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Inspection on 21/04/05 for Sue Ryder Nursing Home

Also see our care home review for Sue Ryder Nursing Home for more information

This inspection was carried out on 21st April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

The existing dining room, which had previously been assessed as not meeting the residents needs, had now been extended, upgraded and refurbished. The new extension also included views over the courtyard, and now met resident`s needs. Residents spoken with confirmed that this was a great improvement to the Home.

What the care home could do better:

This inspection found risk assessments for one resident missing, which were required, and a minor omission within one staff member`s records around identity checks.

CARE HOME ADULTS 18-65 Sue Ryder Nursing Home The Chantry, Chantry Park Hadleigh Road Ipswich Suffolk IP2 0BP Lead Inspector Kevin Dally Unannounced 21 April 2005 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 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 Stationary 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 Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sue Ryder Nursing Home Address The Chantry, Chantry Park, Hadleigh Road, Ipswich IP2 0BP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01473 295200 01473 231397 None Sue Ryder Care Mrs Joanne Marshall Care Home with nursing 29 Category(ies) of Physical Disability (27) Physical Disability over registration, with number 65 (2) of places Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 08.09.04 Brief Description of the Service: Sue Ryder Nursing Home is a large old mansion house, which is located within the grounds of “The Chantry” public park. The house, which is owned by the Local Authority, is managed by the Sue Ryder Care Group, and is registered for 27 young adult service users with physical disabilities, and for 2 service users with physical disabilities over 65 years of age. The Home had been significantly adapted to provide for the needs of its service users, and there is adequate space for wheelchair users. There is a large physiotherapy room fitted with suitable equipment, a Snoozlem room for relaxation therapy, and a large day centre area. There is an expansive well-maintained garden to the House, which can be easily accessed by service users. The premises have 17 single rooms and 6 double rooms. There is a large reception hall, number of large lounges, and a recent extension to the dining area. There is a programme of internal and outside activities, and the home had its own wheelchair accessible minibus. Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report followed a routine unannounced inspection of the Sue Ryder Care Home. The registered manager, Mrs Joanne Marshall, and the deputy manager Mrs Louise Fawkes, were present and fully contributed to the inspection process. This inspection revealed that of the 28 standards inspected, 26 were assessed as fully met, with 2 standards as almost met. As the Home continued to provide a comprehensive range of inclusive and meaningful personal development and leisure activities for residents, these two standards were assessed as “Standard exceeded”. This inspection demonstrated the positive provision of a specialised nursing care service to residents with complex physical disabilities, and residents confirmed that this service fully met their care and support needs. Comments received from residents included the following. “I feel happy in the Home”, and there is “good care”. “The staff are good, the nurses are very good and staff are always around”. Residents confirmed that they felt consulted and included by the Home. What the service does well: This inspection demonstrated that the overall quality of care provided by the Home for residents with complex physical disabilities, continued to be to a very good standard. Staff were found to be a very hardworking and were a committed staff team who enjoyed the work they undertook. The Home was found to be well managed, and the staff team had been well trained to meet the specialised needs of the residents of the Home. Two standards, personal development, and leisure activities for residents were assessed as “Standard exceeded”. This was due to the continued commitment by the Home to provide inclusive and meaningful opportunities for the residents of the Home, which they enjoyed. The provision of the physiotherapy service, the day centre service and the snoozelum, which met the needs of the residents, was considered a very positive and very integral part of the Home. Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 6 The premises, formerly a large mansion house, provided a suitable environment for residents with complex physical disabilities. Excellent features of the Home that met service user need included the large reception hall, wide corridors, and two lifts to the two floors, large lounges, and the new dining room. The premises and décor were well maintained, clean and hygienic. 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 Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 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 standard(s) 1,2,3 Prospective residents can be assured that they will be given the information they need to make an informed decision about the suitability of the Home to meet their needs. They can be assured that a range of comprehensive preadmission assessments will be undertaken. EVIDENCE: Residents were provided with a Statement of Purpose and Service User Guide, which clearly described for them the type of care needs and services that the Home could provide. The Nursing staff and the Physiotherapist would assess a new service user, prior to any offer of a place at the Home. This included staff undertaking an assessment of daily living, which assessed 12 areas of care needs. One service user’s records were examined, and very detailed and appropriate assessments had been undertaken to determine their suitability for a placement at the Home. Sue Ryder Nursing Home is a specialised service for people with complex physical disabilities. The Home had around 20 Registered Nursing staff, one part time Physiotherapist and two Physiotherapist assistants who were trained to meet the specialised needs of the service user group. Staff spoken with, records checked and the Staff Training Plan for 2005 examined, confirmed that staff continued to receive good training, which enabled them to meet the needs of the service user group. The premises were observed to be very spacious, wheelchair