Inspection on 31/08/06 for Sun Woodhouse

This inspection was carried out on 31st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 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 31st August 2006 09.15 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.V310191.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.V310191.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 Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 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 £332.98 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.V310191.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 31.08.06. The visit started at 09:15 and ended at 17:45. At the time of the visit there were 17 service users in residence. During the visit, the inspector spoke with a group of six service users and to seven individual service users, two visiting relatives, two visiting healthcare professionals and staff on duty. Prior to this visit, questionnaires were sent out to obtain the views of service users, relatives, GPs and health and social care professionals. Surveys were sent to a sample of 10 service users at the home; 10 were returned; their GPs; two were returned; four social care professionals; two were returned and a healthcare professional; no response was received. The home’s assistant group care manager also returned a completed preinspection questionnaire to the Commission prior to the visit. The inspection findings are also based on a range of accumulated evidence received by CSCI since the last inspection, for example, notifiable incident reports when service users are involved in an accident or incident. The care records of three service users were inspected, including care plans, risk assessments, medication, any monies and accounting records held by the home. Other records sampled included the food menu, staffing rota, staff recruitment and training records, health and safety records, maintenance records and some policies and procedures. A partial tour of the building was made, including the bedrooms of three service users whose care was casetracked as part of the inspection. The inspector would like to thank all those who contributed to the inspection process. What the service does well: Prospective service users are welcome to visit and are provided with information about the home before making a decision to live there. They also receive written confirmation that the home can meet their needs. One service user said that Sun Woodhouse “Is the right place for me”. Relatives contacted indicated that they are satisfied with the overall care provided at Sun Woodhouse. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 6 It was evident from observation, survey responses and discussion with service users, relatives and healthcare professionals that staff at the home are “caring”; that they act on the advice of healthcare professionals and communicate well with them. Relatives said that they are kept informed of their relatives’ care. Service users are able to maintain contact with family and friends and one service user said friendships had been made with other service users. Relatives also said that they were made welcome when they visited the home. What has improved since the last inspection? What they could do better: It’s evident that the absence of someone with responsibility for the day-to-day management of the home has had a negative impact on the operation of the care home. Record keeping is generally poor, particularly with regard to care planning, risk assessment and the management of the home’s medication system, and current staffing levels are not sufficient to meet the needs of service users, all of which have the potential to place service users at risk. The Commission will consider the use of enforcement action if improvements are not made in these areas. It was evident from surveys and discussion that there are differing views as to whether staffing levels are sufficient. Two relatives’ surveys indicated that there were sufficient staff on duty, however, the majority of service users surveyed indicated that staff are not always available when needed and a service user reported feeling rushed when personal care was provided. During this visit, although staff were working hard to ensure that service users’ needs were met it was evident that the staff on duty were over-stretched. Also, from observation and records seen, staffing levels are not sufficient to meet the needs of current service users. Following the inspection, the registered provider was issued with an immediate requirements notice regarding staffing levels at the home. And discussion held with the organisation’s Assistant Group Care Manager. There is no cook in post at present so care staff are preparing meals, some of whom have not received food hygiene training. This is not satisfactory and domestic staff must be employed in sufficient numbers to ensure that standards relating to food, meals and hygiene are met. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 7 Generally the home was clean and tidy, but standards of hygiene in the ground floor shower and to a service user’s bedding were not acceptable. The dining environment should be made more inviting and service users should have access to culturally appropriate food so that appropriate food choices are available. Although activities are arranged and clearly enjoyed by service users, there is a danger that some service users may be socially isolated. Where one-to-one social interaction was part of a service user’s care plan, there was no evidence that the service user’s needs were being met in this area. Action must be taken to ensure that new employees do not start work in an unsupervised capacity until satisfactory CRB (Criminal Record Bureau) checks have been obtained so that service users are not placed at potential risk. Evidence must also be available that new staff are properly inducted and that they receive the necessary guidance and support to work in their new care setting. Action must also be taken to promote the health, safety and welfare of service users and staff through the provision of fire safety training and the maintenance of records required by legislation. 