Inspection on 09/08/06 for Sue Ryder Care Centre

This inspection was carried out on 9th August 2006.

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 13 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 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 9 & 11th August 2006 11:00 th Sue Ryder Care Centre DS0000015874.V305879.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.V305879.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.V305879.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sue Ryder Care Centre Address Hickleton Hall Hickleton Doncaster South Yorkshire DN5 7BB 01709 892070 01709 890140 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) None Sue Ryder Care Ann Marie Wood Care Home 48 Category(ies) of Physical disability (48), Physical disability over registration, with number 65 years of age (35) of places Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th March 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 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.V305879.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 9 and 11 August 2006. The first visit lasted for approximately five hours and the second visit for six hours. The inspection included a tour of the building and an assessment of physical access and other health and safety issues. The inspector spoke to ten service users and five of them were able to give some information about the service. The inspector also spoke to four visiting relatives. Eight members of staff were spoken to, and they include the registered manager, an activities organiser, a support services staff, three nurses and two carers. A range of documents and records were checked. These included the Statement of purpose, service user guide, care documentation, medicines administration records, training records and health and safety records. The registered manager had completed a preinspection questionnaire and some of the information in the report is taken from it. The weekly fees for the service range between £263.00 and £1,479.00. The registered manager explained that the fees were charged according to the complexity of needs and the source of funding. The inspector would like to thank all the service users, relatives and staff, including the manager, who assisted with the inspection. What the service does well: Service users and relatives who spoke to the inspector were satisfied with the service, although they pointed out that ‘ in a few areas, further improvement would be beneficial’. They praised the standard of both the specialist nursing and personal care being provided at the Home. There is a good staff team, which worked well together to ensure the continuing wellbeing of the resident group. Staff and management worked well with commissioners of local Social Services departments and Primary Care Trusts, health and social care professionals and a number of service user led organisations. The values and principles of care at Home and from its parent organisationSue Ryder Care are well practised for the benefit of the service users. Service users are treated with respect and their rights as citizens are promoted and valued. Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although the Home provides sufficient information to potential service users and their representatives, there is a need for the statement of purpose and service user guide to be improved. These documents need to be to made accessible in appropriate formats to the client group. The admission process needs to be reviewed to ensure that all service users are admitted on the basis of a full needs assessment. Care planning including care recording and care reviews need to be improved. Risks and the use of restraints must be appropriately managed and reviewed. The management of medicines at the Home is on the whole satisfactory, but a few minor shortfalls relating to medicines records are highlighted for remedial action. The quality of meals at the Home is judged as satisfactory, by service users, who are able to express their views. However, there is a need to ensure that menu planning includes the views and preferences of the wider resident group. The Home handles complaints and concerns in a positive manner, but there is a need to improve their management. Concerns and complaints must be appropriately recorded. Details of complaints investigation and their outcomes must be appropriately recorded. The registered manager must have access to staff information relating to recruitment, pre-employment checks and other appraisal, development and Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 7 disciplinary matters. These documents must also be made available for inspection as necessary. Although the overall staffing level at the Home during the period of the inspection appeared adequate, there was a short fall in the deployment of staff involved in the care of a group of older service users. A general review of the staffing level is recommended. The Home is generally well maintained, but minor repairs to some areas of flooring and an adjustment of lighting levels are highlighted for remedial work. 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.V305879.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.V305879.