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Inspection on 12/01/06 for Sun Woodhouse

Also see our care home review for Sun Woodhouse for more information

This inspection was carried out on 12th January 2006.

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

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

Residents and relatives feel that staff and management are approachable. And that good communication exists between them and the home. One resident said he feels "At home" there and another that she was "Happy here". Staff were heard and seen to approach residents in a kind and caring manner. Residents made positive comments such as staff are "Excellent" and "Lovely". A relative felt that staff were skilled and knowledgeable when providing care to their relative. And all those relatives returning comment cards indicated that they were satisfied with the overall care provided. Where improvements are made to the fabric and furnishings, these are of a good standard. The home is clean and bright and the atmosphere is welcoming and friendly. Residents` bedrooms seen were well maintained and reflected their tastes and interests.

What has improved since the last inspection?

Some requirements and recommendations from the last inspection have been addressed. Action has been taken to meet cultural dietary needs so that a choice of food can be provided. Where appropriate, adult protection referrals are made. And staff have received adult protection awareness training. An administrator is now in post. The office was well organised and information easily accessible.

What the care home could do better:

There has been some improvement to record keeping, but further work is necessary to ensure that required documentation is complete, up-to-date and kept under review, for example, care plans, so that residents` needs are fully documented and staff have clear instructions. Also, although CRB and POVA checks and references are obtained before a person starts to work at the home, some required documentation was not available and improvements need to be made in this area to ensure the recruitment process is more robust. There has been a turnover of staff with some new staff employed, so progress needs to be made with staff induction and training so that staff have a full range of knowledge and skills necessary when providing care to older people. And all staff should attend the adult protection training sessions that have been arranged with the local authority adult protection team. There is no activities person in post at present. The vacancy should be recruited to so that residents have more opportunities to engage in social and leisure activities. An Environmental Health Officer who recently visited the home made positive comments about record keeping in the kitchen but did make some recommendations regarding the fabric of the kitchen, which should be addressed. Residents and their relatives made positive comments regarding the manager of the home. However, the manager is not yet registered with the Commission and an application to register must be made. Fire safety needs to be improved through staff training and the provision of fire door hold open devices so that those living, working and visiting the home are not put at risk.

