Inspection on 11/04/07 for Sun Woodhouse

This inspection was carried out on 11th April 2007.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sun Woodhouse 31/08/06

Sun Woodhouse 12/01/06

Sun Woodhouse 23/06/05

Sun Woodhouse 21/01/05

Sun Woodhouse 09/06/04

Sun Woodhouse 11/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Sun Woodhouse Woodhouse Hall Road Fartown Huddersfield West Yorkshire HD2 1DJ Lead Inspector Jacinta Lockwood Key Unannounced Inspection 11th April 2007 10:00 X10015.doc Version 1.40 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 Sun Woodhouse DS0000057837.V336500.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 Older People. 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. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sun Woodhouse Address Woodhouse Hall Road Fartown Huddersfield West Yorkshire HD2 1DJ 01484 424363 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) sunwoodhouse@eldercare.org.uk Eldercare (Halifax) Ltd vacant post Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2006 Brief Description of the Service: Sun Woodhouse is registered to provide personal care and accommodation for up to 24 elderly people. The care home is owned by Eldercare (Halifax) Limited. Mr Brian Vincent is the responsible individual. There is no registered manager in post at the time of writing. Sun Woodhouse is an old detached stone building that has a modern extension dating from 2000. The home is situated part way up a hill in the Fartown area of Huddersfield, close to local amenities such as shops, churches and post office. Public transport is accessible from the home. Car parking is available. The Commission was informed that as at 31.08.08 the home’s weekly fees ranged from £342.00 to £405. Additional charges are made for chiropody and hairdressing. Information about the home and the latest Commission for Social Care Inspection report are available from the home. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection one inspector made an unannounced visit to Sun Woodhouse on 11.04.07. At the time of the inspection there were 22 people living at the home. During this visit the inspector spoke with some of the people who live there, some staff, visitors, a visiting healthcare professional and management. A sample of records was also inspected including care plans, risk assessments, medication, monies, food menus, activity information, quality surveys, staff recruitment and training records and some policies and procedures. Before the visit and to enable people to comment on the service provided surveys were sent out to a sample of people living at the home, ten were returned, their relatives, two were returned and health and social care professionals. One anonymous healthcare professional survey was returned. The inspector would like to thank all those who contributed to the inspection process and to those living and working at the home for their time and hospitality. What the service does well: Before someone is admitted to the home an assessment of need is obtained to determine whether or not their needs can be met there. Information about the home is provided to enquirers to help them decide if the home is what they are looking for. People who choose to live at the home are provided with a contract/statement of terms and conditions, which explains the fees, services and the room to be occupied. The accommodation at Sun Woodhouse is of good quality and refurbishment work is ongoing to improve the facilities. People living at the home have the opportunity to take part in activities and are able to move freely around the home and grounds, spending time in their private or communal accommodation. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 6 From discussions with people who live at Sun Woodhouse they enjoy living there and feel safe. They have access to healthcare services and specialist equipment such as pressure relieving mattresses and cushions are provided where appropriate. What has improved since the last inspection? What they could do better: Some areas of record keeping need to be more detailed so that fuller information is available. The home’s complaints procedure, although available, is not known to all those who live at the home. This is to be discussed at the next ‘residents’ meeting. The food menu should be available in a format accessible to people living at the home and culturally appropriate foods should be made available, so that people are aware of the food choices available to them. The inspector was informed that arrangements are being made for people living at the home to have access to their personal monies over seven days instead of Monday to Friday as it is at present. The provider is to seek the views of other stakeholders such as health and social care professionals, as well as relatives and people living at the home, so Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 7 that they have the opportunity to comment on the quality of the service provided. 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. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 6 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Information about the home is available to enquirers. Before someone moves into the home their needs are assessed and a contract/statement of terms and conditions is provided. EVIDENCE: Information about the home is available in a large print format and is also on display in the foyer for people to look at. Information about the home is provided to enquirers to help them make a decision when choosing a care home. Before someone is admitted to Sun Woodhouse an assessment of need is obtained and the home carries out its own pre-admission assessment to ensure that the home can meet the person’s needs. As confirmation of this a Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 10 contract/statement of terms and conditions is provided which sets out the fees, the room to be occupied and the services and conditions of residence. One of the contracts seen did not specify the fees to be paid and also stated that the home was ‘strictly no smoking’, but a smoking room is available. Also, there was a term specifying that the home does not accept liability for clothing washed in the home’s machines. According to guidance from the Office of Fair Trading, this could be seen as an unfair term. Contracts should be reviewed in light of this, as discussed with the assistant group manager. (See Recommendations.) Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Care plans identify the health, personal and social care needs of people living at the home. Health care needs are met and staff manage medication safely. People at the home are treated with respect and their dignity promoted. EVIDENCE: Care records and associated documents for three of the people living at the home were inspected. There was evidence that people are involved in their care. Improvements have been made to care planning. Care plans, which were based on assessment information, identified the person’s needs and generally noted how these were to be met. However, some areas of care planning need greater detail. For example, where the plan notes a person needs ‘assistance’, the plan should explain what form the assistance should take so that it is clear to all staff what action they need to take and so that Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 12 care and support can be delivered in a consistent way. Also, although it was clear from speaking with a member of the care team how one individual was supported with an aspect of personal care, the detail was missing from the care plan. (See Recommendations.) One individual explained how she was independent in some areas of self-care and this was reflected within her care plan, as were areas where support was required, but again, there was a lack of detail as to what form the support should take. Individual risks had been identified, for example, regarding falls, nutrition, pressure areas and oral health and were kept under review. Risks were reflected in the care plans. Movement and handling risk assessment records had not been completed for two people, although care plans noted how the person was to be supported and the equipment to be used when mobilising or transferring. And equipment was available in people’s rooms and within the home. However, risk assessments should be completed so that it is clear who is at risk, what the risks are and how these are to be managed. (See Recommendations.) An anonymous survey from a health professional indicated that people’s health care needs are not met at the home. However, individual’s health care needs were recorded and it was evident from records and discussion with a visiting health care professional that staff at the home support people to access health care services. Staff spoken with were clear who to contact for advice and support where there were concerns about someone’s health. Eight out of ten surveys received from people living at the home noted that they always received the medical support they need. One said they ‘usually’ did and one that they ‘sometimes’ did. One person spoken with explained that staff look after her when she’s ill and that they phone the GP on her behalf. Another person spoke of receiving health care and that her condition had improved. This person also had pressure-relieving equipment in her private accommodation to promote good pressure area care. Monthly weight monitoring charts were also on file. Relatives returning surveys noted that they were always kept up to date with important issues affecting their relatives and that the home always gives the support or care to their relative that they expected or agreed. Findings of the home’s quality surveys sent to relatives and friends in April this year noted that access to health care services were either ‘excellent’ or ‘good’. Daily reports generally reflected people’s care plans and there were entries relating to follow up appointments with healthcare professionals and care plans had been updated. The assistant group manager explained that they were to introduce care plans to support people who are dying which will also identify their wishes after death. One plan was seen on the file of a person recently admitted to the home. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 13 The aims and objectives of the home reinforce the principle of treating people with dignity and respect. Staff were observed to call people by their preferred name as noted in the care plan. And people can choose the time they get up and go to bed All but one person seen looked well groomed and cared for and he explained that he hadn’t wanted a shave that day. Staff were observed to knock on people’s bedroom doors before entering although one person said that they “don’t knock on the door and they should”. This was discussed with the assistant group manager who explained that all staff know to knock before entering a person’s room. Following the last key inspection on 31.08.06, an additional visit was made on 19.12.06 to check progress with a requirement made regarding medication. Since then, improvements have been made. Medication for destruction is now returned to the pharmacist so it can be disposed of safely and records are kept. Stock samples were easily reconciled against records. A recommendation is made, however, for staff to record the number of tablets administered where the directions state one or two tablets so that there is a clear audit trail. Staff with responsibility for operating the medication system receive medication training. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People enjoy living at the home and are able to take part in community based and in-house activities. Visitors are welcome to the home and are able to make visits in private if they wish. People living at the home enjoy their meals, which are taken in a pleasant environment. EVIDENCE: An activities organiser arranges activities for people living at the home. An activities programme is displayed and included events like quizzes, painting, ladies pamper day, games and outside entertainers who come to the home. A person spoken with said she enjoyed taking part in activities, particularly quizzes and painting. Examples of artwork were on display. Books and music are also available and one person was sat doing a crossword puzzle. The home has large grounds in which one person said she enjoyed walking. Another said he enjoyed sitting quietly and also watching television. At the time of the visit a visitor took their relative out to the shops and another person was on holiday with relatives. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 15 Visitors are offered a drink and people spoken with said that their visitors were made welcome and visitors confirmed this. People spoken with said that had choice as to how they spent their day and could get up and go to bed at times of their choosing. People can spend time in communal areas of the home or their private accommodation. And people were seen to move freely around the home. People spoken with appeared to enjoy living at the home. One said “we do well here” and that “it’s good here” another said that it “was better than it was”. The dining environment is much improved with table cloths, condiments and jugs of cold drinks. People were seen to help themselves and one person spoken with said she enjoys being able to pour her own drinks. Positive comments were received about the choice of food and people spoken with said that it was “good”. The vast majority of surveys from people living at the home also noted that they ‘always’ liked the food. An anonymous healthcare survey remarked that the home “seems to provide very good meals to residents”. As discussed with the home’s management, culturally appropriate food should be available so that it could be offered as an alternative to a person whose family sometimes bring food for their relative. Although the person tends to choose the food on offer, the availability of culturally appropriate food would afford the person a greater choice. (See Recommendations.) A previous recommendation for food menus to be in an accessible format is carried forward within this report. Management explained that they were to address this. The atmosphere in the dining room over the mid-day and evening meal was relaxed and people looked to be enjoying their food. Adapted cutlery and protective clothing is provided to those that need it to promote their independence and dignity. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home’s complaints procedure is available and the provider addresses any concerns raised. People living at the home are protected from abuse. EVIDENCE: The home’s complaints procedure was displayed and is also included in information supplied to enquirers. Relatives returning surveys were aware of the procedure and one reported “I have never had a complaint with the care”. Relatives spoken with said they were able to discuss any concerns and, following discussion with the assistant group manager, action had been taken to address the issues raised. No formal complaints have been received by the home since the last inspection. There were mixed responses from people living at the home about the complaints procedure. Some were aware of how to make a complaint but others were not. Although the complaints procedure is available, it would be useful for people living at the home to be reminded of it so that they would be familiar with the procedure should they have occasion to use it. The home’s management said that the procedure would be reinforced at service user meetings and that a meeting had been arranged for 17.04.07. A previous recommendation about this is carried forward in this report. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 17 A recommendation is also made for a record to be kept of any concerns raised. It was evident from discussion with management that this is not happening at present. A record of concerns would assist in identifying any recurring themes and would provide useful information when auditing the quality of service provided. During the visit it was evident that the home’s management took appropriate action in response to a concern raised by one of the people living there. And it was evident from discussion with relatives that concerns have been addressed. Staff receive adult protection training and relevant checks are carried out on prospective employees to ensure they are suitable to work with vulnerable adults. Where there have been adult protection issues appropriate action was taken to ensure people’s safety. One person said that she felt safe living at the home and that “it’s good here”. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Sun Woodhouse provides a clean and comfortable environment for those living there. People are able to personalise their private accommodation and equipment is provided to meet their needs. EVIDENCE: A limited tour of the building was made including a number of bedrooms and some bedrooms where individuals have continence needs. Bedrooms were personalised and reflected the occupants’ interests and needs with specialist equipment such as pressure relieving equipment in evidence. People spoken with said they could bring possessions with them when they moved to the home and that they liked their rooms. The rooms were odour free, clean and tidy as was the bedding. Some bedding has been replaced and further bedding Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 19 ordered to present a more attractive and comfortable environment for people. Where bedrooms have been refurbished these are to a good standard. Refurbishment work is still ongoing. The shower room floor was looking cleaner and was due to be pressure washed. A new shower chair and toilet surround had been installed and the environment looked better than it did although a lamp shade should be put in to cover the bare bulb currently in place. A recommendation about this is made within this report. Management explained that the shower room was due for refurbishment. Comments were received such as the home is kept “clean and tidy – good cleaners” and the home is “spotless” that staff are “always hovering”. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Seventy-five percent of staff have an NVQ qualification to support the outcome of service users being in safe hands at all times. The home’s current recruitment practices support and protect service users. And upon starting and during their employment, staff receive training to ensure that they are skilled and competent to do their jobs. EVIDENCE: It’s positive to note that since the last key inspection the number of staff with an NVQ (National Vocational Qualification) to level 2 or equivalent has increased to 75 , which exceeds the recommended minimum level of 50 . Staff should be commended for their achievement in this area. Staff receive mandatory training such as movement and handling, first aid, food hygiene, adult protection and health and safety, including fire safety training. Training is ongoing and from information received future training in areas such as health and safety, first aid, mental capacity act and nutrition has been planned. Relatives returning surveys reported that staff ‘usually’ have the right skills and experience to look after people properly and one commented that staff Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 21 “Look after my father with care and meet his needs at all times”. People living at the home reported that they ‘always’ receive the care and support they needed. One said they ‘usually’ did. Staff demonstrated good movement and handling techniques. They were observed to have a warm and relaxed approach to people living at the home and were aware of their care and support needs. Improvements have been made regarding recruitment practices and required information was available. There was evidence that induction in line with the Common Induction Standards is provided to staff and a member of staff confirmed this. Staff have individual training records and certification was seen. A vacant cook and senior carer post were being recruited to and relevant checks were awaited. In the meantime existing staff cover vacant posts. A member of the management team said that staffing levels were under review and that senior staff were being given extra responsibility to develop their skills and knowledge. From records, speaking with staff and observation, staffing levels were sufficient for the needs of people currently living at the home. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home does not, as yet, have a registered manager in post although it’s evident that the current, short-term management arrangements are satisfactory. The views of those living at the home and their relatives are sought so that the home is run in the best interests of those living there. Residents’ financial interests are safeguarded. Action is taken to promote the health, safety and welfare of people living and working at the home. EVIDENCE: Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 23 The home does not have a registered manager at present, although the post has been advertised. A previous requirement for a person to be appointed to manage the care home is carried forward. In the meantime the assistant group manager and a registered manager from a sister home are overseeing the day-to-day running of the home. The supporting manager is experienced in the care of older people and staff spoke positively about the changes that have been made recently and felt the supporting manager was approachable and that she listened and acted on what they said. As part of the home’s quality assurance process, questionnaires have been sent to people living at the home and their relatives to obtain their views about the services provided at Sun woodhouse. The assistant group manager explained that surveys are to be sent to GPs and District Nurses next month. Survey findings are to be collated and the inspector was informed that an action plan would be developed to address any issues raised. Overall, the findings of the relatives’ surveys for April 2007 were positive. The findings were on display and a copy supplied to the Commission. Samples of records and monies held on behalf of two people were inspected and were satisfactory. The supporting manager explained that she is looking to introduce a system which will allow people to access their monies over seven days instead of Monday to Friday as at present. This should ensure that people can access their monies at any reasonable time. A previous recommendation about this is carried forward within this report. The home’s handyperson is responsible for carrying out health and safety checks and records are maintained. Accident records are maintained and the Commission notified as required by legislation. Staff spoken with explained that the supporting manager had made them aware of the need to notify the Commission should there be an incident or event at the home which adversely affects the well being of people living there. Staff confirmed that they had received fire safety training and records show that fire safety checks are carried out. A sample of maintenance documents show that equipment is maintained and serviced as required. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP31 Regulation 8(1)(a) Requirement The registered provider must appoint an individual to manage the care home. (Timescale of 10.01.07 not met.) Timescale for action 30/05/07 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 OP2 Good Practice Recommendations The home’s contract/statement of terms and conditions should be reviewed in light of guidance from the Office of Fair Trading, so that potentially unfair terms are not included and so that it’s clear whether or not smoking is allowed in the home. Greater detail should be included in people’s care plans, so that care is delivered in a consistent manner and so that detailed written information is available to staff rather than the use of words like needs “assistance” which can mean different things to different people. 2 OP7 Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 26 3 4. 5. 6 OP8 OP15 OP15 OP16 7 8 9. OP16 OP24 OP35 Risk assessment documentation should be completed so that it’s clear who is at risk, what the risks are and how these are to be managed. Food menus should be in a format accessible to people living at the home. A choice of culturally appropriate food should be available to an identified individual at the home. A record of concerns raised with the provider should be maintained noting the detail of the concern, the action taken to address it and the outcome. This will provide useful information for the home’s annual quality audit. The home’s complaints procedure should be discussed with people who live at the home during the ‘residents meetings’. The bare light bulb in the shower room should have a lampshade fitted. Arrangements should be made to ensure that people have access, at any reasonable time, to monies held in safekeeping on their behalf. Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Sun Woodhouse DS0000057837.V336500.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!