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People who use this service have information about the Home in order to help them to chose it or not. Needs assessments of service users, are undertaken before their admission, to ensure that the service can meet identified needs. However, both the provision of information and the assessment process require improvement for the further benefit of service users and their representatives. EVIDENCE: Two service users, who had recently been admitted to the Home, stated that they had been provided with adequate information to help them choose a care home. The relative of one service user confirmed that she was given an information pack, outlining the service at Sue Ryder and its facilities, but she added that the Home was recommended to her because of its speciality in neurological care. One service user stated that the funding agency had chosen the Home for her and had not provided her with enough information about it. The care files of the two service users were checked. One service user was admitted for a respite stay. A previous assessment by the placing social worker was used as the basis for this admission, but staff at the Home had reviewed her assessment. Although staff at the Home had undertaken an assessment for the other service user, a full assessment of care needs from the placing agency was not provided until after her admission. The Home’s assessment did not adequately cover all areas of care needs. A full assessment Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 10 is required and this can be undertaken by the care manager of the placing agency or by the Home, prior to admission. The Home’s statement of purpose was checked. It gave information about the Home and made a statement about future developments. It did not reflect the guidance presented in the National Minimum Standards. Both the statement of purpose and the service user guide were not in formats accessible to the service users, who have varying communication needs and some whose first language is not English. Sue Ryder Care Centre DS0000015874.V305879.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 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 is good. This judgement has been made using available evidence including a visit to the service. Service users are satisfied with the quality of care they are receiving at the Home. Each service user had a care plan, ensuring that their needs are catered for. Arrangements for the assessment, planning and delivery of care are mostly good but require improvement in some parts. EVIDENCE: Three service users care records were checked at random. They included a care plan for each service user. Care plans were based on assessments of needs. They included assessments of risks but actions to manage those risks were not always clear and in one instance, no action was proposed. The use of restraints was not appropriately risk and impact assessed and care planned. Relatives, spoken to, stated that in some instances, restraints, such as the use of kirton chairs, seemed to be used to help with the supervision of service users. Risk assessments and the use of restraints and their management must be discussed and agreed with service users and their representatives. It was not always clear from daily entries of care provided to service users, how planned care was being delivered. A number of daily entries appeared too generalised and failed to evidence both general and specific care given. Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 12 Care plans, including risks, were scheduled for review yearly instead of half yearly. Care plans must be reviewed at least half yearly for younger adults and monthly for older adults. The review process should be made clear for the benefit of all interested parties and should be used in a consistent manner. Service users spoken to, and who were able to respond, stated that they were satisfied with the care they were receiving. A few service users stated that they were encouraged to decide how they spend their time and what activities and hobbies to pursue. They were provided with appropriate information and advice but left to make their own decisions. There was evidence that staff at the Home was working with independent advocates for the benefit of individual service users. Some service users commented on the valuable support they were receiving from their key workers and in some instances from named nurses. Sue Ryder Care Centre DS0000015874.V305879.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 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 is good. This judgement has been made using available evidence including a visit to the service. Service users have good opportunities to participate in social and recreational activities to ensure they enjoy a good quality of life. They have the support of staff, friends and relatives, to ensure they continue to be part of the local community. The rights of service users are safeguarded and well promoted. Whilst service users said that they enjoy the food provided at the Home, there is a need to involve them in a better way in menu planning and to reflect the necessary cultural and dietary needs. EVIDENCE: Service users, who were mostly younger adults, stated that there were always a lot of recreational and social activities at the Home. The Home has a separate section, with dedicated staff, that deals with recreational therapy and the organisation of social activities. Staff stated that activities were organised to suit the preferences of service users, their varying levels of communication and overall capability. During the inspection, the inspector was able to evidence some of the activities that were offered to service users. Two ladies Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 14 were assisted with baking a cake. One staff member stated that she was visiting service users in their own rooms to offer companionship. There were some outdoor activities, such as shopping trips and outings to local facilities. The latter appeared to be mostly taken up by the younger service users in the client group. However, it was noted that a distinct group of elderly residents, whose first language was not English, had little recourse to culturally appropriate