Inspection on 29/08/07 for Sue Ryder Care Centre

This inspection was carried out on 29th August 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also 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 09/08/06

Sue Ryder Care Centre 14/03/06

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 Ramchand Samachetty Key Unannounced Inspection 29th August 2007 10:00 Sue Ryder Care Centre DS0000015874.V344883.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.V344883.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.V344883.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 ann.wood@suerydercare.org.uk www.suerydercare.org Sue Ryder Care 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) 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.V344883.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9th August 2006 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 passenger lift. The majority of the communal space is situated on the ground floor with large areas available for activities. The communal areas include the main lounge, a smoker’s lounge, a dining room, hairdressing facility and a visitor’s room. There is a chapel for residents use. The home provides personal and nursing care to mostly young people, who have neurological conditions. The home has been awarded Preferred Provider Status by the Multiple Sclerosis Society for its respite care facilities. The home has produced a statement of purpose and a service user guide, which give further information about the service it provides. The fees charged by the home were between £325.00 and £1420.00 per week. Further information can be obtained by contacting the home manager. Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out on 29 August 2007, starting at 10.00 hours and finished at 18.30 hours. The service is registered to provide nursing and personal care for up to 48 people. There were 41 people in residence at the time of this inspection. This included 36 younger adults and 5 older people. The registered manager, Mrs Anne Woods was present for part of this inspection. All the key national minimum standards for ‘Care Homes for Adults’ (18-65) were assessed. The inspection included a tour of the premises, examination of care documents and other records, including those pertaining to staff rota, complaints, and maintenance of equipment and systems, staff and medicines records. The inspector spoke to a number of people who live at the home, three relatives and five members of staff. The care of three people was tracked and some aspects of care were observed. As part of the pre-inspection planning, the home’s Annual Quality Assurance Self-Assessment’ and other documents, including comment cards received from people who use the service and their relatives, were considered. The views and comments of the people, who use the service and their relatives, have been included in this report. The inspector would like to thank all the people who helped with this inspection. What the service does well: People who use the service and their relatives said that they were satisfied with the service being provided. They praised the standard of both the personal and specialist nursing care being provided. Relatives commented that their loved ones were receiving ‘very personalised and very good care’. There is a good staff team, which works hard to meet the physical, social, psychological and communication needs of people who use the service. Staff and management continue to work well with the local social services department and the Primary Care Trust and other health care professionals in order to provide as good a service as possible. A wide range of social, recreational and leisure activities are regularly provided to people who have a preference and who are capable of participating in them. There is a dedicated group of staff who has the responsibility of organising Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 6 such activities and of making sure everyone living at the home is able to benefit fro them. Health and safety measures regarding the building and work practices were professionally and satisfactorily addressed. What has improved since the last inspection? What they could do better: The care plans of people who use the service must be improved to make sure they address all aspects of identified needs. Appropriate reviews of care plans must be carried out to make sure that changing needs are consistently addressed. This will help staff to provide appropriate care to people using the service. Although, people who use the service were satisfied with the meals provided at the home, there is a need to make sure that menus are developed and presented in a way that gives them more choice. Staff must make sure that equipment, like ‘kirton chairs and lap straps are not used as forms of restraint. They need to consider the implications of the use of such equipment and appropriate risk assessments must be carried out where they are used. Further more, the use of any form of restraint must always be risk assessed, recorded in care plans and regularly reviewed. A recommendation has been made for the home manager to review the use of the dining room, in order to make it more ‘homely’ and ‘friendly’ for groups of people who live at the home and at the same time, enhance their privacy and dignity. The use of the main lounge for people to work on computers should be reviewed to make sure this does not impinge on the purpose and function of this communal area. Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 7 The manager should review and improve the facilities provided at the home for people who smoke, in order to comply with the smoke free legislation and also to protect people’s health. Although staff training and development are well addressed by the service, it should now include more efforts in providing training on ‘Equality and Diversity’ issues, to ensure that people’s diverse needs can be met. 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 DS0000015874.V344883.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 DS0000015874.V344883.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): 1 and 2. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information about the service was accessible to people who were using it and those who were interested in using it. Full assessments were carried out before people were admitted to the home. EVIDENCE: The statement of purpose and service user guide have been produced in large print and in an ethnic minority language for the benefit of some people who use the service and whose first language is not English. Copies of these documents were given to people who use the service and to those who were seeking a place at the home and to their relatives as well. A few people who had recently moved to the home stated that they were provided with sufficient information, including the statement of purpose before their admission. This helped them in choosing the care home. Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 10 The care records of two people who had recently been admitted to the home were checked. They showed that full assessments were undertaken before their admissions, by both the placing social workers and the senior staff. The assessments covered all the relevant aspects of their care needs. Sue Ryder Care Centre DS0000015874.V344883.