Inspection on 25/06/07 for Sue Ryder Nursing Home

This inspection was carried out on 25th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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.

Other inspections for this house

Sue Ryder Nursing Home 21/06/06

Sue Ryder Nursing Home 01/08/05

Sue Ryder Nursing Home 21/04/05

Sue Ryder Nursing Home 08/09/04

Sue Ryder Nursing Home 11/05/04

Sue Ryder Nursing Home 02/02/04

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

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

CARE HOME ADULTS 18-65 Sue Ryder Nursing Home The Chantry Chantry Park, Hadleigh Road Ipswich Suffolk IP2 0BP Lead Inspector Julie Small Key Unannounced Inspection 25th June 2007 11:05 Sue Ryder Nursing Home DS0000024508.V344141.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 Nursing Home DS0000024508.V344141.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 Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sue Ryder Nursing Home Address The Chantry Chantry Park, Hadleigh Road Ipswich Suffolk IP2 0BP 01473 295200 01473 231397 jo.marshall@suerydercare.org www.suerydercare.org Sue Ryder Care Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Joanne Marshall Care Home 29 Category(ies) of Physical disability (27), Physical disability over registration, with number 65 years of age (2) of places Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 The home may also care for two service users, as named in the letter dated 18 August 2004 (from Jayne Stevens, Regulation Manager, to Mrs J Marshall, Registered Manager) who have physical disabilities and who are over the age of 65 years. 21st June 2006 Date of last inspection Brief Description of the Service: The Chantry is situated in a large old mansion house located in the grounds of Chantry Park. The house is owned by the Local Authority and managed by the Sue Ryder Care Group. It is registered for 27 younger adults with physical disabilities and for 2 residents with physical disabilities over 65 years of age. The home specialises in providing nursing care for people who have a neurological condition, such as acquired brain injury or chronic neurological disease. The building has been significantly adapted to provide for the needs of its residents. There is adequate space for wheelchair users, a large physiotherapy room with suitable equipment, a Snoezelen for relaxation therapy, and a large day centre area. Service users who are wheelchair users are able to access the expansive and well-maintained grounds of the park. The home has 19 single rooms and 5 double rooms. There is a large reception hall and dining room, and a number of large lounges. There is a programme of activities, and the home has its own wheelchair accessible minibus. The weekly current scale of charges is £755 to £1300 per week. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Monday 25th June 2007 from 11.05 to 17.50. The inspection was a key inspection which focused on the core standards relating to adults and was undertaken by regulatory inspector Julie Small. The report has been written using accumulated evidence gained prior to and during the inspection. The registered manager, care manager and area manager were present during the inspection and provided the requested information promptly and in an open manner. The inspector was informed that service users were referred to as residents at the home and this term will be used throughout this report. During the inspection a tour of the building was undertaken and three service user’s records, nine staff recruitment records, training and health and safety records were viewed. Further records viewed are detailed in the main body of this report. Several residents were met and three were spoken with and four staff members were spoken with. Five staff members were spoken with. Observation of work practice was undertaken. Prior to the inspection an Annual Quality Assurance Assessment (AQQA) and staff, visitors and residents surveys were sent to the home. The AQAA was returned to CSCI (Commission for Social Care Inspection), five service user, four relatives/visitors and six staff surveys were returned. What the service does well: What has improved since the last inspection? Three new sluice machines had been purchased. The laundry area had been refurbished and there were newly purchased washing and drying machines. There had been some decoration, including various bathrooms. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 6 Resident’s records were signed for in MAR (medication administration records) charts. The home had changed the pharmacy for the provision of medication. The medication policy had been updated and included guidance around the administration of medication with PEG feeds. Regulation 26 visits were regularly undertaken and the reports were routinely forwarded to CSCI (Commission for Social Care Inspection). There had been some work undertaken around the nutrition and menu provision of individual residents, their preferences and needs were clearly identified in their care plans. Resident’s records viewed included falls risk assessments and how staff should work with individual residents who may demonstrate challenging behaviour. 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. The summary of this inspection report can be made available in other formats on request. Sue Ryder Nursing Home DS0000024508.V344141.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 Nursing Home DS0000024508.V344141.