activities. It was also noted that facilities at the Home included a chapel, which is used by service users for prayers. Staff who are responsible for organising recreational and social activities, offer appropriate support and assistance to service users. Relatives spoken to confirmed that they were welcomed at the Home. One relative said that she was involved with the initial care planning and care review for her loved one, but felt excluded in subsequent exercises. Some service users stated that they were able to make friends, if they wanted, both, within the Home or in the local community. The Home has a policy on maintaining ‘sexuality and relationships’ which helps in ensuring the rights of its service users. A few service users, who spoke to the inspector, stated that they were involved in the ‘Residents’ Meetings’. One service user said he helped by chairing the meetings and felt appropriately supported by staff to undertake this task. Service users spoken to and who were able to respond, commented favourably on the provision of meals at the Home. They stated that they were provided with a good breakfast, lunch, dinner and supper. They were satisfied with the food choices available to them, which they described as ‘wholesome and appetising’. Copies of menus checked, did not appear to cater for the varying cultural needs of a group of service users. Menu planning should include the views and preferences of the resident group. However, during case tracking, it was noted that there was no assessment of nutritional needs but nutritional risk assessments instead. A number of service users were prescribed and given oral nutritional supplements and in these instances, staff were following advice of both dieticians and of GPs. However, one relative commented that whilst it was good to provide prescribed food supplements, she found out that her loved seemed to have had almost no cooked food for weeks except for the supplements. There were no records against which this could be ascertained. Staff spoken to, stated that sometimes service users would refuse cooked food but instead choose the food supplements. Arrangements for the serving of meals appear to be institutional. Meals are served in a large dining hall, which is open to all residents between certain times, although these are flexible. Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 15 The meal at lunchtime was observed in the hall. A number of service users were fed and assisted with their food, by staff, whilst sat with others at dining tables. Other service users had lunch in their own rooms. Sue Ryder Care Centre DS0000015874.V305879.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 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 is good. This judgement has been made using available evidence including a visit to the service. Personal care and general and specialist nursing care are provided to good standards and in a manner that takes into account the wishes and preferences of the service users. The management of medicines at the Home is satisfactory. EVIDENCE: The care plans of two service users with complex care needs were checked. They detailed both the specialist nursing interventions and personal care that were required. They also included their social, emotional and communication needs. The plans also outlined the actions that were necessary to both provide the care and support and to allow service users to exercise some of their independence. The preferences of service users, in the way care is provided are also established. There was evidence of close working with other health care professionals involved in the care of the service users. Records of such contacts were kept in service user care files. In discussion, two of the qualified nurses at the Home outlined their experience in the specialist field of rehabilitation and palliative care. The storage, handling and administration of medicines were checked. Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 17 The storage area was rather limited for the medicine trolleys and the quantity of medicines stored in it. There was no apparent overstocking. None of the service users self- administer their medicines. A policy and procedures for the management of medicines was available and staff were aware of it. The medicines administration records (MAR) sheets were checked. There were some handwritten entries and amendments relating to the administration of some medicines, which were not dated or signed to evidence authorisation. Otherwise medication records were satisfactory. Sue Ryder Care Centre DS0000015874.V305879.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 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 is good. This judgement has been made using available evidence including a visit to the service. There is a written and publicised complaint procedure, which service users and their representatives can use to raise concerns about any aspect of care at the Home. There is also an adult protection procedure in place, which ensures multi-agency collaboration in addressing protection issues for service users. However, the need to improve complaint management and for appropriate training on adult protection to be provided, are highlighted for action. EVIDENCE: A complaint procedure was available to all service users and their representatives. A copy of the procedure was included in the service user guide and the Home’s statement of purpose, to enable service users and their relatives to make complaints as necessary. The Home had received and dealt with three complaints since the last inspection. The registered manager stated that all three complaints were partially substantiated. However, records relating to the investigation of these complaints were not available for inspection. In discussion, service users and relatives stated that they had brought up concerns, at different times, to the attention of staff. They also added that most of these concerns were satisfactorily dealt with. However, no records of such concerns could be evidenced. Complaints and concerns should be appropriately recorded to show their management and the outcomes achieved. Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 19 Adult protection procedures are in place and have been used by management in one instance since the last inspection, to address an adult protection issue between two service users. However, in discussion, some care and nursing staff appeared unsure about the Home’s adult protection procedures and the guidance contained in the ‘No secrets’ document issued by the Department of Health. They confirmed that they have not had specific training on adult protection issues. Sue Ryder Care Centre DS0000015874.V305879.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The Home appeared well maintained, clean and tidy and provided a pleasant environment for the service users. The Home also provided a range of equipment and aids to assist the mobility and communication of service users and to improve their quality of life. EVIDENCE: Hickleton Hall is a large country home set in several acres of gardens and woodlands. The accommodation for the resident group is provided over three floors and there is a passenger lift to facilitate access between these floors. Most of the communal areas for service users are located on the ground floor. These include a large dining room and four lounges, the kitchen and a chapel. The building is wheelchair accessible by the provision of a ramp to the front and level access at two doors at the back. There are bathrooms and toilets on all the floors. Some service users’ rooms have en-suite facilities. The inspector undertook a tour of the premises, in the company of the registered manager. Internally, the building appeared to be well maintained and well decorated. The place was clean and appeared hygienic. Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 21 However, in several parts of the buildings the lighting level was rather low and subdued due to the apparent use of low voltage lighting. In areas like corridors, where equipment are left, this constitutes a potential hazard. The wooden floor across the landing and leading to the stairs on the first floor was uneven and had small gaps in it, which could constitute a hazard to service users. Service users’ bedrooms are decorated and furnished differently to reflect their personal preferences. Two service users had chosen to share a double bedroom some years back and were still happy to do so. Three bedrooms were viewed with the permission of the service users. Some bedrooms were provided with special beds and special chairs to enhance the safety of the service users involved. Two service users said that they liked their rooms and showed their personal belongings, with pride. In discussion, service users and staff commented on the various aids to mobility and equipment available to service users who have communication difficulties. These included overhead tracking hoists, transfer equipment, neeter eaters, lite writers and a portable sensory room equipment. Sue Ryder Care Centre DS0000015874.V305879.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 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 is good. This judgement has been made using available evidence including a visit to the service. Staff had a range of qualifications and experience and had received training to help them understand and meet the care needs of service users. However, further training of all staff is required. The dependency of service users at the Home is currently high and this requires appropriate staffing both in numbers and in their deployment. A review of staffing level is recommended. EVIDENCE: During the inspection, the inspector spoke to five members of staff. Two of the nursing staff spoke about their experience in the field of rehabilitation and neurological care. They felt there was a good staff team at the Home, which worked well for the benefit of the service users. Two of the carers also commented positively on the staff team. However, they felt that there seemed to be less dedicated time to ‘ talk to residents’ as complex care needs have increased. The usual staffing level to meet the needs of the client group, consists of 9 carers in the morning, seven in the afternoon and three at night. The home also provides an additional one to one carer service for one named service user. There are usually three first level nurses in the morning, two in the afternoon and two at night. This staffing complement is supported by other staff in the activities and therapy section. Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 23 However, it was noted that only one care staff was deployed to care after seven elderly service users who suffer from varying levels of confusion and dementia but said to have only personal care needs. This arrangement should be reviewed both on dependency and on health and safety grounds. From the duty rota submitted, it was also unclear, as to how staff sickness and other absence were covered, to ensure continuity of care to service users. Most staff spoken to, had experience of working with service users with physical disabilities and who are elderly. Over 50 of the current care staff team have achieved an NVQ qualification in Care. A number of other carers are undertaking similar NVQ training. Staff had also received training on subjects like, ‘moving and handling, food hygiene, fire safety, health and safety and first aid. A number of staff, when asked, said they had not received any training on adult protection issues. They also felt they could benefit from more training on the specialist areas of care, including methods of communication, that people with neurological conditions require. The Home has developed a training plan and such training will be provided at a future date. Staff recruitment procedures could not be checked during this inspection, as the relevant documents were not kept by and were not accessible to the registered manager. In general discussion, it was noted that the current staff team has a good gender balance but that it did not reflect as being culturally diverse to benefit all its service users. Sue Ryder Care Centre DS0000015874.V305879.