Inspection on 05/09/06 for Sue Ryder Care Centre

This inspection was carried out on 5th September 2006.

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

The inspector found 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sue Ryder Care Centre 17/08/07

Sue Ryder Care Centre 27/01/06

Sue Ryder Care Centre 10/08/05

Sue Ryder Care Centre 24/02/05

Sue Ryder Care Centre 04/08/04

Sue Ryder Care Centre 23/02/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

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

CARE HOME ADULTS 18-65 Sue Ryder Care Centre Holme Hall Holme On Spalding Moor East Yorkshire YO43 4BS Lead Inspector David White Key Unannounced Inspection 5th September 2006 09:00 Sue Ryder Care Centre DS0000000955.V309879.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 DS0000000955.V309879.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 DS0000000955.V309879.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sue Ryder Care Centre Address Holme Hall Holme On Spalding Moor East Yorkshire YO43 4BS 01430 860904 01430 869591 linda.chapman@suerydercare.com None 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) Mrs Linda Christine Chapman Care Home 40 Category(ies) of Physical disability (40), Physical disability over registration, with number 65 years of age (40) of places Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th January 2006 Brief Description of the Service: The premises, known as Sue Ryder Care Home, date approximately from 1742 and were previously used as a convent. It is a Grade II listed building set in extensive grounds and has a chapel in the grounds to which the local community attend. Accommodation is currently provided on three floors following a major building and refurbishment programme a few years ago. Bedrooms are provided on the first and second floors with lounges and other communal areas on the ground floor. The home is served by two passenger lifts. The home has achieved Practice Development Unit status accredited by the University of Leeds. The home no longer provides day care services. The current fees at the time of the site visit on 5th September 2006 ranged between £746.75 and £1200.76 per week and did not include costs for hairdressing, chiropody and social activities. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced site visit undertaken on the 5th September 2006. This visit was carried out by two Regulation Inspectors, David White and John Mc Garva and took 8 hours with 7 hours preparation time. The home was able to return the requested information before this site visit, and surveys were sent out to relatives and other professionals who had contact with the home. Surveys were received from a relative, a GP and two health professionals and verbal information was provided by another GP. Information was also used from the Regulation Inspector’s inspection record, which detailed the history of the home and relevant information about what had been happening in the home since the previous inspection visit. The site visit comprised of a look around the premises. The care records of three residents’ were looked at which included residents’ assessments, care plans and medication records. Staff rotas and health and safety documentation were inspected. Time was spent talking to two residents’, three members of care staff, the training officer, the Acting Head of Care Services at the home and the manager. The activity in the home and the interaction between residents and staff was observed. The focus of the inspection was on a number of key standards and inspecting the case records of a number of residents to establish whether they corresponded with their experiences of life in the home. The manager was available throughout the inspection and the findings were discussed at the end of the inspection. What the service does well: Thorough pre-admission processes ensured that prospective residents’ were only admitted to the home if the staff team could meet their needs. Care plans were informative, detailed and easy to follow so that staff had clear guidance and direction as to how resident needs were to be met. The environment offered ample space for all residents including wheelchair users to promote their independence and safety. Residents and relatives felt that the staff were committed to providing good standards of care within the home. Residents’ and their relatives were given the opportunity to voice their views and to contribute towards how the home was run. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 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 DS0000000955.V309879.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Proper pre-admission procedures were in place to ensure that residents could have their needs met by the home. EVIDENCE: The care records of three residents’ were looked at and these confirmed that proper pre-admission procedures were followed prior to residents’ moving into the home. The pre-admission assessments were usually carried out by the Care Centre Manager or Head of Care Services and a senior nurse and took place either in hospital or at the resident’s home prior to admission. In one instance a recent referral had been made to the home and the manager had obtained more information from a number of sources about the prospective resident’s needs before making a decision that the home was not able to meet the person’s needs. Residents’ needs were assessed by the home on admission and this information included details of weight, height, eating and drinking habits, elimination, rest and sleep, communication, breathing, vision, hearing and psychological needs. The care records also had a ‘pen portrait’ of the resident’s personal life and experiences so that staff were aware of the background of the resident and so could interact with them in a personal and meaningful way. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 9 Each pre-admission assessment looked at the individual needs of the resident and a planned action of care was drawn up from this information. The daily records reflected the care that was being provided by the home. The quality of the documentation was very good, neatly presented, well sequenced, detailed, thoughtful, relevant and comprehensive. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 10 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 and 9 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Clear and effective care planning systems were in place to provide a well-motivated staff team with the information needed to meet residents’ needs. EVIDENCE: Three residents’ files were looked at and these all provided clear, wellorganised and easy to follow information about each resident. The plans covered a range of health, personal and social care needs and clearly stated how these were to be met. There was an emphasis on encouraging the independence of the residents’ and risk assessments were in place to promote this. Each resident’s care record included information about assessments, care plans, medical and healthcare interventions and social events undertaken. There was also additional information on charts which recorded resident’s intake, output, weight and pressure care management. Care plans were reviewed on a monthly basis and there was evidence that efforts had been made to get the resident or their relatives to sign to the effect that they had seen the care plans and been involved in the process. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 11 Daily care records were relevant, clear and up to date. It was recommended that the care record entries were recorded utilising the twenty-four hour clock in accordance with good recommended practice. It was also noted that within the care the qualified nurses only made records entries and discussion took place with the Head of Care Services about the support workers making their own records and there were plans to discuss this within the care staff meeting that was soon to be held. The delivery of care is managed through a key worker system so that nursing staff and care workers were allocated to a resident. The residents spoken to were able to identify their named nurse and support workers. Many of the resident’s were very dependant, including several who received nutrition by tube feed directly into the stomach (PEG) and some residents’ were at risk of pressure sores. One resident had been admitted to the home with pressure sores and was being nursed in bed and in receipt of end of life care, which was planned and delivered in a professional and caring way. The home had appropriate aids, adaptations and equipment in place which included pressure relieving mattresses in cases where risk of pressure sores was identified. The wife of a resident said that she was most impressed with the care that her husband was receiving. She had tried other homes on a respite basis and “none came close to meeting all his needs”. She was able to stay overnight in a flat on the premises when travelling in the dark was a problem and she found this of particular benefit to her. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 and 17 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Residents were able to enjoy a range of activities to meet their social and recreational needs. EVIDENCE: The records of the residents seen indicated that social and recreational opportunities were provided within the constraints of their abilities and wishes. An activities room was available and staffed by appropriately trained personnel with a variety of equipment and resources available and the residents could be seen to be enjoying themselves. Many of the residents were unable to participate in much physical activity and preferred to stay in their own rooms although individual activities were offered to people within their bedrooms based on individual choice. All residents were encouraged to interact with others and trips out were arranged on a regular basis so that none of the residents were isolated for long periods of time. Consideration was given to resident’s individual needs in relation to their sexuality and needs and sensitive strategies were in place to manage this. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 13 Residents commented favourably about the quality of the meals and food options available. Many of the residents were immobile and so weight monitoring was taking place to address any issues from weight gain. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 14 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 and 20 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Residents’ received good support and had access to specialist services when required to ensure that their needs were met. EVIDENCE: The interaction between the staff and residents’ was observed to be professional, kindly and considerate and it was clear that staff enjoyed the confidence of the residents. The care records and discussion with staff indicated that the residents’ physical and emotional needs were being met in a thoughtful and considered way. Care staff did say that improved staffing levels would enable them to be able to spend more individual time with residents. The home had access to healthcare services such as the community dietician, epilepsy nurse, tissue viability nurse and occupational therapist and requests for physiotherapy were made through a referral system. The home did have a physiotherapist assistant who assisted by providing passive exercises to residents. There had been some recent discussions between the home and local GP services as to how residents’ specialist healthcare needs would be best met and it was understood that an action plan had been put in place to resolve this. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 15 However at the time of the site visit this had not yet been implemented and will be looked at in more detail at the next site visit. The medication systems were inspected and the Medication Administration Records were found to be satisfactory and a random check of one resident’s controlled drugs supply tallied with the records. None of the residents’ were able to administer their own medications and the risk assessments supported how decisions had been made in regard to this. There were some issues with the medication arrangements that needed to be addressed to promote good and safe practices. It was found that the medication refrigerators were in need of more regular defrosting. The storage of the medicines on the floor was not ideal as many controlled medicines were kept in a Scheduled drug cabinet with a small controlled cupboard within it. The controlled drugs cabinet was not large enough to store all the medications that should have been in there as many were in liquid form and took up a lot more space and the recording of Temazepam was not being made in the controlled drug book. Other medications were stored in a large wooden cabinet, which does not conform to Royal Pharmaceutical recommendations for the storage of medicines. This was discussed with the Head of Care Services who had already identified this as an issue to be addressed. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area was adequate. This judgement had been made using available evidence including a visit to this service. A complaints policy and procedure was in place to address any concerns, however there was a need for an improvement in staff’s knowledge of adult protection procedures to ensure that residents’ were safeguarded from harm. EVIDENCE: The home had a complaints procedure that clearly detailed how complaints would be dealt with. The complaints records showed that concerns were dealt with properly within agreed timescales and complainants were informed in writing of the outcomes from any investigations and what action had been taken. Residents’ and a relative said that they knew whom they would need to speak to if they wanted to raise any concerns and had confidence that these would be dealt with properly. The home had a policy and procedure in place for the protection of vulnerable adults. Staff were given information about abuse as part of their induction to the home. The training records showed that Protection of Vulnerable adult training was provided on a regular basis although one member of staff said that they could not recall having had the training for a number of years. In the past adult protection incidents had been dealt with properly by the home. However a number of staff spoken to including care staff in senior positions although having a good knowledge of what would constitute abuse lacked understanding of what action would need to be taken and who by if abuse had happened or was suspected and this lack of knowledge could put residents’ at risk. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The home provided a comfortable and pleasant environment for residents’ to live in although one health and safety matter needed to be addressed to ensure the safety of the residents’. EVIDENCE: On the day of the site visit the home was warm, bright and comfortable for residents’. The home had a number of wheelchair users’ who had access to all parts of the building via passenger lifts and ramps. There was ample communal space and residents looked comfortable within the environment. Bedrooms were spacious and some had en-suite facilities. One resident particularly enjoyed spending time in their bedroom because of “the nice views from it”. The home had a range of aids, adaptations and equipment to be able to promote the safety and independence of the residents’ All parts of the home were clean and free from offensive odours. There was a plentiful supply of aprons and gloves to promote good hygiene practices and laundry staff were employed to attend to residents’ personal clothing. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 18 Residents’ accommodation was over two floors with each floor having sluicing facilities and systems were in place to deal with soiled linen to reduce risks of cross infection. There were call systems available in all personal and communal areas which enabled residents’ to have access to staff at all times. The home had a fire risk assessment in place and any issues identified from this were addressed. Fire Safety equipment tests were carried out and lifts, aids and adaptations were serviced on a regular basis. A recent health and safety visit had taken place at the home and outstanding issues had been addressed. Hot water temperature checks were carried out on a weekly basis and recorded. There were thermometers in each bathroom so that staff could check bath water temperatures before service users’ had a bath and although all staff said that this practice was being followed the records of the water temperature checks had not been completed to confirm this had been done and this was not in accordance with the home’s policies and procedures to prevent risks to service users’ from scalding. A random check of the hot water temperatures was carried out and in one bathroom the temperature was found to be 47.9 degrees centigrade and this exceeded safe limits and put residents’ at risk from scalding. The manager said that none of the residents’ were able to access the bathrooms without the support of staff and arranged for the maintenance team to deal with this matter immediately to rectify the problem and risk assessment measures were put in place so that residents’ safety was safeguarded until the necessary work had been completed. Written confirmation was received following the site visit confirming that the necessary action had been taken to deal with the problem. A new security system had been introduced at the entrance to the home and this meant that residents could have easier access to and from the home through using a remote control. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 19 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, 34 and 35 Quality in this outcome area was adequate. This judgement had been made using available evidence including a site visit to this service. Improvements were needed in recruitment practices and staff training in order to protect residents’ from harm and to ensure that all their needs could be met. EVIDENCE: Staffing levels within the home were satisfactory. At all times there were at least two nurses on duty through the day working alongside a minimum of eight support assistants in the morning and six for the afternoon shift. There were two nurses and two support assistants on duty at all times through the night. Due to some staff leaving, the home had been using agency staff to cover vacant shifts and where possible the same agency staff were used so that they were aware of the residents’ needs and were familiar to the residents’ to promote consistency. The manager had recently appointed some new members of care staff and the home was nearing its full complement of staff to ensure that residents’ needs could be met. Staff said that staffing levels were “adequate” and that residents’ needs were met. Staff could be observed to be busy but care was being provided in an unhurried manner. The staff files of four newly appointed staff were looked at. The records showed that all the necessary pre-employment checks had been carried out to safeguard residents’. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 20 However in one file the Criminal Record Bureau check had provided information that should have been followed up by the management of the home and this needed addressing so that residents’ interests were protected. Each member of staff had an individual training programme and development plan. The training records showed that staff had undertaken a range of health and safety training and courses were provided by a variety of healthcare professionals on subjects such as epilepsy, multiple sclerosis and other conditions. The home employed a training officer who worked three days a week and who provided the majority of the training. The training officer said that attendance at teaching sessions had improved and staff feedback from the sessions was positive within the training evaluation forms. One member of staff had completed a specialist neurological course whilst another member of staff was undergoing the course and this would equip them to have a more indepth knowledge of people with neurological impairment. Further neurological training needs to be provided for other members of staff. The