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can expect that the information they need to make an informed choice about where to live and that their individual aspirations and needs are assessed. EVIDENCE: The home’s statement of purpose was viewed and included details such as the name and address of the organisation, the manager’s name and qualifications, who lives at the home and how the home meets resident’s needs. A resident was spoken with and said that they had received good information about the home before they decided that they wanted to move in and said that they visited the home before they made their decision. The resident said that the information provided gave a clear explanation about the service, which they received at the home. The resident survey asked if they had received enough information about the home so that they could decide if it was the right place for them. Four answered yes and one did not answer. Comments included ‘things change all the time’ and ‘I am not sure but I think I did’. The survey asked if the Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 9 residents were asked if they wanted to move into the home and five answered yes. Comments included ‘I wanted to come here’, ‘it has nice surroundings and is nice inside’ and ‘I find it much better than the home I was in before I came here’. The relative/visitor survey asked if they got enough information about the home to help them make decisions. Two answered always and two answered usually. Three resident’s records were viewed and each held a comprehensive assessment of their needs which was undertaken prior to them moving into the home. The needs assessments included details regarding communication, eating and drinking, personal cleansing and dressing and their health and psychological well being. Sue Ryder Nursing Home DS0000024508.V344141.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can expect that their needs are identified in an individual care plan, that they are consulted with regarding the care that they receive and that they are supported to take risks as part of an independent lifestyle. EVIDENCE: Three resident’s records were viewed and they contained individual care plans which identified how their needs were met at the home. The care plans included details of the problem/need, goals and desired outcome and care input and actions regarding all aspects of their daily living needs. The care plans identified needs such as mobility, eating, psychological, sexuality and privacy and dignity. There were clear plans which identified support residents received regarding the management of their behaviours and there were guidelines for staff to refer to when working with the residents if they exhibited specific behaviours. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 11 The resident’s records included risk assessments which included personal safety, manual handling, falls, comfort and tissue viability. There was information about the independent lifestyle one resident enjoyed, which included going to the cinema and using a taxi to do so. The records included details of how they preferred to participate in the activity alone and how they chose to undertake the activity. There were documents in resident’s records which identified how the care plans and risk assessments had been updated and reviewed on a regular basis to meet with their changing needs and preferences. The staff survey asked if they were provided with up to date information about the needs of people they supported. Comments included ‘staff are very well informed about the needs of our residents’, ‘the care plans are always up to date, handovers to report anything’, ‘yes and we are expected to up date monthly’ and ‘the care plans – too many to read – folder much too big’. Comments made in the staff survey from the section which asked what the service did well, included ‘we offer a very specialist service where people are able to maintain their independence and have choices. Not only their medical needs are met but also their physical, intellectual, emotional and social needs’ and ‘It has the best of care for patients I have witnessed through my career in different settings. The support workers are fantastic at making residents feel they are being cared for 100 ’. Each resident was provided with a named key worker and nurse, and their names were included in their care plans and on a notice on their bedroom wall. The AQAA stated that the notice was to remind the residents of their named workers. There was a notice on the resident’s notice board, which identified details of advocacy services, which residents could access if they chose to. Resident’s records included daily records, which identified their actions, activities and support that they had been provided with on a daily basis. The records identified how each individual had made choices in their daily living, such as activities they wished to participate in and what they wanted to eat. A resident spoken with confirmed that they made choices in their daily life and the staff listened to what they said. They said that they felt that their needs were met and were aware that there was a care plan which explained their wishes and needs. Minutes from resident’s meetings were viewed where they discussed issues regarding their lives and the living at the home. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 12 The home had a resident’s committee and the residents at the home nominated participants. Outcomes from the meetings were presented to the quality improvement group and the home’s annual plan. Resident’s and respite resident’s satisfaction questionnaires were regularly undertaken and were used in the home’s quality assurance activities. The AQAA stated that residents were involved in the process of interviewing staff. The resident survey asked if they could make decisions about what they did each day. Four answered always and one answered usually. The survey asked if staff listened and acted on what they said. Two answered always and three answered usually. The relative/visitor survey asked if they felt that the care home met the needs of their friend/relative. Three answered always and one answered usually. The survey asked if the home gave the support or care to their friend/relative which they expected or agreed. Four answered always. The survey also asked if the service met the different needs of people and four answered always. One comment was ‘I think each individual is treated according to their needs and their private life is purely confidential as it would be at home’. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can expect to take part in appropriate activities in the home and in the local community, that they maintain personal relationships, that their rights are respected and that they are provided with a healthy diet. EVIDENCE: There was a day centre facility in the home, which residents could access if they wished to. The day centre manager was spoken with and explained activities which were available for resident’s use, which included arts and crafts activities and MS (multiple sclerosis) sessions for those with MS and their families. The home provided a physiotherapy service which residents were observed using during the inspection. A physiotherapist was spoken with and explained some of the equipment, which was used to ensure that residents were as Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 14 comfortable as possible. They explained photographs of each resident, which were attached to their wheelchairs, which provided visual information of how they should be sitting in their chairs. The AQAA stated that the practice was introduced following suggestion from residents. One resident spoken with said that they were undertaking a distance learning course in counselling. The home had a full time activities co-ordinator, who was spoken with and explained the range of activities available for residents to participate in if they wished to. The activities programme was viewed and included trips to local coastal towns, quiz, Bible stories, social evening, skittles, bingo, personal care skills, cake mixing, exercise and visiting entertainers. A music therapist visited the home twice a week and there was a religious service held in the home on a monthly basis. The AQAA stated that the activities programme had been reviewed with the involvement of residents. During a tour of the building the snoozelem area was viewed, which included soft seating, lights and music. There was a portable sensory trolley, which had a ‘disco ball’ and lighting which residents could use in their bedroom if they wished to. There was a garden with seating and raised flower beds where residents could garden and there were several tomato plants which residents were growing. The home was situated in a large park, to which residents had access to the grounds. Each resident was provided with an activities chart, where they could indicate which activities they were interested in and they were then provided with a weekly programme which indicated the times and areas in the home where the activities were taking place. Resident’s records viewed included written evidence of activities which they had participated in and their usual daily routines. A resident was spoken with and said that there was lots to do at the home, and that they also went out to the cinema and used a local taxi company, they attended a sports club in the community and they went out with their family and friends. Their family and friends also visited them at the home. They said that the staff were very good and treated them with respect and respected their privacy. A staff member showed the inspector ‘do not disturb’ signs, which residents could hang on their bedroom door if they wished to have privacy. They said Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 15 that the signs had been provided following requests raised in resident’s meetings. During a tour of the building it was noted that there were televisions and music centres which residents could use and there was a range of video films and books which were available. There was a display of greetings cards for sale in the entrance hall and a staff member explained that residents in the home had made them. The resident survey asked if they could do what they wanted a) during the day, four answered yes and one answered no. b) In the evening, five answered yes. c) At the weekend, three answered yes and two answered no. Comments included ‘on the whole it is quite good’, ‘I would like more bingo’ and ‘I would like more to do at the weekend’. A comment in a relative/visitor survey was ‘it takes into account each individual’s needs and schedules their activities accordingly, nobody is left out unless they wish it’. Interaction between staff and residents was observed to be positive and respectful. The resident survey asked if staff treated them well and four answered always and one answered usually. A comment was ‘the staff are nice to me’. Resident’s records viewed included details of contact they maintained with their families and friends, which included telephone calls and visits. The relative/visitor survey asked if the home helped their friend or relative to keep in touch with them and four answered always. Comments included ‘I visit 5 days a week in the afternoons, they keep them busy in the mornings’ and ‘keep up the good work – the staff ate excellent from top to bottom, all very pleasant and approachable’. Minutes from resident’s meetings evidenced that they participated in the development of the menu. Resident’s records viewed included a detailed description