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 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 is good. This judgement has been made using available evidence, including a visit to the service. There is evidence of good management at the Home. There appears to be good teamwork, which is of benefit to the service users. It was evident that staff were keen to promote service users’ rights and welfare. However, further work is needed to ensure outcomes from the quality monitoring exercises that are being conducted EVIDENCE: Service users, staff and some relatives spoken to, commented favourably on the way the Home was managed. The registered manager and the overall centre manager were seen as well qualified and experienced to be in charge of the Home. They felt the registered manager was approachable and would deal with any concerns that they had in a professional manner. Staff felt that they worked well as a team. Staff showed interest in safeguarding and promoting the rights of service users. Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 25 Health and safety issues were appropriately managed. In the pre inspection statement, the manager had stated that most of the major systems and equipment in the Home had been regularly checked and serviced. This was confirmed during the inspection. The health and safety issues were also addressed during the monthly visits undertaken by the registered provider (Regulation 26 reports). Service users and staff stated that they were asked for their views regarding the service being provided at the Home. Staff stated that they were involved in developing a quality care audit for the Home. One service user said that as chair of the ‘Residents Group’ he was involved in a ‘Quality improvement Group’. However, the outcome of the current quality monitoring exercise was not yet available. Sue Ryder Care Centre DS0000015874.V305879.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 2 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 3 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4, 5 Requirement Timescale for action 20/11/06 2. YA2 3. YA6 4. YA6 5. YA7 The Home’s statement of purpose and service users guide must be improved in line with the guidance within the regulations and must be made accessible in relevant formats to service users and their representatives. 5 Admission of service users to the Home must be undertaken on the basis of a full needs assessment. 12, 15, 17 Care provided to service users must be recorded in order to show that care plans are being appropriately implemented. 12, 15 The process involved in reviewing care plans must be clarified and such reviews must be carried out at least half yearly for younger adults and monthly for older adults. 12, 15 Identified risks faced by service users must be appropriately managed and reviewed. Action to be taken must be agreed with service users and their representatives as part of their care plans. 16/10/06 16/10/06 16/10/06 16/10/06 Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 28 6. YA7 12, 15, 17 The use of restraint must be agreed as part of a care plan and its use must be recorded and reviewed. Service users must be provided with an assessment of their nutritional needs, which must then be addressed in their care plan as necessary. All handwritten entries and amendments on medicines administration record sheets must be signed and dated to show evidence of authorisation. Details of complaint investigations must be appropriately recorded and kept at the Home and made available for inspection as necessary. All staff at the Home must be provided with training on adult protection issues/procedures. The lighting levels in parts of the Home as identified, must be increased to ensure that enough light is available. The wooden floor as identified, must be repaired or made safe as necessary. Staff files relating to records of recruitment, including preemployment checks and other appraisal, disciplinary and staff development issues must be accessible to the registered manager and made available for inspection as necessary. 16/10/06 7. YA17 14, 16 16/10/06 8. YA20 12, 13 16/10/06 9. YA22 22 16/10/06 10. 11. YA22 YA24 12, 13 12, 23 20/11/06 16/10/06 12. 13. YA24 YA32 12, 23 17,18, 19 06/11/06 16/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 29 No. 1. 2. 3. Refer to Standard YA17 YA32 YA22 Good Practice Recommendations Menu planning should include the views and preferences of service users. A review of the staffing level at the Home should be undertaken, in particular, with regards to the care of the older resident group. Complaints and concerns should be appropriately recorded to acknowledge their receipt and show their management and outcomes achieved. Sue Ryder Care Centre DS0000015874.V305879.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sheffield Office Ground Floor Waterside Court Sheffield S9 2LR 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 DS0000015874.V305879.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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