Inspection on 29/11/05 for Sue Ryder Care Centre

This inspection was carried out on 29th November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 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 14/03/06

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 Rob Curr Unannounced Inspection 29th November 2005 08:45 Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 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.V275210.R01.S.doc Version 5.1 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.V275210.R01.S.doc Version 5.1 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 Whitington 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.V275210.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 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.V275210.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between the hours of 8.45 am and 2:30 pm. Chris McLaughlin was present during the inspection. The inspector was escorted on a partial tour of the home. A variety of policies, procedures, and records were checked. The service users were very helpful during the inspection process, offering ample opportunity to talk about what life was like at the home. In all – 6 residents, 4 staff members, and 3 relatives were spoken to. What the service does well: All of the service users that met with the inspector were very happy at the home. One person using the day care services said that she was hoping to live at Hickleton Hall on a long-term basis. Cleanliness and hygiene standards in the home and kitchen area were good. Despite a number of service users having difficulties with continence there were no unpleasant odours. Relatives said that they were always made to feel welcome. There were planned activities every day, provided by a dedicated activities coordinator. The recommendation that 50 of the care staff team are qualified to National Vocational Qualifications (NVQ) level 2 in care had been achieved and a number of staff were undertaking NVQ training at level 3. The manager is on target to attain a management qualification. There was a friendly and cheerful atmosphere promoted by the staff. The staff team displayed a real commitment to improve the service at Hickleton Hall. Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 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.V275210.R01.S.doc Version 5.1 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): 1,2,3 and 4. The service user group is of mixed category. Service users needs were assessed prior to admission and they were fully involved in the assessment process, so this ensured that the home was able to meet their needs. The staff said that the manager did not offer places to any individual whose needs they could not meet. The staff training plan was on target. EVIDENCE: The needs of the service user group were discussed with the management. It was agreed that the organisation would address the issue of registering to care for the most appropriate service user group. Copies of full needs assessments were in the service user files. All the relevant information from the assessments had been built into the care plan. One resident said that they had been invited to view the home and attend a variety of meetings prior to them moving into the home. Staff training records indicated that they had undertaken relevant training. Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 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 clear. The care planning process has empowered residents to make decisions about their lives with support from staff and others. Residents were involved in making decisions about their own lives, including holidays. Advocates were available. Residents could see their GP in private so that their privacy and dignity was respected. Risk assessments need to be reviewed. Systems were in place to ensure that service users confidentiality was maintained in the home. EVIDENCE: Two risk assessments were checked. These did not contained all of the relevant information in order to minimise risks to residents Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 10 Where service users have had a hard floor surface provided, an appropriate risk assessment should be in place. One service users bedroom door did not have an appropriate lock and had an alarm fitted to the door. This system needs a comprehensive risk assessment in place and where possible the agreement of the service user or their representative. Peoples likes and dislikes in relation to food were recorded in care plans to ensure the staff knew the service users personal preferences. Service user meetings are organised regularly. The inspector spoke briefly with the ‘chair’ of the service user group. He confirmed that this gave service users the opportunity to be consulted on how the home was organised and run. The service user files were found to be stored securely and staff showed an awareness of confidentiality issues. The staff and service users said that they could see their files with staff support. Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. Some of the people have regular opportunities to access age, peer and culturally appropriate activities; others with higher support needs had limited opportunities. The service users were supported to have appropriate relationships with their peers and relatives. The staff showed respect for the people; in the way they spoke to and addressed them. The service users were observed to be offered choices and were supported to make everyday decisions. The meals offered a nutritious and balanced diet. EVIDENCE: Service users told the inspector that they took part in a range of leisure and educational activities on a regular basis. Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 12 Recent events had been a ‘Cluedo’ – murder mystery evening, a film night and a computer course. This confirmed that residents were enabled to take part in their local community and to maintain relationships. Staff were observed to treat people with respect as they knocked on doors before entering, addressed people by their preferred names and spoke of them with regard. There was a supply of nutritious food in the home. The menus showed that a varied diet was offered. This enabled the people to make choices at each mealtime. During the lunchtime meal, staff were heard encouraging service users to make choices. The cook had taken the lead on revising the menus. There had been meetings and the service users confirmed that they had contributed to the changes. Discussions with the cook indicated that he had a full awareness of the service users dietary needs, including special diets as such as diabetic and gluten free. Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21. Staff were supportive and helped service users to choose their daily routines. Health needs were met and monitored and people were helped to identify their own needs through their involvement in care planning. This ensured the wellbeing of the service users. The organisation had a medication policy. This was consistently implemented. A range of health care professionals visited the home to assist in meeting the needs of the residents. EVIDENCE: Staff provided sensitive and flexible personal support. Service users said they were encouraged to choose what time to get up and go to bed. One service user needed support with his smoking habits. This was not clearly identified within his care plan how this should be implemented. Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Residents were aware of how to make a complaint and were confident that they would be listened to. An adult protection procedure was in place to ensure people’s safety was promoted. EVIDENCE: The complaints procedure was available, which contained relevant information and provided the reader with details of who to contact outside the home, to ensure complaints were taken seriously. The home kept a record of complaints. Staff training in adult abuse had been identified within the 2006 training plan and a number of staff had already undertaking this training. Service users said that staff would listen and respond to any concerns they raised. Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,24,26,27,28,29 and 30. The home was generally well maintained, decorated and homely. The service users bedrooms were comfortable, individually personalised and furnished to meet their needs. The patio areas and the extensive gardens were well maintained and attractive. The laundry area was appropriately equipped to meet the service users needs. EVIDENCE: An inspection of the environment showed that generally the home was clean, well maintained and provided homely and comfortable accommodation to meet the service users needs. A number of bedrooms were checked. They had all been decorated to meet the individual persons needs and reflected their individual tastes. There was structural improvements taking place – this was to remove asbestos from the building. There was a hole in a bedroom door where the lock had been removed. This could compromise the service users privacy. Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 16 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): 32,33,34,35 and 36. Sufficient staff were provided to meet the needs of the residents. The recommendation that 50 of the care staff team are qualified to National Vocational Qualifications (NVQ) level 2 in care had been achieved. The manager had clearly identified the training needs of the staff group. EVIDENCE: The service users felt that there were enough staff on duty during the day and night to care for their needs. Three service users said that the ‘staff respected our privacy and dignity’. The majority of the care staff had completed the National Vocation Qualification (NVQ level 2) in direct care. A further group of staff are currently on the course and some have registered to commence NVQ level 3. Staff confirmed that they received more than 3 days paid training each year. Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 17 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): 37,38,39,40,41 and 42. The organisation carry out monitoring visits and informs the CSCI of the outcome. A health and safety policy was in place. Staff had received appropriate training, and appropriate recording of accidents and subsequent risk assessments were in place. EVIDENCE: The manager is currently undertaking management training and is on target to complete this. Quality assurance systems ensured that service users and their representative’s views, on all aspects of the home were included in developments and changes. Service users and staff confirmed that monthly monitoring visits took place and said that there was a regular fire drill. There was a shower unit that was able to dispense water at above 60ºC. Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 18 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 3 3 3 4 3 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 2 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 3 3 3 3 3 2 X Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 19 NO 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 2 Standard YA1 YA42YA9 Regulation 4,16 13 Requirement The organisation must register their service within the most appropriate service user group. A risk assessment must be in place for any service user requiring a hard floor service in their own bedroom. A risk assessment must be produced with the service user that has had the lock removed from his bedroom door. A risk assessment must be produced with the service user that has an alarm fitted to his bedroom door. A clear record of ‘rationing’ service users cigarettes must be developed and included in the care plan. The hole in the identified bedroom door must be repaired. The shower outlet should dispense water at or around 43ºC Timescale for action 01/02/06 01/02/06 3 YA42YA9 13 01/02/06 4 YA9 13 01/02/06 5 YA6YA18 24 01/02/06 6 7 YA16YA25 YA42 12 13 01/02/06 29/11/05 Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 20 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 management training. Sue Ryder Care Centre DS0000015874.V275210.R01.S.doc Version 5.1 Page 21 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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