of their likes and dislikes regarding food and the support they required in eating and drinking. Each record included an individual nutritional assessment. There was a balanced and nutritious menu. There were two choices available with supplementary choices such as salad, jacket potato and omelette if residents did not want what was offered on the menu. There had been work undertaken to develop the menus to provide an appealing diet to those who required support with eating. A staff member explained that they had referred Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 16 to a menu book, which identified appetising and inventive foods for those who required soft food. The menu of the day was displayed on a chalk board in the dining room. A staff member said that this had recently been introduced following suggestion by residents. The manager advised that there had been work undertaken to ensure that the hygiene and storage of foodstuffs had recently been reviewed following an issue of illness. Environmental health had visited the home and had reported that the procedures were satisfactory. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are provided with the personal support they prefer and require, that their physical and emotional needs are met and that they are supported by the home’s medication procedures. EVIDENCE: Resident’s records viewed included details of the personal support they required and preferred, including their preferred routines and moving and handling. A comment in a relative and visitor survey was ‘they keep (my relative) clean and smart (their) hair is always nice and clothes clean’. The resident’s records viewed included nutritional assessments, tissue viability assessments and a clinical risk assessment. Records identified medical care and healthcare support they had received, which included psychological, optical, dental and chiropody. The records clearly identified the specific support each resident required with regards to their condition and preferences. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 18 The home provided a physiotherapy service which was discussed in the previous section of this report. The AQAA stated that the physiotherapy department was staffed by two part time neurology clinical specialist physiotherapists, who oversee the planned individual programme for all residents, and two full time physiotherapy assistants. It stated that they work closely with the wheelchair clinic to ensure that resident’s chairs are regularly reviewed and meet their needs. The home had a detailed medication procedure which included guidelines for PEG feeding. Resident’s records clearly identified their medication and the arrangements for administration. Responsibility for administering medication was undertaken by nursing staff. The staff surveys received confirmed that those responsible for administering medication had received training to do so and had shadowed staff and they were observed administering medication when they started working at the home. Training records viewed evidenced that staff had received training from a local pharmacist and in house ‘learning by mistakes’ training. The home had recently changed their providers of medication due to issues with the previous pharmacy’s stock levels. A staff member said that they had had no issues with ordering and disposal of medicines since the change. The home used a MDS (monitored dosage system). Medication was securely stored in the home and during the administration ‘round’, medication was stored in a secured trolley. The MAR (medication administration records) charts viewed were completed appropriately, staff had signed to evidence that medication had been administered. The MAR charts included a photograph of the resident and what medication they were prescribed. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their views are listened to and acted on and that they are protected from abuse. EVIDENCE: The home had a complaints procedure, which included contact details of CSCI. The complaints records were viewed and included details of the nature of the complaint, who it was made by, the date of the complaint, how and when the complaint had been resolved and if it had been to the complainants satisfaction. The AQAA stated that there had been one complaint since the last inspection and it had been dealt with within timescales set out in their complaints procedure. The home’s compliments records were viewed and included copies of letters and quotes from resident and visitor questionnaires. The compliments book was displayed in the entrance area to the home. Five resident surveys and four relative/visitor surveys said that they knew how to make a complaint. They were asked if the home had responded appropriately if concerns had been raised, three answered always, one answered usually and there was a comment ‘very prompt’. Eight staff surveys said that they were aware of what to do if a resident, relative or friend wished to make a complaint. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 20 Training records viewed evidenced that staff were provided with training for POVA (protection of vulnerable adults) and training on how to work with residents who displayed challenging behaviour. The staff survey asked if they know about the procedure for safeguarding adults, five answered yes and other responses included ‘awaiting training for this’, ‘regular updates and training’, ‘yes it is in the policy folder’ and ‘yes recent in house training’. The home had policies and procedures relating to the protection of residents including the acceptance of gifts and abuse. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they live in a homely, safe, clean and hygienic environment. EVIDENCE: A tour of the building was undertaken, it was noted that the home was clean, attractively decorated and well maintained. There had been efforts to ensure that the home had a homely feel, with various plants and dried flowers displayed in areas around the home. The AQAA stated that they had refurbished a bathroom to include a parker bath and refurbished a shower room. New flooring had been installed in a further two bathrooms. There was a lift, which provided access to all floors for residents. The home was accessible to wheelchair users. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 22 The home was located in a large park, which was accessible to residents and members of the public. There had been some instances of stones thrown at windows. The manager advised that the local council had been contacted and floodlights had been installed in the grounds around the home. Residents were observed using various communal areas in the home such as the dining room, lounges and physiotherapy room. Some residents were observed relaxing in their bedrooms. Several resident’s bedrooms were viewed and all were personalised and reflected their choices and personalities. Three residents spoken with said that they were comfortable in their bedrooms and they had everything they needed. They confirmed that they had chosen their personal memorabilia, which were displayed in their bedroom such as photographs. Residents were complimentary about the environment and said that they enjoyed the views of the grounds. There were no offensive odours in the home during the inspection. The resident survey asked if the home was fresh and clean and five answered always. The laundry was viewed and had recently been refurbished, new washing machines and drying machines had been purchased. The washing machines had a facility for automatic detergent dispensing. There was hand washing facilities and a stock of disposable gloves and aprons. A staff member spoken with explained the procedures for infection control, dealing with spillages and handling soiled laundry. They had a clear understanding of the procedures, which reflected good infection control procedures in the home. There were three recently purchased sluice machines in the home. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are supported by staff who are competent, trained and supported and that they are protected by the home’s recruitment procedures. EVIDENCE: Staff were observed undertaking their usual work routines during the inspection, it was noted that they were respectful towards residents. They were observed consulting with residents throughout the day including where they wished their chair to be placed and when they wanted to go to the dining room for their meals. Training records viewed evidenced that staff were provided with a Skills for Care (formerly TOPSS) induction programme. Staff were also provided with an in house induction, where they were introduced to the work practices and procedures of the home. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 24 The staff survey asked if their induction covered everything they needed to know to do the job when they started. Comments included ‘induction was great all aspects covered and supported fully’, ‘I don’t think I realised how physically hard this type of nursing is’ and three just answered ‘yes’. In the entrance hall of the home there was a large display board, which had photographs of all staff working at the home. There was a larger picture of one staff member with the heading ‘Value’s Champion’ above it. A staff member explained that residents and staff could nominate a staff member for the award each month. There was a voting box in the entrance hall. The staff member was nominated for their work practice, which included the home’s set of values, which were professional excellence, innovative, open and honest, effective, teamwork, caring and respect. The AQAA stated that staff were provided with feedback on how they were delivering the set of values. The AQAA stated that the home had twenty three care staff. Twelve care staff had achieved a minimum of NVQ (National Vocational Qualification) level 2 and five staff were working on their awards. The home had achieved the target of 50 staff to have achieved a minimum of NVQ level 2 and were continuing to improve the numbers of qualified care staff. Staff recruitment records were viewed for three newly appointed staff members who were commencing their role the day following the inspection. A further six staff recruitment records were viewed of staff employed at the home since the last inspection. The records contained all required documentation which included a photograph of the staff member, identification such as a copy of their passport and birth certificate, application form, two written references and CRB (criminal records bureau) check. The staff survey asked if they felt that their recruitment was done fairly and thoroughly. Comments included ‘yes my recruitment process was fair and thorough, I was kept well informed throughout the process and felt my needs were met accordingly and all questions answered fully and honestly’ and ‘yes although I do admit that I didn’t feel very welcomed…’ The AQAA stated that prospective staff were questioned at interview regarding their understanding and views of equality and diversity. The staff records viewed of staff who worked at the home included a job description, code of practice, probationary reports and written evidence of regular supervision meetings. The AQAA stated that all staff had an identified supervisor who provides their supervision and that they were provided with an annual performance review. There were records of training undertaken which included medication, manual handling, food hygiene, POVA, gastronomy feeding, nutrition and peg care, Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 25 health and safety and non abusive psychological and physical intervention (NAPPI). The staff survey asked if they were given training which was relevant to their role, helps them to understand and meet the individual needs of residents and to keep them up to date with new methods of working. Comments included ‘statutory training ongoing throughout the year, specific training also available, all staff has MS, managing challenging behaviour’, ‘yes regular training is organised’ and ‘yes there is always opportunity for personal development and all training is very relevant to our residents’. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can expect that they benefit from a well run home, that their comments underpin self monitoring, review and development of the home and that their health, safety and welfare is promoted and protected. EVIDENCE: The Statement of Purpose, which was viewed, identified that the home’s manager had a registered nurse qualification and a diploma in management. They had made an application for their Registered Manager status with CSCI which had been successful. They were required to evidence their qualifications, experience and attributes to undertake their role. The AQAA stated that the manager had twenty years nursing experience and twelve in a management role. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 27 The care manager had achieved a registered nurse qualification and the NVQ RMA (Registered Manager Award). There was a good quality assurance process within the home and residents were regularly consulted regarding the care they received and the running of the home. There were regular Regulation 26 visits, undertaken by a senior manager. The visits included the monitoring of records and the environment and discussion with staff and residents, points for action were made during the visits if required. The visit reports were routinely forwarded to CSCI. There were regular resident, relative and respite resident satisfaction questionnaires. The outcomes of the questionnaires were included in the planning for the development of the home. There were extracts from comments made in the questionnaires included in the home’s compliments book, which was displayed in the entrance hall of the home. There were regular resident meetings and resident committee meetings and their decisions or requests were fed into the quality improvement group, which was held on a bi-monthly basis and informed the action plan. The quality improvement group consisted of the head of care, who chaired the meetings and representatives from all areas of the home including health and safety. The AQAA stated that further quality assurance methods included a public open day which provided evaluation sheets for comments, individual care reviews with families and social workers and two dignity in care champions. A staff member was spoken with regarding the infection control and health and safety issues in the home. They explained the procedures and showed the inspector a COSHH (control of substances hazardous to health) cupboard and the COSHH guidelines and risk assessments they had developed. The guidelines clearly explained how staff should work with regards to incidents such as spillages. The staff member explained that domestic staff were provided with COSHH, manual handling and infection control training. They said that one staff member was hoping to achieve an NVQ in laundry and one staff member had achieved their NVQ in infection control. There was a trolley provided in the laundry room to provide staff with a moving and handling aid when transporting laundry. During a tour of the building it was noted that the home was clean and there were no offensive odours. The toilets, bathrooms, laundry and sluice areas Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 28 held hand washing facilities which included hand wash foam and disposable paper towels. There was a stock of disposable gloves and aprons. The home had purchased a new steam carpet cleaner since the last inspection. The hoists, which were used in the home, were stored in a safe location within the home, when not in use. The accident records were viewed and provided a clear explanation of all incidents. The kitchen used the safer food better business documentation. Records were viewed and showed that regular food, fridge and freezer temperatures were recorded. There were records of when freezers were defrosted and actions which were taken to ensure good hygiene procedures in the kitchen area. The home’s health and safety procedures were viewed and included issues such as manual handling, infection control, risk assessments and clinical waste. The fire procedures were viewed and included written evidence of regular fire safety checks. Training records viewed evidenced that staff were provided with health and safety related training such as health and safety, infection control, food hygiene, fire procedures and first aid. The AQAA stated that portable electrical equipment, lift, hoists, gas appliance, heating system, soiled waste disposal, emergency call equipment and fire detection and fighting equipment were serviced or tested in 2007. Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 4 X X 3 X Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 30 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sue Ryder Nursing Home DS0000024508.V344141.R01.S.doc Version 5.2 Page 32 - 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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