majority of the residents’ had complex needs and some experienced mental health problems, however staff had not received any mental health training. Due to their conditions a number of the residents’ exhibited unpredictable behaviour but there had been no training for the staff on how to manage difficult situations more effectively through the use of de-escalation techniques although the management acknowledged that they felt this was needed and were planning to address this as a training need for all staff. The manager said that the home was looking to set up a Palliative Initiative in Neurological Care (PINC) which was linked to research into end of life studies that had been carried out at Nottingham University with the aim of improving the quality of life for people at the home. The manager said that work would be carried out with the local GP’s in order to facilitate this. Surveys from GP’s and a health professional indicated that there were still communication problems between the home and specialist services and that staff lacked an understanding of some of the residents’ needs. This was discussed with the manager who felt that relationships with the GPs’ in particular had improved more recently and said that additional training was being planned to enable staff to have a better understanding of all the needs of the residents. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 21 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, 39 and 42 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The home was well run and the views of residents were acted upon, although some health and safety matters needed addressing to safeguard the interests and safety of residents’. EVIDENCE: The manager had a lot of experience in running the home and had recently appointed an Acting Head of Care Services to support her in carrying out her management duties. Service users’, relatives and staff were all complimentary about the manager’s abilities and described her as “approachable and supportive”. Systems were in place to seek the views of service users’ and relatives about the care and services provided by the home. The home had a quality improvement plan that identified the actions being undertaken to improve the quality of the home. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 22 Resident and relative meetings were held on a regular basis and relatives of residents were in the process of devising a booklet called “relatively useful” for prospective residents and their families which explained their experiences of the home and what they found useful in getting to know the home better. A relative said that they found the relatives meetings to be particularly “useful and supportive”. Residents said they were invited to their care plan reviews with their family in accordance with their wishes. A representative from the organisation carried out monthly-unannounced visits to the home and reported on their findings. A number of health and safety certificates were looked at and were found to be satisfactory. Staff had received updated health and safety and fire safety training and fire drills were carried out on a regular basis and were recorded. However there were some concerns about some health and safety matters. The water temperatures in one bathroom exceeded safe limits and staff were not adhering to procedures for monitoring bath water temperatures so residents’ could have been at risk from scalding. In one of the staff files some information from a Criminal Record Bureau check had not been acted on and this potentially put residents’ at risk from harm. Individual resident and home records were all in good order, very well organised and information was easy to access. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 23 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 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 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 X 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 2 X 3 X 3 X X 1 X Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 24 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 YA23 Regulation 13 • Requirement Timescale for action 05/12/06 • 2. YA24 13 • • The registered person is required to make arrangements for all staff to receive up to date abuse awareness training so that they know how to report abuse under local authority procedures. The registered person must have systems in place to make sure that staff had fully understood adult protection training received so that residents are protected from harm. The registered person 06/10/06 must make arrangements for the water temperatures to be no more than 43 degrees centigrade in outlets used by residents to prevent risks from scalding. The registered person must ensure that staff adhere to the home’s policies and procedures for the safe monitoring of bath water temperatures to prevent risks to the residents from scalding. Version 5.2 Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Page 25 3. YA34 19 4. YA35 18 The registered person must adhere to the home’s recruitment policies and procedures so that information disclosed within the Criminal Record Bureau check is followed up and dealt with appropriately to safeguard the interests of the residents. The registered person must ensure that staff receive specialist training to equip them with the skills and experience to meet the needs of the residents. (Previous timescale of 01/05/06 not met). 20/09/06 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 1. 2. Refer to Standard YA6 YA6 YA20 Good Practice Recommendations Care record entries should be recorded utilising the twenty-four hour clock in accordance with good recommended practice. Support assistants should be making their own entries within the daily care records. The home should have a larger cabinet to accommodate the amount of Controlled Drugs held at the home and the cabinet should be made of metal in accordance with Royal Pharmaceutical guidelines. Arrangements should be made for a new Scheduled Drugs cupboard in the medication storage room on the first floor of the home to replace the existing wooden one which does not conform to Royal Pharmaceutical recommendations. The medication fridge should be defrosted on a more regular basis. Temazepam should be recorded in the Controlled Drugs register. The home should continue to look at ways of improving DS0000000955.V309879.R01.S.doc Version 5.2 Page 26 3. YA20 4. 5. 6. YA20 YA20 YA33 Sue Ryder Care Centre their communication with specialist services. Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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. Extracts may not be used or reproduced without the express permission of CSCI Sue Ryder Care Centre DS0000000955.V309879.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!