friendly, and the two floors could be easily accessed by the lift. The premises included a Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 9 physiotherapist’s room, which contained a wide range of specialist equipment, a Snoozlem for sensory stimulation and relaxation, and the day centre, which enabled staff to offer a range of programmes and activities for service users. During the inspection, two service users spoken with at the physiotherapy department, expressed their satisfaction with the care received at this unit, and of the importance the unit was to their physical progress. The Physiotherapist confirmed that all residents within the Home had been assessed, and were provided with an appropriate exercise programme. One care plan examined demonstrated that the staff had undertaken appropriate assessments, which confirmed that their care needs could be met. From the information gathered it was clear that the Home was able to meet any specialised requirements of the service user group. Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 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 standard(s) 6,8,9 People who use this service can be assured that this service will assess and review care plans to ensure personal needs and goals are meet. EVIDENCE: Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 11 Three service users were spoken with about the care they received, and one of these service user’s care was tracked by checking their plan of care. Care records included an “assessment of daily living”, which assessed 12 areas of personal need, in summary form. Care plans were then produced from this assessment. The Home continued to use a combination of two nursing models to record care. Only specific problems requiring nursing intervention are recorded in detail, but those listed were in some considerable detail, with evidence of constant review. In discussion with the Clinical Governance manager, it was reported that a newly developed care plan was about to be implemented by the Home, and this was seen and found to be very thorough. Further, the Home had recently trialled a nutritional assessment, but had now moved to a second assessment, which had proved to be more clinically helpful for the Home. One service user plan included a detailed assessment of their personal care needs and had identified 10 areas of nursing intervention that was required. Pressure area assessments were in place, but there was no moving and handling or personal risk assessments found on this resident’s record. These were required to be immediately provided by the Home. The three service users spoken with confirmed that life at the Home and the quality of the care provided was very good. Two of the comments received from residents included the following. “I feel happy in the Home”, and there is “good care”. “The staff are good, the nurses are very good and staff are always around”. Service users felt consulted and included by the Home. Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 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 standard(s) 11,12,13,14,15,16,17 People who use this service can be assured that they will have access to a wide variety of meaningful and appropriate leisure opportunities, including opportunities for personal development and access to the community. EVIDENCE: Residents were found to have a wide variety of appropriate leisure or exercise opportunities to choose from, which included access to the Homes physiotherapy department, the snoozlem for sensory stimulation and relaxation, the day centre for activities, or trips outside the Home. The day centre provided many interesting and varied activities, together with day attendees. Residents could also join one of the many planned outdoor excursions provided or join in on one of the Home’s many social activities or evenings. Three service users spoken with, records checked, the activities coordinator spoken with, and the physiotherapist spoken with confirmed that a very varied range of personal leisure pursuits, personal opportunities and activities continued to be provided by the Home. The day centre was visited and found to be offering music therapy for 5 residents, and they confirmed that this was really enjoyable. Further, two residents spoken with at the physiotherapists department confirmed that they were following a personal Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 13 exercise programme for the morning. Due to the continued quality and high standard achieved by the Home within these areas, the standards of personal development and leisure pursuits were assessed as, “Standard exceeded”. Residents spoken with also confirmed that they were able to maintain links with their family. Several residents confirmed that they could receive family and friends in private, or within a variety of appropriate rooms. One service user stated that their friends called regularly at the Home, and that staff always made them feel welcome. Staff spoken with including a group of care staff and the activities coordinator, confirmed that they were committed to ensuring that residents had the maximum amount of independence and choice, where this was possible. The activities coordinator confirmed that different programmes were organised to ensure the physical, intellectual, creative, social, sensory and spiritual development took place for each resident. Recent programmes for residents had included bingo, quizzes, crafts, social evenings and events, shopping, outings to the beach and church services. The menu choice showed that residents were provided with a balanced, varied, and sufficient diet with appropriate meal choices. Four residents spoken with during the mealtime stated that staff would assist them chose their meal, and that their meals were enjoyable. The meal on the day of the inspection was Pork and Pineapple Curry Pie or Braised Beef, with roast potatoes, swede and leeks. Dessert was apple pie and custard or ice cream. The meal was appetising, smelt and looked good. Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 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 standard(s) 18,19 People who use this service are guaranteed that they will receive personal support and that their physical and emotional needs will be met. EVIDENCE: The Sue Ryder Nursing Home continued to provide a positive environment for up to 29 residents with complex physical disabilities. The routines of the Home were well established; flexible and wherever possible, did not intrude on each individuals need for privacy. Residents and staff spoken with confirmed that staff continued to maintain their privacy by knocking on doors before entering and by the use of appropriate screening when care is given. Further each resident is asked about his or her preferred choice of personal clothing for each day. Staff were observed through out the day treating residents with respect, enjoying their company, and meeting residents personal care needs. One resident who shared a double room, stated that their privacy was respected and, when resting, had their curtains drawn. Further they stated that “the care given 24 hours a day is good”. Sue Ryder promoted and maintained good levels of personalised, holistic health care for its residents. Staff confirmed that staffing levels were adequate ensuring appropriate personal care and time available to meet the health care needs of the residents of the Home. The staff group spoken with confirmed that they “work very hard to meet residents needs, and that care was to a high standard”. Three residents commented, “ I am more than happy with the care Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 15 received. It is very good”, or “I feel happy in the Home and there is good care”, or “the care is good. I have no concerns”. The accident log was checked and found to contain 32 recorded incidents during the last 12-month period. Accident records examined showed that these were mainly minor in nature, and that the Home had appropriately recorded and continued to monitor the incidence of falls. The Home had its own physiotherapy department, and nutritional screening was undertaken with advice from the hospital’s Dietician. The deputy manager stated that the Home had recently trialled a nutritional assessment but that this had not been suitable for the Home’s requirements. They were now working closely with the hospital Dietician and using a new nutritional assessment called “MUST”. The deputy manager confirmed that staff continued to receive training (the NVQ programme) enabling them to meet the needs of residents with physical disabilities. Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 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 standard(s) 22,23 People who use this service can be confident that their complaints would be taken seriously and acted upon. EVIDENCE: The Homes complaints procedure appropriately stated that any complaint received would be acknowledged in writing, within 2 working days, and a full response and outcome would be sent to the complainant within 20 working days. The complaints procedure appropriately recorded the name; address and contact telephone number of the commission, should a complainant wish to complain directly, to the CSCI. The complaints book was checked and the manager confirmed that no complaints had been received within the last 12 months. The Home had suitable Adult Protection policies and procedures in place and the manager was aware of her obligation in the reporting of any allegations of abuse to Social Services, the police and/or the CSCI. One staff members records checked included a CRB disclosure and 2 references. The staff training plan recorded that new staff were required to complete abuse training. Two residents spoken with confirmed that they were “very happy in the Home had had no concerns”. One resident stated that they “felt safe”. Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 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 standard(s) 24,25,26,27,28,29, 30 People who use this service can be assured that the environment is comfortable and safe, well maintained, clean and hygienic. EVIDENCE: The Sue Ryder Nursing Home is a large old mansion house, which is located within the expansive grounds of “The Chantry” Public Park. The house, which is owned by the Local Authority, is managed by the Sue Ryder Care Group, and is registered for 27 younger adult service users with physical disabilities, and 2 with physical disabilities over the age of 65. The Home had been significantly adapted to provide for the needs of its residents, and there is plentiful open space for wheelchair users. There is a large physiotherapy room fitted with suitable equipment, a Snoozlem room for relaxation therapy, and a large day centre area. There is an expansive well-maintained garden to the house, which can be accessed by residetns. The premises have 17 single rooms and 6 double rooms, one of which has an en-suite. There is large reception hall, number of large lounges, and a large newly refurbished dining room. There is a programme of internal and outside activities, and the Home has its own wheelchair accessible minibus. The house was well maintained with fixtures, fittings, décor and Carpets and/or tiling to most areas, and provided in a Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 18 practical style for the residents, but appropriate to the mansion. Garden areas have been landscaped with raised beds. The individual rooms and communal space were found to meet the relevant standards. The front of the House, the reception area, the corridors, two lifts, the large lounges, the physiotherapy department, the snoozlem, and the day room were excellent features of the Home, and been appropriately adapted to meet the needs of the residents. Rooms were furnished and reflected each individual’s personal tastes. Toilet and bathroom facilities, and aids and equipment were spread throughout the Home, and were sufficient to meet the needs of residents. The existing dining room, which had previously been assessed as not meeting the residents needs, had now been extended, upgraded and refurbished. The new extension also included views over the courtyard. The dining room was visited during the busy lunch time period and was being fully utilised by around 12 residents. This was observed to provide sufficient space without congestion, and which allowed the free access and movement of wheelchair users. Staff were able to move easily among residents and were able to offer assistance, to those who needed this. Residents spoken with confirmed that this was a great improvement to the Home. The Home provided 13 WCs, 5 bathrooms, 2 shower rooms, and 4 rooms with a shower sink. The latter enabled the occupants to be showered in their rooms on one of the three shower trolleys. On the day of the inspection the Home was found to be very clean and hygienic, well maintained and free of any odours. Bathrooms and toilet areas were found to be clean and hygienic and were provided with liquid hand wash and paper hand towels. Residents and staff confirmed that the Home was well maintained, hygienic and clean. Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33, 34, 35,36 People who use this service can be assured that they will be supported by competent and qualified staff who are able to meet the care needs for younger adults with physical disabilities. EVIDENCE: The Home used an established system to determine the dependency levels of the residents. 2 trained nurses are usually required to be on duty each shift, with 6 care assistants in the mornings, 4 in the afternoon, and 2 at night. Care Staff, on duty the day of the inspection were 2 Registered Nurses with 7 carers. Domestic and kitchen staff were around but not checked on this occasion. Other staff on duty included the activities co-ordinator, three administrators, the receptionist, 1 physiotherapist and 2 assistants, the day centre manager and the maintenance person. The manager and deputy manager were also working within the Home. Three residents commented, “ I am more than happy with the care received. It is very good”, or “I feel happy in the Home and there is good care”, or “the care is good. I have no concerns”. The staff group spoken with stated that they believed that the care offered by staff was to a high standard. Staff stated that they thought that staff morale had improved, as the Home had recently been able to attract some new permanent members of staff. This had meant that Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 20 the Home would now be less dependent on the usage of agency staff. One night staff member spoken with confirmed that the night team consisted of 4 permanent registered nurses and 6 care assistants, of which there was mostly 2 registered nurses and 2 care assistants on each night duty. From the residents and staff spoken with, and the records checked confirmed that the Home maintained good numbers of staff to meet the specialised needs of service user group. Further records checked confirmed that staff had been appropriately trained and were able to undertake their respective job roles, and were able to meet the needs of the service user group. One new staff member’s recruitment records were examined and suitable recruitment and employment procedures were found in place. The staff member’s records included many of the relevant records for example CRB, and reference checks but had not included a record of their proof of identity, which was required. A group of staff spoken with and one new staff member’s records checked confirmed that the Home continued with the provision of training to its employees. For example, moving and handling, first aid, infection control, and TOPPS training. One new staff members records demonstrated that they had achieved an NVQ 3 in care so had received induction and foundation training. The Home also provided the staff training and development programme for the 2005 year. This plan included the provision and allocated finances to allow training to continue to the staff group. Proposed training included manual handling, first aid, food hygiene, fire safety, health and safety, abuse training, infection control, managing challenging behaviour, complaints training, supervision and appraisal skills, equal opportunities, and NVQ training. Professional nurse training opportunities and a team-building day was also planned for. Supervision was undertaken on a regular basis to ensure that staff were regularly supported within the team. One new staff member’s records included 3 probation reports. The staff group stated that they were regularly supervised and felt supported by the Home. Supervision could include discussion around their job role, training needs, any problems experienced and their general performance. Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 42 People can be assured that this service is well managed with a positive culture of inclusion, offering choices and providing residents with opportunities for some independence. EVIDENCE: The Home was found to be well managed with sufficient administration and management staff to ensure the efficient and effective management of the Home. The Home’s ethos encouraged a culture of resident inclusion, choice, self-determination, and positive care outcomes, and which has been fully outlined within this report. Some staff stated that they felt that the management team were not always easily accessible to staff however, also admitted that they were unaware of what problems or challenges the management might have to face. This was discussed with the manager who was not surprised by some of these views. The Home was currently undergoing an agenda for change, and there were challenges ahead. However, the manager stated that there was a team away day shortly in which hopefully this matter could be discussed more fully. Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 22 A short environmental tour was undertaken of the ground and first floor, which included a sample of hot water tap temperatures of a bath and hand wash basin. All areas inspected were seen as meeting the required standards. Further the fire log was examined which included appropriate documentation, and a fire risk assessment. Hoists seen had been appropriately maintained. One staff member’s records checked and staff spoken with demonstrated that the Home had undertaken fire, moving and handling, food hygiene, first aid and health and safety training. The Home environment was observed to be well maintained, clean and hygienic. Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 4 3 3 4 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sue Ryder Nursing Home Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 3 x I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 24 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. Standard 9 Regulation Requirement Timescale for action Immediate 2. 34 13(4)(b)(c A moving and handling and ) personal risk assessment had not been provided for one resident. This must be provided and a record maintained within their file. 19(4)(b) Staff identity checks must be 9.06.05 Scheduule undertaken for each staff 2(1) member and a record maintained 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 Good Practice Recommendations Sue Ryder Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 5th Floor, St Vincent House Cutler Street Ipswich IP1 1UQ 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 Nursing Home I54-I04 S24508 Sue Ryder V222638 050421 Stage 4.doc Version 1.30 Page 26 - 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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