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.V310191.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.V310191.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 The needs of prospective service users are assessed before they are offered a place at the home and a contract/statement of conditions provided as confirmation that their needs can be met there. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Sun Woodhouse does not provide intermediate care. An assessment of need is obtained before a service user moves into the home. And confirmation that the home can meet assessed needs is provided in the form of a local authority contract or a statement of terms and conditions with the home. Four service users who returned surveys indicated that they had received a contract and nine said they had received enough information about the home to help make a decision about moving there. A service user said a visit had been made to the home and information about the home had been provided. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 10 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, 8, 9, 10 Not all service users’ care needs are risk assessed, set out in a plan of care or kept under review. Service users’ medication is not managed safely. Service users feel they are treated with respect and their privacy upheld. The outcome in this area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care records for three service users were examined. Overall the quality of care planning was poor. Not all care plans seen had been completed nor had they been reviewed on a monthly basis as recommended. Care plans lacked specific detail as to how service users’ care and support needs were to be met. Entries such as ‘needs supervision’; ‘needs assistance’; ‘uses hand gestures’ do not provide sufficient detail as to what form the supervision or assistance should take nor what any hand gestures may mean for the individual service user. From discussion with staff it was evident that some service users were able to do some things for themselves, for example, with regard to washing and dressing, but this information was not included in the plan of care. It is Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 11 important to identify service users’ strengths as well as needs so that service users’ independence is promoted and supported wherever possible. There was some evidence of risk assessment, but not all areas of risk had been assessed and where they had been completed, there was a lack of attention to detail. One risk assessment noted the service user had no history of falls although a history of falls was noted on the pre-admission assessment. Care planning and risk assessment information needs to be accurate so that service users’ needs are not overlooked and so that staff have complete, accurate and up-to-date information available to them when providing care and support. Daily records do not tell the reader whether or not outcomes for service users have been met. A random inspection of the home was conducted on 22.05.06 when similar concerns regarding care planning and risk assessment were identified. It is of concern that the home continues to fail in this area. Where improvements are not made in this area, the Commission will consider the use of enforcement action so that service users’ are not placed at risk. Requirements and recommendations regarding care planning, risk assessment and daily reporting are made within this report. Service users spoken with indicated satisfaction with the care provided at the home, although one mentioned feeling rushed by staff when getting dressed and that, sometimes, it takes a long time for staff to respond when the call bell is used. Seven service users returning surveys indicated that they always received the care and support they need; three indicated that they usually received this. As noted under the staffing section below, staffing arrangements must be reviewed to ensure that sufficient staff are on duty to meet the needs of service users. It was confirmed from discussion with service users, healthcare professionals, surveys and records that service users have access to healthcare services. The medication of four service users was checked. Medication for two service users corresponded to records held, but medication for two other service users did not. Handwritten directions on the medication administration record (MAR) sheet did not correspond to the directions on a medicines container. Also, for one sample of medication, no directions at all were recorded on the MAR sheet. The lock to the medicines fridge, which is kept in the kitchen, was broken so medicines were not being stored securely. And it was evident that the temperature records were inaccurate. Such poor practice is unacceptable and has the potential to place service users’ at risk. Where improvements are not made in this area, the Commission will consider the use of enforcement action so that service users’ are not placed at risk. Requirements and recommendations regarding the management of medication are made within this report. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 12 Staff were observed to approach service users in a kind and caring manner and good practice was seen with regard to movement and handling, with service users being given praise and encouragement. Service users confirmed that staff treat them with dignity and respect. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14, 15 Service users maintain contact with family and friends and social activities are generally available. Service users can exercise choice in their day-to-day lives. Service users generally enjoy the meals provided. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A member of the care team who is also the activities co-ordinator on three days a week, has arranged a number of events for service users. A list of forthcoming events was on display where service users could see them. The inspector sat in the lounge with a group of service users who spoke of how much they had enjoyed the previous nights’ entertainment and buffet, which some relatives had also attended. One service user said she “had loved every minute” of it. Photographs on display clearly show that service users have enjoyed recent activities. From discussion with service users and surveys, activities are provided which the majority of service users said they enjoyed. Library books are also available. One service user said that she is asked if she wants to join in activities, but that she likes to sit and watch television in her room. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 14 One service user’s care plan notes that one-to-one interaction should be provided to prevent social isolation. It was noted throughout the inspection that the service user had no social contact. When asked if staff sat and spoke with the service user, the reply was “it would be marvellous” if they would “spend five minutes”. It’s important for all service users to have the opportunity for social interaction. Staff need to be aware of those service users who are at risk of social isolation and to ensure that the service user’s care plan regarding this is implemented. A recommendation about this is made within this report. Service users confirmed that there is flexibility in how and where they spend their time; one service user was seen to access the spacious grounds for some fresh air and sunshine, which the service user said was enjoyed. Visitors confirmed that they are welcomed when they visit the home and that they could see their relative in private. There were mixed responses from service users about the food provided with 50 indicating that they ‘usually’ liked the food. Menus show there is some choice of food and the main meal of the day was noted on a display board near the lounge, but menus are not in a format accessible to service users nor are menus sufficiently clear as to what the food choices are or whether alternative food choices are available. A service user was not sure if a food choice was available. Special diets, such as soft foods are provided, but culturally appropriate food is not. The provider should address this and a recommendation about this is made in this report. The dining room receives natural light and the décor is clean. However, the dining tables did not look inviting. The dining area should provide a pleasing setting and the use of tablemats, tablecloths and the provision of condiments would improve this. A recommendation about this is made in this report. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 15 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): 16, 18 Procedures are in place to deal with complaints, which indicate that complaints will be taken seriously, listened to and acted upon. Service users are protected from abuse. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home’s complaints procedure was clearly displayed. Pre-inspection information received by the Commission notes that no complaints have been received during the last twelve months. Health and social care professionals returning surveys said they had received no complaints about the home. Relatives reported that they knew how to make a complaint. Fifty per cent of service users responding to surveys were aware of how to make a complaint and whom to talk to were they were unhappy about anything. The remaining service users said they ‘usually’ or ‘sometimes’ knew. Service users reported that they had no complaints. One said “I can find no fault at all” with the home. Training records show that the majority of staff have received adult protection awareness training and some have received adult protection training from the local authority. From information received from the provider no further training has been planned. This should be addressed so that all staff currently employed receive adult protection training to equip them with the knowledge necessary to protect vulnerable older people and so they know who to contact should they have occasion to do so. A requirement about this is made within Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 16 this report. Staff spoken with were aware of the action to take were they to see or suspect abuse. Where, in the past, there has been an adult protection incident appropriate action has been taken. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 17 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, 26 The home is well maintained and is generally clean and hygienic. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Sun Woodhouse is well maintained. During this visit there was a fault with the electricity supply to some ground floor areas. This was reported immediately and action taken to rectify the situation during the visit. The provider’s preinspection questionnaire states that action has been taken to address the issues identified following recent visits by a Fire Officer and an officer from Environmental Health. Redecoration of the home is ongoing and completed areas are bright and tastefully decorated to a good standard. Service users made positive comments about the accommodation, as did a visiting healthcare professional. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 18 A limited tour of the premises was made and generally those areas seen were clean and tidy. The majority of service users said that the home is kept fresh and clean; however, some said it ‘usually’ or ‘sometimes’ was. The raised tiling to the ground floor shower room was grubby and must be thoroughly cleaned to promote good hygiene. Also, it was of concern that one service user’s bed had been made up even though there was soiling to the drawer sheet. This is not acceptable practice. A similar issue was identified at a previous inspection. The registered provider must take action to ensure this does not happen in the future and that good hygiene standards are promoted. A requirement about hygiene standards is made within this report. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 19 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): 27, 28, 29, 30 Staffing levels are insufficient to meet the needs of current service users. NVQ (National Vocational Qualification) training is provided to ensure that service users are in safe hands at all times. Service users are not fully supported by the home’s recruitment practices. Training is provided to ensure that staff are trained and competent. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There is a mix of long-standing and newly appointed staff at the home. During this visit, the staff on duty demonstrated some of the skills necessary when providing care to older people and they approached service users in a kind and caring manner. Service users made positive comments about staff that they were “alright” and staff “are all very good”. A relative said that staff “work as a team”, that they are “efficient and well organised” and one said that staff are “very nice”. Staff were working hard to meet service users’ varied needs but it was evident from observation, discussion with staff and staffing rotas that the number of staff on duty, particularly during the afternoon shift, were insufficient to meet the needs of current service users. The cook’s post is vacant at present. Over the tea-time period one of the two carers on duty prepares the meal which means one carer is left to meet service users’ needs. This is not acceptable. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 20 An immediate requirement letter has been sent to the registered provider requiring that this situation be addressed so that service users are not placed at unnecessary risk due to poor staffing levels. A requirement about this is also made within this report. From records and discussion with staff NVQ (National Vocational Qualification) training has been provided with thirty-nine per cent of staff having achieved the NVQ level 2 award or above. A recommendation is carried forward within this report for a minimum level of fifty per cent of staff to achieve an NVQ qualification as recommended in the National Minimum Standards for Older People. Three staff files were inspected. A CRB (Criminal Record Bureau) check was available for one staff member. POVAFirst (Protection of Vulnerable Adults) checks were available for the remaining two members of staff, and there was some evidence that CRB checks had been applied for. The staffing rotas indicate that staff employed on the basis of a POVAFirst check were working as full members of the staff team. Where staff are employed on the basis of a POVAFirst check, they must be supervised at all times and must not have unsupervised access to service users. Staffing rotas indicate that this may not be happening, particularly on the night shift. A requirement and recommendation about staff recruitment is made within this report. From discussion with staff and records it’s evident that mandatory and other relevant training is provided to equip staff with the necessary skills and knowledge. However, records show that just over half of staff have received movement and handling training and most staff who cover the vacant cook shifts have not had food hygiene training. Also, there was no evidence seen that new employees have received induction training to (NTO) (National Training Organisation) targets, nor the home’s in-house induction. A previous requirement about staff training is repeated and a requirement made about structured induction training within this report. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 21 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 absence of a full-time manager has contributed to poor or adequate outcomes for service users in some areas of care provision. There is a lack of evidence to demonstrate that the home is run in the best interests of service users. Service users’ monies are safeguarded. The health, safety and welfare of service users and staff are generally promoted and protected. The outcome in this area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There is no manager in post at the present time. It is evident from the findings of this inspection that the absence of a full-time manager has contributed to poor or adequate outcomes for service users in some areas of care provision. It’s clear from previous discussions with senior management within the organisation that the organisation wants to ensure the right person Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 22 is appointed to post. However, action must be taken to ensure that the home is managed in accordance with The Care Homes Regulations 2001 and the National Minimum Standards for Older People. A requirement about this is made within this report. Monthly management reports have been supplied to the Commission, which indicate that service users’ views are sought. The home’s quality assurance procedure notes that feedback will be sought on a 6-12 monthly basis from service users, relatives and visitors. The inspector was informed that satisfaction surveys have been returned but the findings have not yet been analysed. It’s clear that little progress has been made regarding quality assurance since the last main inspection of the home in January 2006 when a requirement about this was carried forward. Until the quality assurance process is complete and a copy of the report supplied to the Commission and made available to service users, a previous requirement stands. Records show that the last recorded meeting with service users was on 20.05.05. And that staff meetings are held once a year. Meetings afford an opportunity to seek service users’ and staff’s views about the home and to share information. Therefore, it is recommended within this report that more frequent meetings are held. Three samples of service users’ monies were checked against records held and were satisfactory. From discussion with staff it appears that no arrangements are in place for service users to access monies held in safekeeping if the home’s administrator or a member of the management team is not available. Service users should have access to their monies at any reasonable time, therefore, arrangements should be put in place to allow this to happen. A recommendation about this is made within this report. The organisation employs maintenance personnel and maintenance records and health and safety checks were sampled and found to be satisfactory. Accidents records are maintained and the Commission has been informed of some incidents as required, but not all accidents to service users had been recorded or notified to the Commission as required by regulation. A requirement about this is made within this report. Not all staff spoken with had received fire safety training. Records showed that between February 2005 and March 2006 only six staff had received such training. A requirement is made within this report for all staff currently employed at the home to receive fire safety training from a competent person. And detailed records of such training should be kept as recommended by the Fire Authority. Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 23 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X X X X 2 Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 24 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: (a) set out in detail the action to be taken by staff to ensure service users health, welfare and social care needs are met. (b) be fully completed (c) be kept under review (d) be put in place for short-term interventions. (Timescale of 19.08.05 and 31.03.06 not met.) Where there is an identified risk, service user risk assessments must be completed and be accurate. Accurate medication records must be maintained; Medication must be stored securely. Current staff who have not yet done so must receive training in adult protection. Satisfactory standards of hygiene must be maintained, therefore, the raised tiling to the ground floor shower room must be thoroughly cleaned and service users’ bedding must be DS0000057837.V310191.R01.S.doc Timescale for action 30/09/06 2. OP7 13(4)(b) 30/09/06 3. OP9 4. 5. OP18 OP26 13(2) 17(1)(a) Schedule 3 (i) 13(6) 16(2)(j) 30/09/06 30/11/06 30/09/06 Sun Woodhouse Version 5.2 Page 25 6. OP27 18(1)(a) 7. OP29 18(1)(c) OP30 clean. Sufficient numbers of staff must 30/09/06 be on duty at all times as are appropriate for the health and welfare of service users, therefore, current staffing levels must be increased and the vacant cooks’ position recruited to. All staff employed to work at the 30/09/06 home must receive training appropriate to the work they are to perform. (Timescale of 22.07.05 and 28.02.06 not met.) A training plan identifying when mandatory training, including structured induction training, is to be provided for individual staff must be supplied to the Commission within the timescale opposite. (Timescale of 28.02.06 not met). Staff appointed on the basis of a POVAFirst check must be appropriately supervised by a member of staff who is appropriately qualified and experienced. Persons employed to work at the care home must receive structured induction training. And a record of this training must be maintained. The registered provider must appoint an individual to manage the care home. A report of the home’s quality review must be supplied to the Commission and made available to service users. (Timescale of 31.03.06 not met). All accidents to service users must be recorded. DS0000057837.V310191.R01.S.doc 8. OP29 18(2)(a) as amended in 2004 under the Care Standards Act 2000 30/09/06 9. OP30 amended in 2004 under the Care Standards Act 2000 18(1)(c)(i ) as 30/09/06 10. OP31 8(1)(a) 31/10/06 11. OP33 24 30/11/06 12. OP38 17(1)(a) Schedule 30/09/06 Sun Woodhouse Version 5.2 Page 26 13. OP38 3(j) 37 The Commission must be 30/09/06 informed of any notifiable incidents without delay. (Timescale of 31.01.06 not met). Staff must receive suitable 31/10/06 training in fire prevention. (Timescale of 28.02.06 not met). At a minimum current staff who have not yet done so, must be involved in at least one fire safety training session and be involved in one fire drill within the timescale opposite. And appropriate records of such training must be maintained. 14. OP38 23(4)(d) 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 OP7 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. Entries such as ‘needs supervision’; ‘needs assistance’; ‘uses hand gestures’ do not provide sufficient detail as to what form the supervision or assistance should take nor what any hand gestures may mean for the individual service user. This should be clearly explained within the care plan. Daily records should clearly evidence whether or not care plan outcomes are being met for individual service users. Medicines should be stored at the correct temperature. And temperature records should be maintained. Service users should be supported to engage in social activities in accordance with their assessed needs and wishes to prevent social isolation. DS0000057837.V310191.R01.S.doc Version 5.2 Page 27 2. OP7 3. 4. 5. OP7 OP9 OP12 Sun Woodhouse 6. 7. 8. 9. 10. 11. OP15 OP15 OP15 OP15 OP28 OP29 Food menus should be in a format accessible to service users. Food menus should be detailed and make clear the food choices available. A choice of culturally appropriate food should be available to service users. Dining tables should be made more inviting by the use of tablecloths/tablemats and the provision of condiments. A minimum of 50 of staff should achieve NVQ level 2 or equivalent. Staff appointed on the basis of a POVAFirst check should work on the day shift where they can be appropriately supervised until a satisfactory CRB (Criminal Record Bureau) check has been received. Until staff have received food hygiene training they should not be involved in food preparation. Service user and staff meetings should be held on a more frequent basis to provide both groups with an opportunity to express their views, share information and contribute to the running of the home. Arrangements should be made to ensure that service users have access, at any reasonable time, to monies held in safekeeping on their behalf. All staff should receive two fire lectures and two fire drills in a 12-month period from a competent person. And detailed records of such training should be kept as recommended by the Fire Authority. 12. 13. OP30 OP33 14. 15. OP35 OP38 Sun Woodhouse DS0000057837.V310191.R01.S.doc Version 5.2 Page 28 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.V310191.R01.S.doc Version 5.2 Page 29 - 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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