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 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service People who use the service were satisfied that appropriate care and support were being provided to enable them to lead their lives in the manner they preferred. EVIDENCE: The care records of three people who use the service were checked and the care provided to them was carefully considered and discussed with them and the staff. Individual plans of care were available and they addressed areas of assessed needs, risks and preferences and aspirations of the people concerned. Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 12 People who use the service stated that they were involved in developing their care plans. In one instance, a relative explained that she was able to read the care plan of her loved one each time she visited him and she was also invited to take part in the review of his care plan. She felt that this care review process gave her a good opportunity to make sure that her husband received the best care possible. There was evidence that some people using the service and who had complex needs and communication difficulties were receiving help and support from their key workers and named nurses to make decisions about their daily activities. They were provided with sufficient information and advice to help them take risks and to benefit from various activities. Staff explained that some people also had access to independent advocates. This helped them in making important decisions and in making choices. People using the service and who were able to express their views, stated that they were satisfied with the care they were receiving. This view was also confirmed by those who took part in our service user survey. However there were a few shortfalls in the care planning process. In some cases, changing needs were not always recorded in the care plans and therefore actions to meet those needs were not clearly stated. Care plans were reviewed but it was not clear how the reviews were conducted. The outcomes of such reviews were often too simplified to be able to contribute to care improvement. The use of restraint, as in kirton chairs, and its implications were not adequately addressed in care plans. Sue Ryder Care Centre DS0000015874.V344883.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 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home had good opportunities to participate in a range of social and recreational activities, which helped them enjoy their civic rights and a better quality of life. EVIDENCE: People who use the service, who were mostly younger adults, stated that there were provided with regular recreational and social activities. Dedicated staff from the recreational therapy section would take into account the assessed social care needs of each individual in developing a programme of activities to suit their individual preferences and capabilities. A number of people said that Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 14 they were satisfied with the support they were receiving from staff in order to maintain their lifestyle and also to develop their independence. A few people commented that they had a “ fishing group” and enjoyed going out to fish with the support of staff. A few others commented that they were encouraged to join computer and art courses at the local college to assist with their personal development. A number of people have been provided with personal computers, which they can use at the home. For people who have communication difficulties, the computer technology was being used to improve their communication and interaction. Other activities like indoor board games, baking sessions, shopping trips, outings, music and other in-house entertainment were also organised. On the afternoon of the inspection, a professional singer provided entertainment, which was well enjoyed by a number of people. There were also opportunities for individuals to spend time in their own rooms, in one to one sessions with staff or in the special sensory room, the Snoozelum. People, who had expressed a preference to observe their spiritual and faith needs, were supported to do so. The home has a small chapel where people who use the service can pray. A few people who live at the home stated that they were regularly asked for their views and opinions on the way the service is run on a day- to- day basis. There were regular “Residents Meetings” which were chaired by an individual who use the service. This helped to encourage other people who use the service to participate in the meetings and to share in making decisions. One person said, “ In the meetings, sometimes we talk about where we would like to go and what we would like to do to spend our time and staff help and guide us to choose.” A small number of people living at the home stated that they had made friends with “fellow residents” and felt that they were well supported to do so and in particular where they had formed a relationship. Staff commented that they were guided by the appropriate policy and procedures in order to support such relationships. Relatives stated that they were always welcomed and felt that staff kept them well informed about their loved ones. People living at the home said that they were satisfied with the meals that were provided. They commented that meals were “varied, good and tasty”. The relative of one person, who was not able to express himself verbally, said that she could tell her husband always liked the meals served at the home. Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 15 Care plans which were checked, showed that nutritional needs were being assessed. A number of people were unable to eat were given prescribed tube feeds or nutritional supplements, in accordance with their care plans. Some people were assisted by staff to partake in their meals. However, the dining facility remained institutional in character. There were a number of tables of different sizes at which people were offered their meals. As the dining area is rather large, the way in which it was being used showed that it was not always possible for staff to preserve the dignity of some people who were unable to eat independently. It was also noted that a number of people chose to have their meals in their own rooms and they were supported by staff to do so. In discussion, the manager stated that the issues regarding the dining area had been discussed at a residents’ meeting and there were plans to improve it. The menu for the day was checked and it did not offer two options for the main protein part before suggesting an alternative. This practice therefore limited people’s choice of meals. Sue Ryder Care Centre DS0000015874.V344883.