair access and a passenger lift to all floors The home is a mixed gender home which takes residents between the ages of eighteen and sixty-five. The home was set up ten years ago to provide long term care for people with life threatening conditions and illnesses such as Huntingtons disease, multiple sclerosis, acquired brain injury and other neurological disorders. Other facilities include a multi sensory room, large activities area, Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 5 physiotherapy department and a range of specialist equipment tailored to meet the residents’ needs. The home has a designated activities team that provides a wide range of recreational events and activities. At the time of inspection there were thirty-seven people living at the home. Current weekly fees start at £489 with no upper limit, as this is dependent upon assessment of needs. Additional extras like hairdressing, chiropody, newspapers, outings etc are paid for by the residents. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. Under IBL (Inspecting for Better Lives) Sue Ryder Care Centre was assessed as requiring a statutory key visit (inspection) between April 2007 and June 2007. An unannounced key site visit was carried out on 22nd June 2007. The inspection lasted for 6 hours. The inspection was carried out against the National Minimum Standards for Adults (18-65). The inspection despite being an unannounced one was carried out in a friendly atmosphere and with the full cooperation of the manager, the staff and the residents. During the inspection, some records were looked at and several residents, some staff and two relatives were spoken to. The residents were very positive about the care and the level of activity they receive and the way the staff treat them. There were 37 residents staying at the home at the time of the inspection and there was a very good compliment of staff of duty. They include care staff, ancillary staff, management and specialist staff like physiotherapist and activity organiser. There was a very pleasant atmosphere in the home with staff and residents talking and laughing. What the service does well: The home provides a very pleasant environment for the residents to live in. All the bedrooms are of good proportions to meet the different needs of the residents. The staff were found to be in good temperament to care for the residents. They were observed to be friendly and caring. Staff recruitment is good, with appropriate checks being made prior to new staff starting work. The staffing level was found to be sufficient to look after the residents, There was a total of 26 staff of all grades at the time of the inspection. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 7 Residents were observed to be able to move freely around the home. They said that they were very happy with all the services provided and the way the staff treat them. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 8 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 DS0000025555.V338540.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There are very good practices to ensure that new people are assessed properly. Prospective residents are provided with good and relevant information. EVIDENCE: Prospective residents and their families are encouraged to visit the home to meet with other residents and staff. This could involve more than one visit depending on the person. The admission procedures involve all relevant information including medical history and assessments from relevant health and social care professionals being obtained. When someone enquires about a place at the home, an enquiry form is completed. Preliminary information is recorded and the person is invited to visit the home. Where a visit by a prospective resident is not possible due to ill health or other reasons, a member of the senior staff will do a domiciliary visit for an assessment. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 10 Once admitted, the new resident is fully assessed and all strengths and weaknesses, likes and likes recorded. The assessment will involve the nursing staff, the physiotherapist and other staff as required. Information from external sources like GP’s, social workers and other interested parties forms part of the assessment. The manager said that the assessments play a vital role in providing good quality care. The cost of residence is calculated upon needs. The files of two of the people were seen and they clearly show that a lot of information was received. Information obtained is about mobility, ability to attend to personal care and other relevant areas to determine acceptance and cost. Some of the residents spoken to said that they visited the home and spend some looking around and talking to people before they came to stay. Residents made comments like “ this place is like home and I can do what I like”. “You could not ask for a better home”. “The staff are marvellous”. Residents are given a contract of residence written in simple language and an information pack full of useful information about the home and its facilities. The inspector observed good interactions between the residents and the staff. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There are good practices to ensure that people are assessed properly. There are good policies and practices which allow residents to remain independent. Residents are encouraged and supported to do as much for themselves as they are able to. EVIDENCE: The files of two residents were viewed and they contained clear care plans with each element being clearly identified and the intervention required from staff to meet their needs. One resident has complex needs and her care plans identified the input from the physiotherapist to help with breathing exercises and posture. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 12 Residents are risk assessed from information of their assessments and by observing and talking to them. The manager said that reviews are carried out on a daily basis due to residents’ changing needs. The manager said that the residents are given complete autonomy in choosing what they would like to do. Residents are encouraged to remain independent and they were seen moving around the home in their wheelchair or walking. The staff were observed assisting those residents who needed help with patience and kindness. Residents spoken to confirmed that they were able to make daily decisions in respect of their care and how they spend the day. They confirmed that the staff consult them about their daily activities. They said that they are able to do what they want according to their own abilities, and that the staff are there to help them achieve them. The manager said that she ensures that the residents who are willing and able be involved in their care plans and reviews. The inspector chatted with several residents. All were very welcoming. Residents were very relaxed, and said that they were well cared for. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides opportunities for residents to follow their interests and hobbies, promoting their involvement and inclusion in the local community. Residents are able to do what they want and the staff support and respect their wishes. EVIDENCE: Residents living at the home vary in age and abilities. Those who are able can access the beautiful grounds either on their own or with the help of staff. Several residents and staff were seen in the grounds chatting or playing soft balls. The staff provide support to the residents who have poor mobility and complex needs. Staff were seen assisting residents in their bedrooms and also socialising with them in the lounge. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 14 One resident is very active in the community and helps in the local school. She said that she enjoys meeting the children and despite her disability has found something useful to do. The home has its own minibus to transport residents to and from events and activities. The manager said that the home having its own transport is an invaluable service which the residents really need. Some residents were seen using the transport to go out. Residents continue to maintain contact with family and friends. Relatives and friends are encouraged to visit as this helps the residents to continue with relationships and support from others. We spoke to two relatives who were present during the inspection. Their comments were that the home and the staff provide the best care for all the residents. The menus were examined and they showed that a variety of meals are provided. The chef said that if residents do not like what is on the menu, she would make them something they like. Suitable arrangements are made in relation to offering food to meet different dietary and cultural needs. Meals are offered in different forms including pureed, soft and normal to meet the different needs of the residents. The inspector observed lunch being served and found that the residents were not rushed and staff appeared to give adequate time for this. Several residents need to be fed by the staff. They were observed doing this without rushing the residents. The staff said that this a time consuming task but find that they have enough time to do it properly. The residents who were able to comment about the food said that it is very good and that they get plenty to eat and drink. Relatives present during the inspection said the food is good and that the staff provide good support to those who need assistance with feeding. The home is set in beautiful grounds but away from all amenities. However, a group of volunteers has set up a coffee shop, a second-hand shop, and a garden centre. The people who manage the shops said that they get good support from the local people and that there is always plenty going on. Residents of the home were seen using these facilities freely. They said that they sometimes go for a coffee or buy things from the shop. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 15 The manager said that the residents are consulted about their daily activities and are guided by the staff where needed to choose age appropriate and suitable activities. There is a good range of activities for the residents to choose from. These include handicrafts, computers, bingo and quizzes and much more. An activity organiser is employed to coordinate all activities and to encourage residents to participate. There is large room available for handicraft and activities. There was a wide range of handicrafts which the residents have made on display. Some are on sale in the shop. The residents appeared to be very relaxed and content. They said that they have no worries and were able to do what they want. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There are excellent practices to ensure that residents’ personal and health care needs are met. The health care needs of the residents are met by staff providing support. EVIDENCE: Personal care provided by the staff is based on the assessments and care plans. Each resident is cared for according to his needs and requirements. The residents are supported with their physical, emotional and mental health needs. The staff were seen spending time and talking to the residents. They said that they are there to make sure that all the needs of the residents are met in a friendly and efficient way. The residents said that they do not have to stick to a rigid routine and can get up and go to bed when they want. They added that the routines in the home are very flexible and that the staff are wonderful. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 17 Residents who are able to manage their own personal care needs are encouraged to do so, however staff will prompt and offer assistance where necessary. Personal care is provided in the privacy of the resident’s bedroom or the bathroom. They said that the staff always respect their privacy. Additional support to provide total care for the residents is sought from other professionals like district nurses, GP’s, hospital, dentist, optician etc. Only qualified trained nurses administer the medication. The administration records and storage of medication were seen to be safe and complied with the requirements. The manager said that if a resident wishes to keep her own medications, then a full risk assessment is carried out. This will include the ability of the resident to take the medications at the prescribed times, store and look after them safely. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The processes in relation to abuse are thorough to make sure people living at the home were protected. Residents are protected and safeguarded form abuse and neglect. EVIDENCE: The management of the home has produced policies and procedures for dealing with complaints and abuse. The complaint procedure is included in the Service User Guide. It is available to residents and their families. The home had an adult abuse policy and whistle blowing policy, in addition to a copy of guidance issued by the department of health. Discussion with staff showed that they were aware of the above documentation and were quite clear about what they would do if an allegation or suspicion of abuse came to their attention. The manager was aware of her responsibilities in relation to protecting people living at the home and making sure staff were appropriately trained to recognise and act upon any signs of possible abuse. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 19 Induction training records for new staff included information and guidance about abuse so that all new staff were familiar with the subject and how to respond to any allegation or suspicion of abuse. Staff confirmed that they received regular updates so that they continued to be made aware of the need to protect the people they care for. Some staff spoken to confirm and that they have had training in respect of abuse and some had covered this in their NVQ studies. Residents said that they are well looked after and that all the staff are kind and helpful. There were no visible signs of abuse or neglect. The staff spoken to said that that they would not harm the residents in any way and care for them with respect and dignity. The residents were heard speaking their minds and did not appear to be frightened. The manager said that everyone is encouraged to participate in discussions. Any shy or withdrawn resident is given the opportunity to speak to staff in private. Resident’s spoken to felt that they were encouraged to raise any concerns they might have about the home, that they would be listened to and action would be taken on any issues raised. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a good and clean environment for the people. . Residents live in a clean and well kept home. EVIDENCE: During a tour of the building, the home was found to be clean and in good hygienic order. Bedrooms are personalised and spacious. Residents are encouraged to bring as much of their own personal items as they will need during their stay. The occupied bedrooms were visited with the permission of the residents. The manager said that the residents are encouraged to look after their rooms if they are able to. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 21 Cleaning of the home is done by the staff during the course of the day. The residents can help if they want. All the staff have had training on the use of cleaning materials and hazardous substances. All the communal areas were found to be clean and furnished with easy chairs and sofas and other equipments to make the residents’ stay comfortable. Most of the central heating radiators had been appropriately covered to protect residents from coming into contact with very hot surfaces, however, a small number remained unguarded. Unprotected radiators present a possible health and safety risk to residents and steps must be taken to remove or reduce this risk. The manager said that she would make sure that the home’s programme of maintenance, which included completion of fitting radiator guards, is implemented as soon as possible. The ceiling and the walls in the dining room were found to be in need of repair and decorating. The manager said that work is due to start soon to redecorate this room. There are policies and procedures on health and safety issues to ensure that the residents are kept safe from harm. The home is well maintained and there is a rolling programme of maintenance. The home was accessible to all residents. Ramps allowed easy access to the outside and a passenger lift was provided to access all floors. Doors to the main lounge opened automatically allowing easy access for residents who use a wheelchair. A large number of aids and equipment were seen around the home which promoted independence or provided assistance with the management of care needs. The home was clean and free from offensive odours. One resident said, “It’s great here, my room is always clean and tidy”. Discussion with staff showed that they were familiar with infection control polices and procedures used at the home and most had received appropriate training. The manager said that the Trustees of Sue Ryder have put planned forward to build a brand new home within the area within the next few years. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 22 Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home’s recruitment procedures are robust and these provide safeguards for the protection of the residents. Residents are cared by staff who have been appropriately trained and have the skills and experience to manage and meet their needs. EVIDENCE: At the start of the inspection there were 10 care staff, 3 qualified nurses, the manager, the care manager, a physiotherapist, 8 ancillary and 3 administrating staff on duty. This was well within the staffing required to care for the number of residents in the home. The staff spoken to said that they enjoy working with the residents and the staff. They said that there is usually enough of them to care for the residents. The staff rotas were checked and found to have an adequate number of staff on duty at all times. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 24 Staff were seen to be interacting well with the residents. One staff was seen crouching on the floor and talking to a resident. Some staff were overheard talking to residents in a friendly way and paying attention to what they were saying. The written recruitment policy gives detail of the way a member of staff is employed. This is done according to good practice ensuring that new staff have all the necessary checks done before they are offered a post at the home. All new staff are given an induction training which include orientation of the home, basic health and safety issues. Staff spoken to had a clear understanding of their roles and what is expected of them during their shift. They said that this was a settled staff group and that they felt well supported. Communication with some of the residents at Sue Ryder can be difficult due to the medical conditions from which they suffer. Staff were observed using a variety of methods developed to suit the individual, to communicate with residents. A lot of time had been spent getting to know residents and the ways in which they were able to express their needs. The percentage of care staff who have completed their NVQ (National Vocational Qualification) is now 87 . This is commendable. Residents said, “staff are great here”, “ I can do some things for myself and they help if needed, it’s great”. The mother of a resident said “I find the staff very helpful and very good with my daughter”. The home had a training and development programme linked to the service provided and the needs of residents. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place to ensure the health and safety of residents and staff are promoted and protected. Residents lived in a well run home, managed by a responsible person who was able to make sure the home met its stated purpose, aims and objectives. EVIDENCE: Sue Ryder Care Centre is owned by Sue Ryder Care and managed by trustees. A manager is employed to run the home on a day-to-day basis. She is supported by an area manager who visits the home on a regular basis. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 26 The registered manager has been promoted to a new post and there is a need for the person managing the home to be registered with CSCI. The home has policies and procedures in place to ensure the health and safety of residents and staff are promoted and protected. The area manager visits the home regularly and once a month completes a Regulation 26 form. This form is completed to ensure that owners who do not work at the home looks at all areas of the home and leaves a written report. A copy of the report is also sent to CSCI. Residents have day-to-day contact with the manager and staff and feel able to discuss any matters or ideas they have. Residents meeting are also held. Feedback is sought from the staff during the periodic team meetings and supervisions. Additional comments are also received during the residents review meetings, which involve health and social care professionals. Information provided in the pre-inspection questionnaire stated that all safety equipments were regularly serviced. The policies and procedures in the home ensure that the health, safety and welfare of the residents and staff were promoted and protected. Discussion with staff showed that the manager provided leadership and direction so that every one knew what their role was and what was expected of them. The home had been accredited with a nationally recognised quality assurance award that was reviewed regularly. The management team carried out a quality audit of the operational systems in place at the home. Both systems made sure that the home was complying with company policies and procedures, current legislation and best practice. Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 27 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 X 2 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X X 3 x Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 28 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. 3. Standard YA24 Regulation 23(b)(d) Requirement Damaged areas within the home must be redecorated and maintained to an appropriate standard. Radiators must be appropriately guarded or of a guaranteed low surface temperature. (Timescale of 31/03/06 not met). Timescale for action 31/08/07 4. YA24 13(4)(a) 31/10/07 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 appointed manager of the home should seek registration with CSCI Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sue Ryder Care Centre DS0000025555.V338540.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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