Inspection on 23/06/05 for Sun Woodhouse

This inspection was carried out on 23rd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 11/04/07

Sun Woodhouse 31/08/06

Sun Woodhouse 12/01/06

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 HD2 1DJ Lead Inspector Jacinta Lockwood Unannounced 23 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sun Woodhouse Address Woodhouse Hall Road Fartown Huddersfield HD2 1DJ 01484 424363 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Eldercare (Halifax) Ltd Miss Karen Wilson Care Home 24 Category(ies) of 24 x Old age (over 65 years) registration, with number of places Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 21.01.05 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 J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection, which started at 9.45am and ended at 6.30pm. The inspector was assisted by the registered manager, Miss Karen Wilson, and the assistant group care manager, Ms Nicola Wilson. The following inspection methods were used: discussion with 8 of the 16 service users in residence, 3 relatives, a district nurse, 4 staff and management; a limited tour of the premises; inspection of a sample of records including service user assessments, care plans, medication, accident log, complaints log, menu, quality survey, catering survey, activities log, policies and procedures, staff recruitment and training, staffing rota, health and safety and maintenance records, equipment service records. It is positive to note that progress has been made to address requirements and recommendations following the unannounced inspection in January 2005. What the service does well: What has improved since the last inspection? Generally, care planning has an improved level of detail. Action has and is being taken to ensure a safer environment for service users. Improvements made to the internal environment are to a good standard. Service users have been consulted about their dietary preferences. Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 6 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 J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 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 standard(s) 3 Service users’ needs are assessed before they move into the home. EVIDENCE: Sun Woodhouse does not provide intermediate care. Assessment information was available for those service users case tracked as part of this inspection. There have been no new admissions to the home since the last inspection in January 2005. New pre-admission assessment documentation has been produced which should provide a good overview of prospective service users’ care needs based on the National Minimum Standards for Older People. The document also provides confirmation to the service user that the home can meet their needs. Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 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 standard(s) 7, 8, 9, 10 There is some good, detailed information in care plans but attention to detail would ensure that all the service user’s needs are included in a care plan. There is evidence of good multi-disciplinary working taking place to meet service user’s healthcare needs. Generally the home has safe systems for administering medication to service users. In general, service users are treated with respect and their privacy respected. EVIDENCE: Generally, care plans provided a good level of information about service users’ needs and risks and there was evidence of monitoring and reviews. Service users’ relatives are also invited to the reviews. Staff spoken to were aware of service users’ care and support needs and said they found the care plans useful. Service users said that staff help them but also encourage them to do things for themselves. Relatives spoken to felt that their relatives were well cared for at Sun Woodhouse. Information about service users’ support needs was available although it had not been formulated into a care plan in all cases. For example, one service user’s social care needs assessment identified favoured activities but these Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 10 were not included in the social care plan; another service user’s care plan did not provide sufficient detail as to the interventions staff should take when aggression was displayed and a care plan had not been formulated for a service user who was having ear drops administered. One care plan stated ‘ensure clothes are left on the bed in order’ the outcome being that the service user could retain some independence in this area. It is important that the order the clothes are laid out for the service user is recorded so that staff are consistent in their actions and the possibility of confusion for the service user is minimised. There is a need to pay attention to detail when completing documentation. One risk assessment identified that a service user was ‘at risk’ but when the scoring was checked with the registered manager the form had been completed incorrectly. Also, when amendments are made to documents, these should be signed and dated so that currency of the information is clear. It is positive to note that following risk assessment a service user’s nutritional intake and weight was being monitored, however, the monitoring form had not been completed for the previous day. Care should be taken to avoid errors of omission. A district nurse was visiting at the time of the inspection and discussion with the nurse, service users, relatives and records examined indicate that service users receive appropriate healthcare. Generally, medication records were well maintained. There is a photograph of each service user with the medication record. There were no gaps in recording although two different tablets were unaccounted for. When changes are made to a service user’s medication regime the medication record should note the GP’s agreement and be signed and dated. The temperature of the medicines fridge was too high. Medicines should be stored at the correct temperature. Service users were clear that staff at the home respect their choices and help maintain their privacy and dignity. Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 11 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 standard(s) 12 - 15 Consultation take place with service users so that the lifestyle experienced meets their interests and needs. Service users maintain contact with family, friends and the local community. Service users can choose how to spend their day. On the day of the inspection, the food provided looked appetising and well presented, but cultural dietary needs are not adequately met. EVIDENCE: It was evident from observation and discussion with service users, relatives, staff and records that service users are able to use facilities in the local community and to maintain contact with family and friends. Service users spoke of going shopping and to a park and a relative explained how staff support a service user to feed ducks on the canal. Organised activities take place three times a week and include coffee mornings, art work, music, reminiscence, quizzes, bingo and visiting entertainers. One service user said a recent entertainer sang old songs and that it “Was lovely.” Service users spoke well of staff saying they are “Very good”, “Lovely” and that they “Never say anything wrong to me.” Relatives also made positive comments about the staff and that they are made to feel welcome when they visit the home. Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 12 Service users said they have choice about how they spent their day, the time they go to bed and get up and what they wear. Staff were seen to offer service users a choice of food and drinks. Service users who were able were seen to move freely around the home and staff were heard to provide the door code to a service user who wished to leave the building. It is positive to note from information seen and discussions held with management that arrangements are being made to involve a local advocacy group for the benefit of service users. Resident and relative meetings are held at the home and it is positive to note that comments made by service users during a recent quality survey are being acted upon. Service users have also been asked individually about their food choices and new menus are being drawn up based on comments made. This should ensure that culturally appropriate food is also available to service users. Meals are taken in the communal dining room although service users can eat elsewhere should they choose to. The dining room receives good natural light and the table settings were attractive. Where appropriate, service users have adapted cutlery to enable them to eat independently. It was positive to see a member of staff share a meal with service users who were given sufficient time to finish their meal. Service users commented positively about the food provided which was freshly prepared and well presented. Fresh fruit and vegetables were available. Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 13 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 standard(s) 16, 18 Complaints are dealt with appropriately. Some processes are in place to protect service users from abuse, but all staff need to receive adult protection training and the home’s policy and procedure reviewed to ensure that adult protection referrals are made and service users protected from the potential risk of abuse. EVIDENCE: The home’s complaints procedure was clearly displayed in the entrance area. Service users and relatives were clear whom they would speak to were they to be unhappy about anything. Complaints are recorded and dealt with appropriately. Staff spoken to had awareness of adult protection issues. However, records show that not all staff have received adult abuse awareness training. The registered manager explained that she is in the process of arranging training for staff with the local adult protection team. Recently purchased training videos on adult protection were shown to the inspector. These are to be used to raise staff awareness. The home’s policy and procedure on adult protection does not include the action to be taken where abuse involves two service users. It was evident from checking service users’ records and discussion with the registered manager that an incident involving two service users had not been reported to adult protection. The registered manager said that lessons had been learnt Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 14 following a separate incident involving two service users and that adult protection referrals would be made in the future. A service user said that she felt safe at the home and a relative also said that she felt her relative was safe at Sun Woodhouse. Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 15 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 standard(s) 19, 26 Generally a safe and well maintained environment is provided for service users, but some areas require attention. Generally, the home provides a clean, pleasant and hygienic environment for service users, but some poor hygiene practices place service users at potential risk of infection. EVIDENCE: Some areas of the home are showing signs of wear and tear. There has been some decoration of the home and those areas completed are of a high standard. A maintenance person is employed and records show that maintenance checks are carried out and action taken. Service users said they liked their bedrooms and had their own things around them. A fire guard protects service users from getting too close to the gas fire in the lounge and a programme of putting radiator guards in place is ongoing to Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 16 ensure low surface temperatures and so protect service users from potential harm. The fire system is checked on a regular basis and serviced as required. However, confirmation has yet to be received from the registered provider that the fire safety work identified by the fire authority meets requirements and confirmation must be obtained and supplied to the Commission. On the day of the inspection the home was generally clean, pleasant and hygienic. However, the inspector was concerned to see that a service user’s bed had been made up but there was soiling on the sheet and on a bumper covering bed rails. This is poor practice on the part of care staff who make up service users’ beds and such practice is not acceptable. The registered manager has systems in place to monitor care practice and was to address this with the member of staff concerned. The mattress to another service user’s bed was stained and needs replacing to ensure good hygiene and comfort for the service user. It is positive to note that a sluice has recently been installed to promote good hygiene and to prevent commodes from being cleaned in a bath. Liquid soap and paper towels are readily available to promote good hygiene practices. The laundry floor surface has been repainted so that it is readily cleanable. Soiled clothing is dealt with appropriately. Service users’ clothing looked well laundered and cared for. Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The numbers and skill mix of staff meets the needs of current service users. Staff need to ensure they consistently provide good care practice, particularly in relation to the movement and handling of service users. Staff recruitment practices ensure that service users are supported and protected but all required information must be obtained to ensure the home’s recruitment procedures are sufficiently robust. EVIDENCE: At the time of the visit there were sixteen service users in residence and staffing levels were sufficient. Staff were observed to demonstrate some of the skills and knowledge necessary when providing care to older people. Training is provided in a number of areas including movement and handling, food hygiene, health and safety, first aid, infection control, tissue viability, dementia, adult protection, NVQ and induction and foundation training. Not all staff have yet received all of the training necessary to ensure they have a full range of skills and knowledge, however, it is positive to note that the skill mix includes some long-standing, trained and experienced members of staff. Both good and poor practice by the same members of staff was observed when they were assisting service users with transfers. On one occasion a dangerous lift was used but on another occasion good movement and handling skills were demonstrated. It is important that staff use their skills and knowledge in a Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 18 consistent way to ensure the health and safety of the service user and themselves. It is positive to note from records and discussion with management that action is taken where there are concerns about care staff practice and performance. Three staff recruitment files were inspected and contained all the information required to ensure they are suitable to work with vulnerable people with the exception of a recent photograph. Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36, 38 Staff are supervised as part of the management process. Systems are in place to promote and ensure the health, safety and welfare of service users and staff. EVIDENCE: Staff receive regular supervision and it is positive to note that direct observation of their work forms part of this. Management reports indicate that privacy, dignity and choice are topics to be discussed with staff during supervision this month. Annual staff appraisals are also held. Staff were seen to wear appropriate protective clothing when assisting service users with personal hygiene and when involved in serving food. It was of concern, however, to see a member of staff enter the kitchen wearing a protective apron and gloves used when providing personal care to service users. This is poor practice and an infection control issue. Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 20 Accident records are maintained and accident monitoring carried out. The registered manager raises any concerns with staff. It was of concern to note that some accidents appeared to be as a result of the poor movement and handling of service users by staff. It is positive to note that staff receive fire safety training and are involved in fire drills. A sample of service certification was checked for gas, electrical wiring and portable appliance testing and was satisfactory. Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x 1 STAFFING Standard No Score 27 3 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 x x x x x x x x Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement Care plans must set out in detail the action to be taken by staff to ensure serivce users health, welfare and social care needs are met. All staff must receive training in the protection of vulnerable adults. Adult protection referrals must be made when an incident of abuse by one service user on another has occurred. Stained and soiled mattresses, bedding and bed bumpers must be replaced or cleaned as appropriate to ensure good hygiene is maintained and to prevent the risk of infection. There must be a recent photograph held on record of all staff employed to work at the care home. The registered person must confirm in writing when this will be addressed. All staff employed to work at the home must receive training appropriate to the work they are to perform. Timescale for action 19.08.05 2. 3. 18 18 13(6) 13(6) 16.09.05 22.07.05 4. 26 13(3) 22.07.05 5. 29 17 & 19 22.07.05 6. 30 18(1)(c 22.07.05 Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 23 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. 5. 6. 7. Refer to Standard 7 9 9 9 15 18 19 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. When changes are made to a service users medication regime, the medication record should note the medical practitioners agreement and be signed and dated. Medicines should be stored at the correct temperature. Where tablets are unaccounted for this should be investigated and the outcome recorded. Cultural dietary needs should be catered for and recorded in the service user’s care plan. The homes adult protection policy and procedure should be reviewed to incorporate service user to service user abuse. Written confirmation from the registered provider should be provided to the CSCI that the fire safety works carried out in response to the fire officers report dated 13.10.03 meets the requirements of the fire authority. The recommendations made by the qualified occupational therapist on 08.10.03 should be implemented, therefore, improvements should be made to the lighting on the first floor corridor; radiator guards should be fitted and metal nosing should be put in place on the stairs. Ensure that staff promote the health and safety of themsevles and service users through good movement and handling practices. Ensure that staff promote good infection control practices. - 8. 22 9. 10. 11. 30 38 Sun Woodhouse J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 24 Commission for Social Care Inspection 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 J51J01_s57837_sun woodhouse_v234974_230605.doc Version 1.30 Page 25 - 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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