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 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal general and specialist nursing care was provided to a good standard and in a manner that took into account the wishes and preferences of people who use the service. EVIDENCE: The care plans of three people who use the service were checked in some detail and their care was tracked in order to find out if they had received the planned care. The care plans were based on the assessments of both their specialist and personal care needs. The care plans included various aspects of their physical, social, emotional and communication needs. They also included information on the way the individuals wished their care to be provided. The people using the service and their relatives commented that they were satisfied with the care being provided. One person said that she was helped in the way she preferred, in moving in and out of her ‘special chair’ and that allowed her to be as independent as possible. Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 17 There was evidence of good collaborative work with a range of health care professionals who were either involved in the specialist care of certain people or who were available for advice and support. Examples included the work with the local primary care trust and with MacMillan nurses on the end of life care. It was noted that a number of people who required ‘end of life care’ would need specialist nursing interventions, like pain management and the use of syringe drivers, and that training on the subject has been provided to nursing staff. However, the home’s policy on the use of syringe drivers was yet available for staff guidance and this could place people at risk. The storage, handling and administration of medicines were checked. Whilst the storage area remains very limited, medicines were adequately stored and managed. Only one individual was administering his own medicines and he had been risk assessed as being safe to do so. The medicines administration records were checked and they were satisfactorily maintained. Sue Ryder Care Centre DS0000015874.V344883.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 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service were confident that their concerns were listened to and acted upon. The complaints procedure is well publicised and the service uses the procedure as a way of continually improving the service. There were effective systems in place to safeguard people from harm. EVIDENCE: A complaint procedure was available to people who use the service and their representatives. A copy of the procedure was included in the service user guide and in the home’s statement of purpose. A copy of the procedure was also given to each person living at the home, to inform them of how they could complain if they felt something was not right for them. Complaints records showed that the home had received 5 complaints in the last year. They had been appropriately dealt with. Three of these complaints had been upheld. Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 19 People using the service and their relatives said that they could easily raise their concerns with senior staff and the manager, if they had reason to do so. They felt confident that their concerns would be appropriately addressed. However, the local office of the Commission had received an anonymous complaint in relation to a shortage of care staff. The complainant alleged that “care staff were leaving and were not being replaced”. This complaint was investigated during the inspection. The registered manager explained that in the last three years, very few staff had left the home. She said that more recently six members of the care staff had stopped working at the home. Three care staff had resigned for personal reasons, two had retired from work and one had moved to night duty at the home. A programme of staff recruitment had been immediately put in place. Staff records showed that five new care staff had been recruited and had since started working at the home. The manager explained that the required number of care staff was always deployed, either by use of agency staff or colleagues who agreed to work additional hours. This complaint was therefore not upheld. There was also an adult safeguarding policy to guide staff on the prevention of abuse and on the procedures to be observed in reporting any allegations of abuse within the home. Staff spoken to, were aware of these procedures. There had been no adult safeguarding issues. Sue Ryder Care Centre DS0000015874.V344883.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 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was well maintained and clean. It provided a pleasant, comfortable and safe environment for people who live in it. EVIDENCE: Hickleton Hall is a large country home, set in several acres of gardens and woodlands. The accommodation for people using the service is provided over three floors, including the cellar, and there is a passenger lift to facilitate access between these floors. There was ramped access in two areas of the building to facilitate its use by wheelchair users. People who live at the home said that it was very comfortable. They spoke positively about their bedrooms, which they could personalise by bringing in Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 21 their own memorabilia and small items of furniture. They said the home was always kept clean and tidy. The inspector was able to look round some parts of the home, in the company of a senior member of staff. A small number of bedrooms were viewed with the permission of their occupants. The home appeared well maintained and well decorated. It was found to be clean and tidy and this made it a pleasant environment for people living it. The bedrooms viewed were well furnished and people who use them said they were very ‘happy’ with their personal accommodation. It was noted that two bedrooms, which had been used for two designated people each, were no longer occupied by them. In discussion, the manager confirmed that the two bedrooms would now be used as single rooms. Some bedrooms were provided with special beds, tracking hoists and other transfer equipment, in order to meet the complex needs of people using the service. A snoozelum (room with equipment to stimulate various senses) was also available to people living at the home. There was a smoking lounge on the ground floor. It was apparent that tobacco smoke was drifting from that lounge into the adjoining corridor. Staff said that senior managers were aware of the home’s likely non-compliance with the smoke free regulations that are currently in force, and that this issue was being addressed in order to protect all people at the home. The main lounge had some armchairs around and some people were sitting there in their own special chairs. There was a table at which people using the service, sat around to play various board games. However, a number of desktop computers, for people who use the service, had been installed along one wall in that lounge. This arrangement made the lounge appear as a classroom and added to the institutional feel of the home. Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 22 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 and 36. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff had a range of qualifications, experience and skills and had received training to help them understand and meet the care needs of people using the service. EVIDENCE: There were 41 people in residence at the time of the inspection. Five of them required personal care only and the rest needed mostly specialised nursing care. There were three first level nurses during daytime and two at night. There were eight care workers on the morning shift and six on the afternoon one. Two first level nurses and three care workers were scheduled to work on the night shift. The senior nurse said that the staffing level was based on the level of needs of the people living at the home and this ensured more flexibility Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 23 in order to meet their complex needs. It was noted that agency staff would be called in to cover staff absences. The duty rota showed a consistent level of staff being deployed at the home. The care team was also supported by a group of dedicated activity staff (also known as recreational therapists). There was a student nurse on work placement and she commented that she was well supported by senior nurses at the home. It was noted that the composition of the staff team was now more diverse as it included a number of nurses of different ethnic origins. Five members of staff were spoken to. Two were qualified nurses. They stated that they were receiving on going training in a number of areas. These included moving and handling, first aid, health and safety, fire safety and infection control. The nursing staff said that they had received some training on palliative and neurological care. Training records showed that about ten members of nursing and support staff had received some training on ‘Leadership and Management’. Staff spoken to, said that they had not received training on ‘Equality and Diversity’ issues. They were aware of the ‘Sue Ryder Care Values’ and did not think these covered equality issues in full. The training records seen did not show what areas of training each member of the care team had undertaken since the last inspection. It was noted that 26 out of 31 care staff had achieved their ‘National Vocational Qualification’ level 2 in Care. In discussion, staff members stated that they were satisfied with they were working as one team. They said that they were well supported in providing care to people living at the home. Staff members spoken to, confirmed that they were receiving regular supervision from senior staff and the registered manager. People who use the service commented positively on the staff team. They said that they found staff and managers to be approachable and helpful. They felt that they were listened to and that most staff knew how to care for them and how to help them use some of their disability equipment. Staff records of three new workers at the home, were checked. They showed that the home’s recruitment and selection procedures had been appropriately followed. All pre-employment checks had been completed before they started working at the home. Appropriate induction had also been provided in order to protect people who live at the home. Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 24 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 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was well managed and staff promoted the best interests and the safety of the people who live in it. EVIDENCE: People who use the service, their relatives and staff said that they were satisfied with the way the home was managed, which meant good care was being provided. They felt that the registered manager was well qualified and experienced to be in charge of the home. There was good management support from senior managers of the parent organisation- Sue Ryder Care. Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 25 This was reflected in the monthly visit reports undertaken on behalf of the responsible individual of the service. These reports were also used as a quality monitoring tool, as identified actions to improve the service were followed up and appropriately concluded. A number of other quality audits were regularly undertaken in order to continually improve the service. These included audits of care records, management of medicines and health and safety issues. Staff said that there was a ‘Quality improvement Group’ and it included a representative of the people who live at the home. The group meets on a monthly basis to consider and report on the quality of the service that is being provided. However, no reports of this group were available for inspection and this process could not be evidenced. A satisfaction survey has recently been sent to people who use the service and their relatives and the report was not yet available. People living at the home commented that they were regularly asked for their views about care provision and felt that their views were taken into consideration by staff. During the inspection of the premises, no obvious hazards were noted. Risk assessments regarding wok practices and the environment were in place. The fire alarm was regularly tested. Systems and equipment, including the passenger lift, were also regularly tested and serviced to ensure they were in good working order. Health and safety issues were regularly discussed and reported on, by the home’s ‘Health and safety Committee’. Minutes of the last committee meeting were checked and this showed that the service was proactive in ensuring good health and safety standards. Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 26 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 3 2 3 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 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15 Requirement Care planning including care reviews must be improved to make sure that changing needs of people, who use the service, are appropriately identified and acted upon to make sure people are offered appropriate care. The use of any form of restraint, for any purpose, must be risk assessed, recorded in care plans and regularly reviewed. The use of kirton chairs must be risk assessed to ensure they were not used as a form of restraint. (Not met by previous timescale of 16.10.06.) Timescale for action 31/10/07 2 YA6 15 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 YA17 Good Practice Recommendations The way the dining room is used should be reviewed and consideration given to form some discreet groupings for people living at the home, in order to protect their privacy DS0000015874.V344883.R01.S.doc Version 5.2 Page 28 Sue Ryder Care Centre 2. 3. 4 YA17 YA24 YA24 and dignity. The menus should provide at least two options for the protein part of meals, in addition to alternatives, in order to give more choice to people using the service. Facilities for smoking should be in line with the smoke free legislation and to protect people’s health. The location and use of personal computers in the lounge area should be reviewed to make sure such arrangements do not impinge on the purpose and function of the lounge and also to avoid reinforcing an institutional feel to the home. All staff should be provided with training on ‘Equality and Diversity’ issues in order to ensure they can meet the needs of all people who live in the home. 5 YA35 Sue Ryder Care Centre DS0000015874.V344883.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. 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