Inspection on 01/03/06 for Sunningdale House

This inspection was carried out on 1st March 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sunningdale House 19/02/09

Sunningdale House 22/11/06

Sunningdale House 15/06/05

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Sunningdale House 103/105 Franklin Road Harrogate North Yorkshire HG1 5EN Lead Inspector Mrs Maggie Coxon Unannounced Inspection 1st March 2006 10:30 Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 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 Sunningdale House DS0000063606.V283311.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sunningdale House Address 103/105 Franklin Road Harrogate North Yorkshire HG1 5EN 01423 505856 01423 569188 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) Franklin Homes Limited Post Vacant Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 2005 Brief Description of the Service: Sunningdale is a care home made up of two semi detached properties and provides personal care and accommodation for up to 13 adults who have mental health problems. The accommodation provided is in 11 single bedrooms and 1 double bedroom located on the top 3 floors of the house all of which are accessed by flights of stairs. There is a wide range of communal space including two lounges, a main kitchen and a number of small kitchens for use by the service users as part of rehabilitation programmes. There is a garden to the front of the home, street parking at the front and private parking at the rear of the home. Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second to be undertaken between April 2005 and March 2006. It was done on 1st March 2006, at a time when most of the people living in the home would be present. It took 4.5 hours plus 1 hour’s preparation time. Any key standards not assessed during this inspection have been assessed at the last inspection and reported on in the subsequently published report. Discussions were held with a number of the people currently living in the home, with the care staff on duty and with the general manager. A number of records and many areas of the home, including bedrooms and shared areas were seen. What the service does well: What has improved since the last inspection? What they could do better: Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 6 Residents’ health and safety could be improved through more stringent fire safety precautions being followed, through improvements in the home’s medication system. The registered person could improve the confidentiality of some of the health and safety records pertaining to residents. The quality of services provided could be improved through an increase in staffing levels and the deployment of staff could be improved to meet the needs of residents at all times. Although some staff training is provided this requires further development, particularly in respect of training on adult abuse issues in order to safeguard people living at the home from potential abuse and NVQ training. Prospective residents could be more confident that their needs would be met by the home if a recorded pre-admission assessment of their needs were undertaken. Once identified, individuals’ care needs could be written down in a clearer way including detailed risk assessments. The physical environment is in need of some refurbishment to improve the home for the people who live there. The manager should submit an application to become registered with the C.S.C.I. The organization could strengthen the quality assurance and monitoring system for the home and develop an annual development plan for it. 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. Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Residents can be confident that their needs will be understood and met by staff although a more comprehensive assessment process would reinforce this. EVIDENCE: Two residents have recently been admitted to the home. Whilst staff said that they believed the previous registered manager had met with one individual to discuss their needs no written assessment appears to have been undertaken for either of them by the home although some information had been obtained from other professionals involved in their care. The current manager and staff team have begun assessing these individuals since they moved in and are in the process of producing a personal support plan for each. Whilst it seemed that these individuals are having their currently identified needs met, the manager must ensure that no further admissions are made without a full assessment of need having first been undertaken. Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. People are considered individually and efforts made to help them develop their aspirations, meet their needs and encourage choice. Documentation to support this however needs further development. EVIDENCE: Existing care plans do not identify clearly the strengths and needs of the individual or describe how these needs are to be met by staff. Care staff talked to however explained that the new manager is planning to introduce a system whereby each resident, with assistance from their key worker, will draw up a pen picture of themselves and a personal support plan. Each resident now has a diary in which comments are recorded on a daily basis. Residents said that they are able to make individual decisions on a daily basis as well as choices about what they do. It was identified at the last inspection however that individuals’ risk assessments were insufficiently detailed and under developed. These have yet to be amended and updated. Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 15 and 17. Residents have varied and interesting lifestyles and are fully involved in their local community. They enjoy a wide range of social opportunities and develop and maintain good relationships with family and friends. EVIDENCE: Residents explained that they lead interesting and active lives with the support of a committed staff team. Individuals have an individual programme of activities in a variety of local community based settings including part time voluntary employment. Activities are also organized within the home; these include arts and craft work. Residents are supported to develop and maintain relationships with families and friends. Residents said that they have a choice about their meals and said that the meals provided are good. Residents are able to get their own breakfasts and several of them cook their own meals with support from staff. Two residents have their own kitchen in which they cook some of their own meals. Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. Residents’ personal and health care needs are fully met. Residents could benefit however from a stronger medication system. EVIDENCE: None of the residents is able to take their own medication. Individuals’ medication is adequately stored with the exception of controlled drugs, which should be more securely stored. Improvements have been made to the completion of the medication administration records these are now well maintained. The staff team has recently undertaken certificated medication training from a qualified pharmacist. Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Residents’ concerns are appropriately dealt with and their interests are safeguarded. Their safety could be further promoted through the appropriate training of staff in adult protection issues. EVIDENCE: There is a comprehensive complaints procedure in operation that is made available to anyone who wishes to see it. People living in the home are able to make a formal complaint if they wish to and those spoken with said that they are aware of how to raise any concerns. Staff were seen to have developed very good relationships with residents and to communicate very well with them. No complaints have been made to the home or to the C.S.C.I. within the last twelve months. Staff spoken to were clear about the procedure they would follow if they were to witness the abuse of a resident. They have not however had any adult protection training and would benefit from this. Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28 and 30. Although clean the environment does not reflect the standard of care in the home although some action is being taken to improve this. EVIDENCE: At the last inspection it was identified that the home was in need of some redecoration and refurbishment. Action to address these issues has commenced and one of the residents’ kitchens is in the process of being refurbished. A number of bedrooms were seen and residents said that they are happy with them. Eleven bedrooms are for single accommodation one is a double room. All rooms are of a suitable size and are situated on either the ground, first or second floors. Communal WC facilities and bathrooms are appropriately situated throughout the home. A good standard of cleanliness is maintained throughout. Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33 and 34. The residents receive a good standard of care from a skilled and experienced staff team. The safety and wellbeing of residents could potentially be compromised however by a shortfall in current staffing levels. EVIDENCE: A recently employed care worker said that she has completed induction training and is shortly due to undertake foundation training. The care team is working towards achieving NVQs in care. Four of the five care staff are currently undertaking this award. Appropriate recruitment procedures are followed. The records for a newly appointed carer and the new manager showed that the necessary personnel checks had been taken up in respect of these individuals by the organization’s administrator. There have been a number of changes to the staff team since the last inspection and the home currently has 21.5 care hours less than before. The staffing roster for the week including the inspection showed that the total number of hours worked by the manager, care staff, domestic staff and administration staff falls below the minimum required for twelve residents by the national minimum standards. Several residents said that sometimes staff were not readily available and care staff said that at times, whilst they had domestic support, there were in their views insufficient carers. Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 15 This roster was poorly recorded but the general manager explained that the new manager has developed new, legible rosters, which will be introduced forthwith. Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 and 42. Residents benefit from a well managed home in which their needs and wishes are put first despite there currently being no registered manager in post. Some improvements to health and safety issues would ensure a safer environment for residents and staff. EVIDENCE: A new manager has been appointed but has not yet submitted an application to register with the Commission for Social Care Inspection. Staff said that she has introduced a number of improvements to the running of the home since being in post. As well as becoming registered she will need to complete an appropriate management award if this has not already been completed. Annual quality audits of the service are undertaken and the General Manager of the organization works from the home and therefore has a good overview of the service on a day-to-day basis. Some improvements to health and safety procedures have been introduced although there are still shortfalls. Since the last inspection a fire risk Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 17 assessment of the home has been undertaken, recommendations made at the time by the Fire Safety Officer have been complied with, staff are receiving regular training and regular tests and checks of the fire system and equipment are being carried out. It was noted during the inspection however that one bedroom door was held open by a wedge thus preventing it, as a fire door, from closing automatically. A formal letter requiring a prompt response to address this issue on a permanent basis has been sent to the registered person. A record is maintained of all accidents to residents. This record is in a single composite record and as such does not provide an appropriate level of confidentiality to the individual concerned as is required by current legislation. Sunningdale House DS0000063606.V283311.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 1 X 1 X 3 X 1 1 X Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 19 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 YA2 Regulation 14 Requirement No resident must be admitted to the home without a full written assessment of need having first been undertaken. (This requirement remains outstanding from a previous report). All controlled drugs must be stored in a double locked facility. A programme of refurbishment of the home must be developed prioritising areas in need and establishing timescales for completion. This must be submitted to the Commission for Social Care Inspection. (This requirement remains outstanding from a previous report). The registered person must ensure that staff are employed in sufficient numbers and for sufficient hours to meet the needs of the residents at all times. An application to register the manager of the home must be submitted to the Commission for Social Care Inspection. DS0000063606.V283311.R01.S.doc Timescale for action 01/03/06 2 3 YA20 YA24 13 23 07/04/06 14/04/06 4 YA33 18 01/03/06 5 YA37 CSA 2000 sec. 12 21/03/06 Sunningdale House Version 5.1 Page 20 6 YA41 17 7 YA42 23 All accidents to residents must 21/03/06 be recorded on individual records and not be kept in a composite record. Fire doors must not be held open 01/03/06 by unauthorized means including the use of wedges. (This requirement remains outstanding from a previous report). 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 6 9 23 32 Good Practice Recommendations An individual support plan should be developed for every resident. This should identify the individual’s strengths and needs and describes how these needs are to be met. Risk assessments for individuals should be further developed to clearly identify each potential risk and include a plan of how the risks can be minimised. All staff should be provided with adult protection training. A minimum of 50 of care staff should be qualified to NVQ level 2 or above. Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Sunningdale House DS0000063606.V283311.R01.S.doc Version 5.1 Page 22 - 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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