Inspection on 18/12/09 for Sunnycroft

This inspection was carried out on 18th December 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sunnycroft 27/03/07

Sunnycroft 11/01/06

Sunnycroft 09/08/05

Sunnycroft 21/01/05

Sunnycroft 08/09/04

Sunnycroft 29/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

Extracts from inspection reports are licensed from CQC, this page was updated on 14/03/2010.

Key inspection report CARE HOME ADULTS 18-65 Sunnycroft 39 Oldnall Road Kidderminster Worcestershire DY10 3HW Lead Inspector Dianne Thompson Key Unannounced Inspection 18th December 2009 09:00 Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Sunnycroft Address 39 Oldnall Road Kidderminster Worcestershire DY10 3HW 01562 829000 01562 829001 shirley@sunnycrofthomes.com www.sunnycrofthomes.com Sunnycroft Homes Limited 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) Mr Peter Sarll Mr Neil Arthur Maddock Care Home 5 Category(ies) of Past or present alcohol dependence (5), registration, with number Learning disability (5), Mental disorder, of places excluding learning disability or dementia (5), Physical disability (5) Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia (MD) 5 Physical disability (PD) 5 Learning disability (LD) 5 Past or present alcohol dependence (A) 5 The maximum number of service users who can be accommodated is: 5 27th March 2007 2. Date of last inspection Brief Description of the Service: Sunnycroft offers personal care and accommodation for up to five adults. The home is registered to provide a service for the following categories of service users; Past or present alcohol dependence; Learning disability; Mental disorder excluding learning disability; Physical disability. These conditions are most usually associated with an acquired brain injury. The home is situated in a residential area of Kidderminster and is approximately ½ mile from the town centre. The home is an adapted bungalow. All accommodation is provided in single rooms, without en-suite facilities. There is a garden area at the back of the home which affords privacy to service users. The home is operated by Sunnycroft Homes Limited and managed by two registered managers, Mr Peter Sarll and Mr Neil Maddock. Mr Sarll is the Director of Care. Mr Maddock works full-time in the home and Mr Sarll divides his time between the Sunnycroft and their sister home offering support and guidance. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 5 The current fee for the service ranges from £800 to £2300 per week. Charges which are additional to the fee include: Personal toiletries, clothing and electrical items Activities not covered by the allowance made by the provider or in the funding authority contract Holidays Major extra outings Hairdressing Beauty therapy Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this care home is two stars good service. A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. This inspection was done to see what the home was like for the people who live there. We spent some time with the people who live at Sunnycroft and some of the staff working there. We looked at some of the policies and procedures. Policies are rules about how to do things. We spent some time looking at records. We sent out surveys to get views about the service from other people. The registered manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to us when we asked for it. What the service does well: People are given information about the home, and the chance to visit before they come to live at Sunnycroft. People say they are happy living at the home. People are given help and support to do the activities they choose. Everyone leads an active and interesting life. People who live at Sunnycroft are supported to keep in touch with their families and friends. People can choose what they want to eat from the healthy menu that is available. Sunnycroft looks after people well and writes down what help everyone needs. People are supported in their medical appointments. Staff are trained to help them understand how to meet people’s needs and give them the support they want. Sunnycroft makes sure that suitable staff are employed and that all checks are made to keep people safe. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 7 The manager has the skills and experience to make sure the home is well run. The management team supports staff. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 8 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 Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that they will be looked after by the staff at Sunnycroft. This is because detailed assessments are completed to make sure peoples support needs can be met before they move into the home. EVIDENCE: Sunnycroft makes sure information is accessible to everyone who uses their service. We saw the statement of purpose, service user guide and copies of a contract agreement. The statement of purpose and service users guide is available in formats that people can understand. We looked at the files belonging to 3 people living at the house, including one person whose needs have changed since the last key inspection. These files show that a detailed assessment is carried out by the manager at the persons place of residence or hospital. This includes their likes and dislikes as well as their care needs. Other people such as their family, psychologists, and psychiatrists are involved if appropriate. We saw copies of Local Authority Community Care Assessments included in the assessment process. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 10 The Annual Quality Assurance Assessment (AQAA) tells us that there is a long, thorough, referral process which includes the receipt of relevant reports from care planning approach, including social and psychiatric reports. Visit to service user in current placement to make full assessment and complete Strengths and Needs Assessment. Visits to the Home by the prospective individual are encouraged, supported by Social Worker and family. Opportunity to meet staff, other service users, have a meal. Individuals are only admitted after a long and thorough assessment process to ensure that they can be successfully cared for at the Home’. Surveys completed by people living at Sunnycroft confirmed they had been asked if they wanted to move to the home, and that information was provided before they moved in. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sunnycroft keeps care plans up to date to make sure that people can be confident they will receive the support for their specific care needs. Risk assessments are in place to manage risks in a way that promotes independence, although these must be acted upon to make sure everyone is kept safe at all times. EVIDENCE: Information obtained from care needs assessments is used to develop a care plan. A care plan tells staff about each persons care and social needs and the level of support required for maintaining their health and independence. The manager states in the services Annual Quality Assurance Assessment (AQAA) that they have ‘appropriate, clearly written documentation to promote independence based upon the needs and decisions of individuals who use the Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 12 service; promotion of independence within a risk assessment framework; key worker allocation and discussion with key individual’. We case tracked the care for 3 people. This is where we look at what life is like at Sunnycroft for the people who live there. This includes looking at care plans, and seeing how health and social care needs are being met. Care plans are drawn up with the involvement of the person who uses the service together with family, friends and any relevant agencies as appropriate. From the care plans we could see that regular reviews are carried out. Information provided in care plans covers areas such as likes and dislikes, diet, communication and personal care. Staff are provided with information to help them give consistent support. Information about people’s preferred routines is included. Risk assessments are completed where risks have been identified, such as going out in the community and safety for individuals in the home. We saw an assessment that had last been reviewed 08/09 which identified the kitchen as a high risk area for one person. During the inspection visit the difficulties for staff and the associated risk when cooking/preparing meals was observed. The potential for harm to both service user and staff needs to be addressed in a way that keeps people safe. Staff confirmed a maintenance request had been made for a possible adaptation to the kitchen area. A removable barrier staff felt would give protection to both residents and staff during preparation and cooking of meals. It is of concern we saw no evidence that this work is to be completed or alternative suggestions sought. If, on further assessment the adaptation of the physical environment is not considered appropriate, then serious consideration must be made for additional staff during the preparation and cooking of meals. Sunnycroft completes Mental Capacity Act assessments where people are unable to comprehend or make their own decisions through cognitive impairments or due to the nature of their head injury. The manager said in the services AQAA that Mental Capacity Assessments have been carefully undertaken for each service user and our consultant psychiatrist and neuropsychologist have been involved in this process. Best Interest decisions have been made for individuals only as required based on the above. Care plans set out any restrictions on choice and freedom in accordance with the Mental Capacity Act. These assessments are reviewed regularly or as changes occur. Staff give people information they need to help them make decisions about their lives, and records demonstrate how people have been supported in their decisions. The manager ‘has implemented a structure to maintain regular dialogue to assist key workers with their role’ and plans to ‘increase staff training in these areas’. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16, 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to lead active and interesting lives. Staff encourage people to maintain links with their families and to develop friendships. Dietary needs are well catered for with a varied and healthy menu provided. EVIDENCE: The manager said in the services Annual Quality Assurance Assessment (AQAA) that ‘daily and regular use of a range of local community facilities by all service users is supported by staff individually or in small groups. Attempt to develop an appropriate lifestyle which promotes a quality of life despite complex and diverse needs. Provide an annual holiday for each person where health and risk allow; regular days out and trips to places of interest and to the coast’. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 14 Time was spent talking with residents in the kitchen. Everyone appeared to be happy to talk about their life at Sunnycroft and what they were doing. It was a very busy time with the coming Christmas festivities. People talked about their plans for Christmas and about their holidays for the coming year. We looked at records of activities that had taken place. We saw that activities include going for a local walk, or into Bewdley to feed the ducks. The manager said in the services AQAA that they have ‘encouraged a greater variety of different courses at College, encouraged greater social interaction [for one person] by purchasing a digital camera’. Information given in surveys showed a varied response to the question ‘can you do what you want?’ One person responded that ‘it depends due to lack of transport’, two people said they could do what they want, and another person did not give a response to this question. Further comments included ‘could provide more transport as [one person] enjoys going out for a drive and can’t do this in a taxi’. ‘Could supply own transport instead of using public’. ‘They organise games and trips well. Could do better - have our own transport instead of public transport - its too restrictive’. ‘Good trips out. They could take me out more in the cars not public transport’. ‘They could provide transport for the home’. There have been changes to the way transport is organised within the home. Sunnycroft no longer has the use of two cars for getting out and about and now uses taxis for all journeys. We saw the operating system in place for ordering taxi’s, structured according to distance and price. The convenience of using the home’s own vehicle must be measured against the use of public transport especially where there are issues and concerns about people and their inability to travel using public transport. Such information and concerns are evident in some of the care plans we looked at. There is emphasis on planning for the use of and booking taxi’s, which is to be commended. This does however greatly reduce the flexibility that the home’s own transport provides and the ability to simply go for a drive at short notice. The AQAA tells us that Sunnycroft’s plans for the next year include promoting ‘a greater and varied use of community facilities for those service users who are reluctant to use them and induction for additional staff at the gym to increase the attendance opportunities for service users’. It is evident that visits and contact with family and friends is supported. Staff support people to visit their family members where they are unable to visit at Sunnycroft. Survey comments say that staff at Sunnycroft ‘welcome my family when they visit’. Records show that varied and nutritional meals are provided with alternative meals recorded where these have been chosen. People who live at Sunnycroft have chosen to have their main meal at lunch time and a lighter meal in the Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 15 evening. The choice for lunch on the day of the inspection was sausages, with mashed potatoes, peas and gravy. Apple pie and custard was offered for desert. Lunch was eaten at tables in the dining area. Everyone said they enjoyed their food and one person said ‘sausages are my favourite’. The manager states in the AQAA that menus are available offering variation and choice and that dietary intake records’ are maintained. Records examined confirmed this. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sunnycroft has a medication policy and procedure in place which staff to follow so that medication is administered and stored safely. Staff training in the administration of medication needs to be reviewed and updated so that everyone keeps up to date with current practice. This makes sure that people are kept well and safe. EVIDENCE: There are plans in place to help and support people with their health care and appointments. These plans sets out how their health needs are to be met. We saw information giving details of personal and health care support to be given. The manager states in the services Annual Quality Assurance Assessment (AQAA) that they provide individual, dignified, personal care to meet the assessed needs of the service user in an unhurried manner. Provide detailed care plans of how to provide personal support to maximize independence, privacy and dignity. The provision of specialist support accessed privately by Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 17 the Company for physiotherapy, hydrotherapy, psychiatry and psychology. Change care practice to meet the changing, challenging and deteriorating needs of the individual service user. Staff training includes training in moving and handling. Provision of aids and adaptations, including wheelchair access vehicle for one person based on assessment by Physiotherapist. Have a good, safe, medication system which is regularly audited. People have good access to medical support through their doctor, clinical psychologist, behavioural team, community health care team, and dentist as required. Staff were observed providing support for people in a respectful way, making sure that each persons dignity and self esteem was important. Time was spent talking with residents who spoke about their health care and the support staff give them for their appointments in a positive way. We saw that detailed Mental Health Capacity Assessments (MHCA) are completed in relation to personal health and welfare concerns where people have been assessed to lack capacity to make their own decisions. Medication is well managed by staff at Sunnycroft. Medication is stored securely and given to people at the right time and full records are kept which show this. A medication policy and procedure is in place and give staff guidelines to follow should any medication error occur. These policies and procedures are reviewed regularly, with the most recent review completed in November 2009. Guidelines and the use of non prescribed medication have been revised since the last inspection. We checked the administration of medication records and found that all medication given had been signed for. Although staff have been trained to administer medication we saw from records that for some staff this training took place many years ago. For example, one member of staff completed medication training in 2001. Medication administration training must be reviewed to make sure that people complete up to date, accredited training. This will make sure that all staff have knowledge of current practices and information so they can continue to give medication safely. Ordering, disposal and audit records for medication were seen. The supplying pharmacist carries out annual audits of all medication stored in the home. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected by the homes safe working practices and people can be confident the staff will give them the support they need to keep them safe. People are encouraged and supported to take risks in order to be as independent as possible. EVIDENCE: There are systems and procedures in place to make sure that everyone who lives at Sunnycroft are kept safe. Care records contained a number of risk assessments showing potential hazards and control measures to reduce or eliminate an identified risk. For example, environmental risk assessments are in place to keep people safe in the home. In addition we saw where a risk assessment had been completed to consider ways of keeping a person safe while maintaining their independence when they are out in the community. These risk assessments are reviewed regularly or as needs change. Staff are able to access Sunnycroft’s safeguarding policy. This policy tells staff how to recognise different forms of abuse and how to protect people. The service makes sure people are protected through their safeguarding policy, and by maintaining accurate records and daily notes. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 19 We looked at the complaints log and records show that no complaints have been received. The Care Quality Commission (CQC) has received no complaints about Sunnycroft since the last inspection. The complaints procedure is made available in alternative formats as required and everyone who uses the service is given a copy. Surveys told us that people would know how to make a complaint should they need to. The manager states in the Annual Quality Assurance Assessment (AQAA) that ‘all Staff have received training in the Non-Aggressive Physical Intervention Techniques as certified through the Crisis Prevention Institute and an annual certified refresher programme where required. The AQAA also states that Sunnycroft ‘safeguard vulnerable people from abuse by staff training and observation. Safeguards are in place to protect from abuse and exploitation’. This includes ‘reporting of physical assaults and other untoward events under Regulation 37 to the Care Quality Commission (CQC) and individual Social Workers. Robust policies and procedures [are in place] for dealing with concerns and complaints. Respond to complaints in a systematic and understanding manner, attempting to resolve any problems raised’. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sunnycroft is spacious and is kept clean, although repairs and regular maintenance is needed to make sure the home is comfortable and safe to live in. EVIDENCE: Sunnycroft is located in a residential area of Kidderminster close to local amenities with access to the bus route into town. Sunnycroft has a comfortable lounge and a kitchen/dining room. There is a bathroom, shower room, three toilets and separate laundry. There is an enclosed garden to the rear of the house with table and chairs available for use. The bedrooms are single and individually furnished and decorated. The manager states in the Annual Quality Assurance Assessment (AQAA) that ‘we provide a homely atmosphere for a small group of five people who all have Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 21 individual bedrooms. Each service user is encouraged and assisted to personalise their own room to meet their own needs and requirements. The Home is accessible to all people including one individual who has restricted mobility. The Home is clean and well maintained, systems are in place for hygiene and the control of cross infection. Staff training has always had a high commitment, staff are knowledgeable in all areas of health and safety’. The manager acknowledges in the AQAA that ‘maintenance to some environmental repairs could be undertaken more routinely and regularly’. While looking around the home it was evident that some significant work is needed to the home. We saw evidence of damp to the walls in the kitchen, lounge and several of the bedrooms. We saw a bed positioned against a wall that is damp, with mildew on the wallpaper which is peeling away from the wall. This is not good for the individual as sleeping against a cold, damp, mildewed wall can have a detrimental affect to a person’s health and well being. Similarly, in the dining/kitchen we saw damp, mildewed walls to the soft seating area of the room. We understand that this is normally the sleeping area for staff at night, but because of the dampness of the walls staff are sleeping in the lounge instead. We saw the spread of mildew from walls onto curtains, especially in the lounge. We examined the maintenance log book and found examples of requests for work that remain outstanding. Requests for repairs to faulty electrical sockets were recorded 20/9/09 and remain outstanding. A request for repair to the cutlery drawer lock remains outstanding from 15/8/09. Where maintenance work has been completed the timescales recorded show that work has not been carried out promptly. A request for repairs to a toilet not working was recorded on 12/2/09 and repaired on 17/2/09. We saw that the kitchen extractor fan is rusty and there is a possibility that rust may fall into food if the fan is used. We found that an extractor fan in one of the bathrooms was not working and in need of repair or replacement. The second floor area was very cold due to the open window in the bathroom and the radiator which was turned off. There was no extractor fan in this bathroom. Some of the radiators in the home are rusting and in need of attention. The curtain pole in one of the bedrooms needs to be made good and a lampshade or light fitting is needed. The responsible individual commented that ‘general maintenance in the Home is prompt however a new reporting system is being introduced to encourage Staff to report/record problems more quickly’. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 22 The premises are clean and tidy. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Paper towels and liquid soap are available in the communal bathrooms. Staff records show that all staff receive training in infection control. Surveys confirmed that the home is ‘always fresh and clean’. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that the support they receive will be delivered by well supervised and skilled staff to help maintain their health and independence. People can be confident that checks are made so that suitable staff are employed to protect them. EVIDENCE: Sunnycroft has a committed and stable staff team. Time was spent with the assistant manager who said the staff team are very well motivated and always look to improve the lives of the people who use the service. Sunnycroft provides regular staff training. Staff complete mandatory training such as Health and Safety, Fire Safety, First Aid, Food Hygiene, Moving and Handling, Infection Control and Vulnerable Adults. Staff said that the training provided is very good. Training records confirmed that regular training takes place, including induction training for new staff. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 24 The manager said in the services Annual Quality Assurance Assessment (AQAA) that ‘all documentation is reviewed and given to staff at the time when they commence, during induction or at the completion of the probationary period. Staff receive regular supervision and an annual appraisal. Staff selection is a careful process to attract the appropriate people. References, CRB and PoVA checks are carried out prior to taking up the post. Staff receive Induction to Skills for Care standards plus regular in-house and external training. All Staff hold an NVQ II, III or IV. Manager holds appropriate managerial qualifications. A range of specialists are employed by the Company to compliment the Staff team and add to the ability to meet the needs of the individuals’. The AQAA tells us that Sunnycroft has robust staff recruitment and selection procedures. We looked at staff personnel files which confirmed that recruitment procedures are followed and appropriate safety checks have been made to make sure staff are suitable to work with vulnerable people. These checks include a Criminal Record Bureau clearance (CRB) and two written references and are completed as routine. Records are well maintained and confirm that all staff are required to work a probationary period. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 25 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and staff receive the leadership and support they need, although the management of the building needs to be addressed to make sure the welfare of residents and staff are not compromised. Sunnycroft monitors and evaluates their service to protect the health and welfare of the people they support. EVIDENCE: Sunnycroft has an effective management team to make sure the home is well run. The registered manager Neil Maddock who has experience and qualifications in care management has been employed by Sunnycroft Homes for over fourteen years. Mr Maddock was on annual leave at the time of the inspection. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 26 Management responsibilities in the home are shared with and assistant manager and two senior support workers. The manager, the assistant manager and senior support workers are involved in organising day-to-day activities, health and safety promotion, staff supervision and induction. The Annual Quality Assurance Assessment (AQAA) was completed and sent to us when we asked for it. The manager said in the services AQAA that ‘there is a comprehensive system of Quality Assurance in operation within the Home. This includes gaining the views of other people with use of a Questionnaire. Policies are comprehensive but succinct; they are regularly reviewed, signed and dated, and available to staff and service users. There is a comprehensive Home Management system in place to ensure that all records are maintained as detailed in the Care Standards Act, 2000, Care Homes Regulation, 2001, Schedules 2, 3 and 4. There is a comprehensive system to ensure and maintain the health and safety at work for service users, staff and visitors’. The manager confirms in the AQAA that regular monthly checks are carried out on the service provided. ‘A monthly Directors Report under Section 26 of the Care Standards Act, 2000. Quality Assurance is managed in a number of ways involving service users, staff, family and friends and stakeholders views. Monthly in-house Inspections take place following the format of the National Minimum Standards. A Business and Financial Plan is available which explains the Company accountability and responsibility to budgeting, human resources and financial accountability. An Annual Development Plan for the Home has been produced’. Staff confirmed that the manager is approachable and supportive. Surveys completed by people living at Sunnycroft confirmed that the manager and staff always treat them well and listen and act on what they say. Health and Safety is being well managed within the home through staff training, regular monitoring and safety checks. The Health and Safety folder contains copies of all policies and procedures together with a signing sheet for staff when they have read the information. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Generic risk assessments are in place. A copy of the report from an inspection carried out by the Fire officer on 17/9/09 was sent to CQC. A requirement was made by the Fire Officer for the existing fire alarm to be extended as it was considered to be inadequate for the size of the building and the needs of the people living there. A deadline of 17th Dec 09 was given for compliance with this requirement. Following the inspection visit the responsible individual has provided a copy of the letter from the Fire Officer confirming that this work has been completed. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 27 While the running of the service provided is well managed, the condition of the building needs to be addressed before there is significant impact to the safety and well being of all residents and staff. Following the inspection visit the responsible individual has confirmed that an action plan is in place to address the concerns raised in this report. Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 28 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 4 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 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.3 Page 29 Sunnycroft DS0000018487.V378787.R01.S.doc 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. 1. Standard YA9 Regulation 12 Requirement Where assessments have identified specific risks such as the kitchen area of the home, guidelines must show how support is to be given and what steps are being taken to make sure people are kept safe from harm. Staff training in the administration of medication needs to be reviewed and updated so that everyone keeps up to date with current practice. This will help to make sure that people are kept well and safe. Repairs and regular maintenance must be maintained to make sure the home is comfortable and safe to live in. Timescale for action 20/02/10 2. YA20 13 20/04/10 3. YA24 23 20/04/10 Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 30 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 Sunnycroft DS0000018487.V378787.R01.S.doc Version 5.3 Page 31 Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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