CARE HOMES FOR OLDER PEOPLE Sun Woodhouse Woodhouse Hall Road Fartown Huddersfield West Yorkshire HD2 1DJ Lead Inspector Jacinta Lockwood Announced Inspection 12th January 2006 09:30 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.V268767.R01.S.doc Version 5.1 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.V268767.R01.S.doc Version 5.1 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) karen.gould@eldercare.org.uk Eldercare (Halifax) Ltd Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 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 who purchased the home in February 2004. Mr Brian Vincent is the responsible individual. Karen Wilson is the registered manager. 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 also accessible from the home. The home is staffed twenty four hours a day. Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out an announced inspection on 12 January 2006. The inspection started at 09.30 and ended at 17.40. Karen Gould, care manager, assisted throughout. The following inspection methods were used: Observation. Discussion with nine residents, two visiting relatives, staff and management. Fourteen resident comment cards and 12 relatives’/visitors’ comment cards were returned. A sample of records were inspected, including care plans, risk assessments, medication, residents’ monies, food records, staffing rota, staff records, maintenance records. A tour of the building was made. At the time of the inspection there were five resident vacancies. And two staff vacancies, which are being recruited to. The range of fees at the home are £329.27 to £395.00 per week. What the service does well: What has improved since the last inspection? Some requirements and recommendations from the last inspection have been addressed. Action has been taken to meet cultural dietary needs so that a choice of food can be provided. Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 6 Where appropriate, adult protection referrals are made. And staff have received adult protection awareness training. An administrator is now in post. The office was well organised and information easily accessible. 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. Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 7 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.V268767.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were assessed. EVIDENCE: Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 Not all residents’ health and personal care needs are set out in the individual plan of care. EVIDENCE: There has been some improvement to care planning documentation, although further work is necessary to ensure that instructions to staff are clear and specific. Also, care plans must be kept under review to ensure that information is up-to-date. Where a resident’s needs change and short-term interventions are necessary, a care plan must be put in place. One service user’s care plan had not been fully completed. A requirement is made. Also, the service user or their representative should sign care plans. A recommendation is made. The care manager explained that care plans are currently being reformatted so that they will be clearer and easier to use. It was evident from comments made by relatives that they are kept informed of important matters. Residents felt well cared for. Medication is stored securely. However, temperature readings of the medicines fridge are not being recorded at present. This should be addressed. Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 On the day of the inspection, the food provided looked appetising and well presented. EVIDENCE: Progress has been made with regard to food choices so that residents’ cultural dietary needs can be met. The manager explained that she and the cook are developing the menus and that a resident has been involved in shopping for culturally appropriate foods. Residents made positive comments about the food provided; such as the food is “Good”. The dining room was well laid out. Adapted cutlery was provided, where appropriate, to enable residents to eat independently. Where residents were supported to eat this was done in a sensitive manner. Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Processes are in place to ensure that service users are protected from abuse. EVIDENCE: Although not assessed on this occasion it was evident from comments received, that the majority of relatives and residents know who to speak to where they to be unhappy about anything. Residents commented that they felt safe at the home. And relatives who spoke with the inspector also felt their relative was safe at the home. Staff have received in-house adult protection awareness training. It is positive to note that formal adult protection training from the local authority has been arranged for staff. This is to take place in the near future. Adult protection referrals are made when appropriate. Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 Sun Woodhouse provides a safe and generally well-maintained environment for residents. Specialist equipment is available to promote residents’ independence. The home is generally clean, pleasant and hygienic. EVIDENCE: An Environmental Health Officer recently visited the home and made some recommendations regarding the kitchen, which should be addressed. Fire safety work was said to be completed. Records show that the fire system meets required standards. However, written confirmation should be supplied to the Commission that completed fire safety works meet legal requirements. A lot of redecoration has taken place over recent months to lounge areas, some bedrooms, toilets and hallway resulting in a brighter and welcoming environment. Some chairs have also been recovered and new pictures and light fittings installed. Redecoration is to a good standard and is ongoing. Some positive comments about this were received from residents and relatives. Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 13 Specialist equipment is available to maximise residents’ independence. The home was generally clean, pleasant and hygienic on the day of the inspection. However, floor tiling to the ground floor shower area was discoloured and should be cleaned to ensure hygiene standards are maintained. Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29, 30 Although NVQ training is provided, the 50 minimum standard has not been achieved to support the outcome of service users being in safe hands at all times. The home’s current recruitment practices do not fully support and protect service users. Not all staff have received all mandatory training to ensure that they are trained and competent to do their jobs. EVIDENCE: Some staff have left employment and this has affected the percentage of staff who hold the NVQ Level 2 qualification. The manager reported that 25 of current staff have obtained the award. Further progress needs to be made so that a minimum of 50 of staff achieve NVQ 2. A recommendation is made. It is a requirement for new staff to receive structured induction training. Induction documentation was not available for a new member of staff, neither was a signed declaration that a new employee was fit to undertake the work for which the person was employed. Recent photographs of staff were being obtained. A requirement is made. Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 15 Not all staff working at the home have received mandatory training, for example, movement and handling, food hygiene, infection control and fire safety. The manager explained that training is being arranged. Training must take place as a matter of priority. A previous requirement is carried forward. Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The home’s manager has yet to make an application to be registered with the Commission. Some processes are in place to ensure that the home is run in the best interests of residents. Residents’ financial interests are safeguarded. Some systems are in place to ensure the health, safety and welfare of residents, although the lack of staff training has the potential to place residents at risk. EVIDENCE: Positive comments were received from residents, relatives and staff regarding the manager of Sun Woodhouse, Karen Gould. All felt she was approachable and staff felt supported by her. An application has not yet been made to the Commission to register Ms Gould and a requirement is made in this matter. Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 17 As part of the home’s quality assurance process, questionnaires have recently been sent to relatives to obtain their views about the services provided at the home. As discussed during the inspection, the views of other stakeholders, such as health and social care professionals, should also be sought. And the process must allow for consultation with residents. Until the quality assurance process is complete and a copy of the report supplied to the Commission and made available to residents, a previous requirement stands. It was evident from discussion and records that the views of residents, relatives and staff are obtained through informal and formal meetings. Samples of records and monies held on behalf of two residents were inspected and were satisfactory. The inspector recommends that, as an added safety measure, two signatures be obtained when money transactions are made. Records show that health and safety checks are carried out. Accident records are maintained. The Commission has not been informed of all notifiable incidents as required. Staff have not received fire safety training or been involved in a fire drill for some time and this must be addressed to ensure the safety of residents, staff and visitors to the home. Also, the office fire door hold-open device had been removed and must be replaced. Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 18 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 2 X X 3 X X X 2 STAFFING Standard No Score 27 X 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 19 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 OP7 Regulation 15 Requirement Care plans must: • set out in detail the action to be taken by staff to ensure service users health, welfare and social care needs are met. (Timescale of 19.08.05 not met.) • be fully completed • be kept under review • be put in place for shortterm interventions. There must be: • a recent photograph held on record of all staff employed to work at the care home. (Timescale of 22.07.05 not met.) • documentary evidence that an employee is physically and mentally fit. All staff employed to work at the home must receive training appropriate to the work they are to perform. (Timescale of 22.07.05 not met.) A training plan identifying when mandatory training, including structured induction training, is to be provided for individual staff must DS0000057837.V268767.R01.S.doc Timescale for action 31/03/06 2 OP29 17 & 19 03/02/06 3 OP29OP30 18(1)(c) 28/02/06 Sun Woodhouse Version 5.1 Page 20 4 5 OP31 OP33 CSA2000 Pt II 11(1) 24 6 7 8 OP38 OP38 OP38 37 23(4)(d) 23(4)(c) (i) be supplied to the Commission within the timescale provided. A registered manager application must be made to the Commission. A report of the home’s quality review must be supplied to the Commission and made available to service users. The Commission must be informed of any notifiable incidents without delay. Staff must receive suitable training in fire prevention. The office fire door hold open device must be replaced or the door must be kept closed. 24/02/06 31/03/06 31/01/06 28/02/06 31/01/06 Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 21 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 2 3 4 Refer to Standard OP7 OP7 OP9 OP19 Good Practice Recommendations When amendments are made to care planning documentation, entries should be signed and dated so that the currency of the information is clear. Service users or their representative should sign care plans. Medicines should be stored at the correct temperature. And temperature records should be maintained. The registered provider should forward written confirmation to the Commission that the fire safety works carried out in response to the fire officers report dated 13.10.03 have been completed and meet legal requirements. Recommendations made by the Environmental Health Officer should be actioned. Floor tiling to the ground floor shower area should be cleaned. A minimum of 50 of staff should achieve NVQ level 2 or equivalent. All staff should receive two fire lectures and two fire drills in a 12 month period. 5 6 7 8 OP19 OP26 OP28 OP38 Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Sun Woodhouse DS0000057837.V268767.R01.S.doc Version 5.1 Page 23 - 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!