Inspection on 31/01/06 for Sunny Bank (P.R.S.) Ltd

This inspection was carried out on 31st January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sunny Bank (P.R.S.) Ltd 18/05/07

Sunny Bank (P.R.S.) Ltd 19/08/05

Sunny Bank (P.R.S.) Ltd 25/11/04

Sunny Bank (P.R.S.) Ltd 08/06/04

Sunny Bank (P.R.S.) Ltd 11/03/04

Similar services:

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

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

CARE HOME ADULTS 18-65 Sunny Bank (P.R.S.) Ltd Sunny Bower Street Tottington Bury Lancs BL8 3HL Lead Inspector Kath Smethurst Unannounced Inspection 31st January 2006 09:30 Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.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 Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.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. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sunny Bank (P.R.S.) Ltd Address Sunny Bower Street Tottington Bury Lancs BL8 3HL 01204 883621 01204 888947 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) Sunny Bank (P.R.S) Limited Mrs Laraine Margaret Villiers-Colbran Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21) of places Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 21 service users to include: Up to 21 service users in the category of MD (Mental disorder under 65 years of age, excluding learning disability or dementia). The service should employ a suitably qualified and experienced Manager, who is registered with the Commission for Social Care Inspection. 19th August 2005 Date of last inspection Brief Description of the Service: Sunny Bank is a care home providing medium to long-term support to 21 people with mental health needs. An active rehabilitation approach is taken, with each resident supported to maintain and develop personal and practical life skills. The home is a large, converted, detached house over three floors, with an extension to the rear. All bedrooms are singles (with wash hand basins), with one room also having an ensuite shower. There is a mature, terraced garden to the front and private parking to the front and side. The home is on an unadopted road, in a semi-rural location. It is near to Tottington village centre and close to bus routes and local amenities. Although a manager is employed, the two owners also work in the home on daily basis. Two satellite houses are also managed by the home. These are not regulated by CSCI and do not receive inspection visits. They are occupied by exresidents who continue to receive a low level of support from the Sunny Bank staff team). Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over five and a half hours during the morning and afternoon. The inspector looked around the home, checked care plans and some records. In order to obtain more information about the home the owner, four residents, two care staff and the housekeeper were spoken with. What the service does well: What has improved since the last inspection? The way staffs training records are kept have been computerised. This allows management to more easily see what training staff need. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 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. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.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 Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.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): 3, 4 & 5 The assessment process is very good ensuring prospective residents were given time to make an informed decision about moving into the home and staff received detailed information about their care needs. Terms and conditions of residence/contracts are issued, which ensures residents/representatives have detailed information about what their rights are. EVIDENCE: The management at Sunny Bank are very clear they will only admit people whom they can help progress their lives. As part of the assessment process prospective residents are introduced to the home over a long period of time. This enables both the resident and staff to make a decision as to whether or not Sunny Bank can meet their needs. The care file of the most recently admitted resident was examined and good practice noted. This resident’s admission was very carefully planned and tailored to meet her individual needs. Prior to admission she visited the home to “test drive” it. This process included a number of visits, which enabled staff to access whether the placement would be suitable for both the prospective resident and residents already living at Sunny Bank. It was apparent from discussions with this resident she was happy with the way she had been introduced to the home. All new residents have a three month settling in period. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 9 The assessment process is very good. A full assessment of care needs is undertaken and social work assessments had been taken note off. The homes own assessment documents detailed and cover living, cognitive, social and physical skills and also psychological and social aspects. This ensured the needs of prospective residents were known before a permanent place was offered. Any potential restrictions on choice and freedom that may become part of the individual’s care plan are also discussed and agreed with residents. It is evident from the documentation that expectations of the placement are fully discussed and clarified before admission. All assessment documents had been signed and agreed by residents. All residents spoken to felt their needs were being met. During the inspection staff were observed to be attentive to the needs of residents and knew what care was needed. Management had identified where staff required training and had arranged training sessions for staff in different aspects of care such as NVQ (National Vocational Qualifications), food hygiene, first aid, moving and handling, anger management and depression. All of which demonstrates resident’s needs were being fully met. Currently all residents living at Sunny Bank have their care funded by local authorities. The funding agencies issue a service delivery agreement. The local authority contract contains broader terms and conditions of residence. In addition Sunny Bank has a detailed Terms and Conditions of Residence, a copy of which is given to each new resident when they come to live at the home. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 10 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 A knowledgeable staff team, who followed detailed and thorough written guidance, met the personal care and support needs of residents. Consequently, residents were kept safe (with the risk of accidents or harm reduced) and treated as individuals. EVIDENCE: Three care plans were examined. Good practice was noted, as there was an extensive amount of personalised information about residents needs. All contained comprehensive information relating to residents personal, social, emotional and health care needs. Daily entries in care notes were completed in all the plans examined and gave a good indication of the care provided and residents well being. Details of risk management were in place with clear details of individual and environmental risks. Decisions reached to reduce risk are clearly documented and in line with good practice guidelines residents these had been signed and agreed by residents. The plans were easy to read, had been regularly reviewed and set out clear guidance for staff to take when providing care. Formal Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 11 reviews arranged by the placing social worker, usually take place every six months. Good practice was noted in that it was evident residents were fully involved in drawing up the plan of care. For example in regard to both long term and short term goals, needs and activities. One resident was able to describe how one of her goals was to make regular home visits with her family. She had just returned from a weekend home, which she felt had gone well and was looking forwarded to her next visit. Copies of care plans are available for residents to refer to in their bedrooms. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 12 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): 15, 16 & 17 Residents are actively supported to maintain contact with their family and friends. Within agreed restrictions daily routines promote residents independence and individual choices. Mealtime arrangements are good offering variety, choice and interest for people living in the home. EVIDENCE: Family and friends are welcome to visit the home. Discussion with the manager indicated the only restrictions placed would be at the request of a resident or if contact was assessed as being detrimental. During the day most of the residents take part in activities outside the home so visitors are requested to contact the home before visiting. This is relevant given some of the resident’s families and friends live some distance from the home. Residents in the home are fully involved in activities within the community so have the opportunity to develop friendships outside the home. Good practice was noted, as residents if appropriate are encouraged to maintain contact with their families. The owner found that in some cases relationships and contact Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 13 between residents and their families often improved following admission to Sunny Bank. Discussion took place in respect to more intimate personal relationships residents may develop. The owner advised that in the past this has happened. She described the steps taken to enable residents to make appropriate decisions in such cases. For example considering the feelings of other residents, birth control and sexual health. Staff were observed to respect service users privacy entering bedrooms and bathrooms. Interactions between staff and service users were observed to be frequent and friendly. For example staff were observed sitting having a drink and a chat with residents. It is evident from speaking with staff that this is considered to be an important aspect of their role and is encouraged. An essential feature of the care provided is to enable residents to relearn daily living skills. As part of that process resident’s assist in the preparation meals, keep their rooms clean, do their laundry and take part in therapeutic activities. Where this is the case these activities are clearly indicated and agreed in individual care plans and treatment programmes. Residents who commented said the food was good. Mealtime arrangements are flexible enough to accommodate individual preferences and the activities residents take part in. For example on the day of the visit one of the residents had visited the dentist and had a filling. A member of staff ensured this resident was offered an option she could easily eat. Menus were inspected and were found to be well balanced and varied. Very little convenience foods are used and residents are encouraged to eat a healthy diet. Within planned menus residents can choose an alternative if the prefer. For example some residents like the occasionally “take away” meal and this is readily accommodated. As part of individual treatment programmes residents are encouraged to participate in the preparation of meals. This is clearly detailed in care plans. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 14 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): 18 Staff provided personal care and support in ways that reflected individual needs and encouraged residents to retain control and independence whenever possible. EVIDENCE: Relationships between staff and residents seemed warm, friendly, caring and supportive. Staff were seen to actively listen to residents, to treat residents with courtesy and to support them to make choices and reach their goals. Residents spoken with were very complimentary about the staff team. One resident said that the “Staff really care” and the care provided was “Very good”. There were detailed records about how each resident liked their care to be delivered or conversely the reasons for not doing so. For example if an agreed goal was to maintain personal hygiene or undertake a therapeutic activity this was clearly detailed and agreed by residents in the care plan. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 15 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 The home has a satisfactory complaints system with evidence that residents feel their views are listened to and acted upon. EVIDENCE: A detailed complaints procedure is in place. Details of how to complain are provided on the notice board and contained in the “Information File” which each resident has a copy of. A system is in place for recording complaints. When residents are admitted to Sunny Bank staff discuss the process of raising a concern or making a more formal complaint. Evidence of which was seen in the residents induction checklists examined. No complaints have been received by the home or the CSCI since the last inspection. Anecdotal evidence from residents indicated they felt able to approach staff with any concerns and these would be taken seriously. None of the residents had made a complaint but all indicated they were aware of how to do so if the need arose. In addition to the formal complaints system the home holds regular residents meetings, which provides residents with the opportunity to for residents to air their views and raise any concerns. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 16 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 The standard of the environment within this home is good providing residents with an attractive, homely and clean place to live. EVIDENCE: Sunny Bank is a detached house, set in its own grounds close to Tottington village centre within close proximity to bus routes and local amenities. The Home is well maintained both internally and externally. The home has several lounges, which include areas for smokers and nonsmokers, quiet areas and activity areas. These areas are furnished with good quality items. Ornaments, fireplaces, pictures and flowers enhance the homeliness of the home. The garden areas are tidy, well maintained and accessible for residents. Bedrooms were also viewed during this inspection. These were extensively personalised, had wash hand basins and a suitable range of furniture and fittings. Bedrooms were individually decorated and had colour co-ordinated soft furnishings and curtains. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 17 No items of maintenance were identified at this inspection and residents spoken with made no adverse comments about the standard of the environment. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 18 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 Comprehensive induction plus excellent ongoing training ensures that residents’ individual and joint needs were properly and fully met. EVIDENCE: Good practice was noted as Sunny Bank has a training plan and a dedicated training budget. New staff undertake a comprehensive induction package both outside and within the home. There was evidence that new staff undertake induction training that meets the National Training Organisation (NTO) specification following which foundation training is undertaken. An extensive range of mandatory is provided including fire safety, food hygiene, first aid, moving and handling. Specialist mental health training is also organised. Specialist training is targeted to the needs of the residents living at the home. For example depression, schizophrenia and anger management. One member of staff spoken with confirmed that when she started working at the home she undertook through and comprehensive induction training and further ongoing training was available. Each member of staff has an individual training profile, which details internal and external training completed and training needs. Since the last inspection training records have been computerised. This has enabled management to more easily identify when refresher training is needed and of any future Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 19 training needs. For example future training planned includes POVA (Protection of Vulnerable Adults) and risk assessments. Since the last inspection the home has achieved Investors in People status. Ongoing training is available and there is ample evidence that these opportunities are taken up. NVQ (National Vocational Qualifications) are actively promoted. Currently 99 of staff are in receipt of NVQ level 2 and 3. This is commended as the percentage is significantly above the required standard. In addition to the more formal training staff are given time within their working day for “independent learning”. Two hours is set aside for staff to familiarise themselves with policies, procedures or other care topics. Staff who commented confirmed that training was encouraged and widely available. One member of staff said that the training provided was “ Very good”. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 20 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): 39 The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of residents, staff, relatives and other stakeholders. EVIDENCE: Effective internal and external quality assurance systems are in place such as staff and residents meetings and resident/relatives/stakeholder surveys. A sample of the most recent completed surveys was examined to find a high level of satisfaction. The owners take an active involvement in the running of the home and know the residents and staff very well. They also undertake regular audits of care plans, policies, records and training. They also have some very innovative ideas in respect to quality assurance systems. As previously mentioned Sunny Bank has attained the Investors in People award and are currently considering whether to apply for the ISO quality status. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 21 The home has a system for recording the complaints of those who don’t wish to complain formally. Regular residents and staff meetings take place. Additionally satisfaction surveys are sent to residents, relatives and other stakeholders in order to ascertain whether they are satisfied with the care provided and organisation of life in the home. Residents are informed of CSCI inspections and inspection reports are available for visitors and residents to read. Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 22 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 X 3 4 4 4 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 4 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 X X X X X 4 X X X X Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sunny Bank (P.R.S.) Ltd DS0000008457.V280914.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. 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