Inspection on 09/08/05 for Sunnycroft

This inspection was carried out on 9th August 2005.

CSCI 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 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

Sunnycroft 18/12/09

Sunnycroft 27/03/07

Sunnycroft 11/01/06

Sunnycroft 21/01/05

Sunnycroft 08/09/04

Sunnycroft 29/01/04

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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 09/07/2008.

CARE HOME ADULTS 18-65 Sunnycroft 39 Oldnall Road Kidderminster Worcestershire DY10 3HW Lead Inspector Dianne Thompson Announced 9 August 2005 10:00 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sunnycroft Address 39 Oldnall Road, Kidderminster, Worcestershire DY10 3HW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01562 829000 01562 829001 Sunnycroft Homes Limited Mr Peter Sarll and Mr Neil Maddock Care Home 5 Category(ies) of AA Alcohol dependency past/present (5) registration, with number LD Learning disability (5) of places MD Mental disorder (5) PD Physical disability (5) Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21 January 2005 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. The home is approximately ½ mile from the town centre. The home is an adapted town house and was first opened in 1995. 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 two homes offering support and guidance. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place on a weekday morning. Both registered managers and the assistant manager were available throughout and facilitated the inspection. Time was spent with service users, on a tour of the home and reading the home’s files. As part of the inspection process questionnaires were sent out to service users and their relatives/carers. Five service users responded and all were happy with the care they received at the home and all felt safe. Two people said they liked the food sometimes while others stated they liked the food. All service users felt that the activities provided were suitable, but one service user would like to be more involved in the running of the home. Two relatives responded and stated they were happy with the care provided, although one relative indicated they had not received a copy of the home’s complaints procedure. What the service does well: Sunnycroft is located in a residential area of Kidderminster, with access to the local community. The home provides residential care in a homely environment for 5 adults, and meets most of the standards which were assessed during this inspection. Care plans are completed and used effectively, and include appropriate risk assessments, protocols and guidelines to assist both service users and staff. The home maintains detailed and accurate records, which includes comprehensive risk assessments. Service users have flexibility and choice within their daily lives and are supported where needed in their choice of activities, holidays and trips. Health needs for all service users are well attended, with regular monitoring and reviews with appropriate support from health professionals. The home is well managed by registered and experienced managers who are supported by a suitably trained and supervised staff team. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 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 standard(s) These standards were not assessed on this inspection. EVIDENCE: There have been no new admissions to the home since the last inspection. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 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 standard(s) 6, 7, 8, 9, Files are informative and contain completed, reviewed and up to date care plans for service users. The detail in the individual files ensures consistency of care for all service users and informs the home’s responses to individual and changing needs. The home ensures that all service users are given opportunities for making choices and the encouragement to do so. EVIDENCE: Through identified, assessed needs the home is actively promoting a move on towards a more independent lifestyle for service users. This was evidenced in a service user file. Care plans are clear, detailed and regularly reviewed, signed and dated. There is a good level of information including emergency contacts. Although one service users file contained no profile sheet, this was rectified during the inspection. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 10 Some service users have complex needs. These are being managed within the home using effective and manageable protocols, which give clear guidelines for all staff on appropriate intervention(s). Risk assessments are comprehensive and cover all the required elements, e.g. personal safety of the service user, staff and the environment. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 11 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 standard(s) 11, 12, 13, 14, 15, Service uses have flexibility and choice in their daily lives. Staff provide the support where needed for service users to take part in planned activities, holidays and day trips. One service user would like to be more involved in the running of the home. Contact with families and friends of service users is supported and facilitated within the home. EVIDENCE: Service users take part in community-based activities, which include night out beauty sessions, and going to the local shops. In house activities include weekly video evenings. The home has access to local amenities, and two vehicles are available for transport. At the time of the inspection one service user was attending Headway for a pottery session, and other service users were preparing to go to the local garden centre and have coffee while they were there. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 12 One service user informed the inspector that he helps with the washing up, cooking and making sandwiches for lunch. He also likes to watch cricket on TV. One service user told the inspector that he had attended Kidderminster College to do a life skills course. This has now finished for the summer and he is waiting to find out what courses will be available for the new term. He likes the meals and ‘staff are good to me. My room is comfortable’. Holidays are organised with service users and are very varied depending upon likes and interests. These include a holiday to Anglesey and Ireland which has been booked for September; a holiday to Welshpool on a canal boat in August. Other holidays have included the Caribbean, Kenya, Isle of Wight and Blackpool, decided through choices made by service users. Service users are supported to maintain regular family contact, e.g. one service user visits parents regularly. One service user indicated on the completed comment card a wish to be more involved in the running of the home. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 13 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 standard(s) 19, 20 Care plans detail care needs and personal support for all service users, with particular attention to ensure that all individual health and emotional needs are met. Medication is well managed and service users’ consent to medication is obtained and recorded in their care plans. EVIDENCE: Records demonstrate the monitoring of all health issues and the actions of staff. There is evidence that healthcare professionals from outside the home are involved to give guidance both to service users and staff on specific problems, e.g. from psychiatrist and GP. A visiting professionals chart, which records details of all visits, is completed in each service users file. There is consent to medication agreement and weight chart included in the individual files. However, the weight chart needs amending, e.g. on the record sheet staff are directed to record information weekly, but weights are being recorded monthly. The chart needs to be amended to reflect the required timescale. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 14 Service User comment cards had been completed prior to the inspection. All service users returned the cards. Feedback indicated that they all felt well cared for, and that staff treated them well. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 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 standard(s) 22, 23 The home has a suitable complaints procedure, which is followed when complaints are received. However, copies of the complaints procedure should be re-issued to all relatives/carers. Staff engage with service users by observing, listening and responding in a positive manner. EVIDENCE: There has been one complaint since the last inspection, which was made to CSCI. The complaint which was anonymous which was investigated by CSCI and not upheld. The home has a complaints procedure, which includes contact information for CSCI and other agencies. Relatives/visitors comment cards were sent out prior to the inspection. Two of these cards were returned. Both indicated that they had never had to make a complaint, while one indicated they were unaware of the home’s complaints procedure. Both cards indicated that they were satisfied with the overall care provided in the home. The inspector observed staff interaction with service users: service users appeared comfortable. Staff take time to listen to service users and service users appear relaxed with these interactions. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 30 The home is suitable for its purpose and offers service users secure, modern, comfortable and homely accommodation. Sunnycroft is clean and hygienic, with well furnished communal rooms, although there is no separate area for service users to meet with visitors in private. EVIDENCE: The inspection included a tour of the home. Sunnycroft consists of a comfortable lounge with 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. All bedrooms are single and are individually furnished and decorated. This was evident in two of the bedrooms shown to the inspector by service users. The home is clean and hygienic and well furnished. The communal rooms are comfortable, well furnished and with adequate space for shared activities. There is however, no separate area for service users to receive visitors in private, and there is no space for a separate staff area other than the very small office. This office would benefit from improved ventilation or perhaps office space being provided in a larger/alternative location. This was included Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 17 in the previous inspection in the form of a recommendation that consideration be given to the provision of an area for service users to meet with visitors in private, and the provision of improved staff facilities. The proprietor’s response advised that their architect has been instructed to look into the viability of providing an extension to the property to accommodate these additional facilities. Service users have keys to their rooms, although one service user told the inspector that he doesn’t feel the need to keep his room locked. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, The home has a stable staff team and appropriate staffing levels ensure that the best interests and safety of service users are maintained. The staff approach to service users and general atmosphere indicates a caring and supportive environment and commitment to the home’s aims and purpose. The homes recruitment policies and procedures are followed when recruiting new staff, which ensures that the best interests and safety of service users is maintained. EVIDENCE: There are clear roles and responsibilities within the staff team. An assistant manager and two senior support workers support the home managers and seven care staff. This ensures that a senior member of staff is on duty at all times. The rota indicates that three staff are on duty on each shift. The home experiences very little staff sickness. The home’s recruitment policies and procedures are followed when employing new staff. A recent recruitment campaign was very successful. Service users are involved in the interview process, with set questions to ask of the candidates. The manager states that service users enjoy this involvement, Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 19 which promotes their value and self worth. Their contributions are included as part of the evaluation of the interview process. Reports of monthly visits to the home by the Responsible Individual are completed and a copy is provided to CSCI as required. The format of the report covers the standards on a rotational basis. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 40, 41, 42 Sunnycroft is well managed with inclusive communication and a positive approach to service delivery. The home benefits from having two registered managers and an assistant manager. There are clear lines of accountability, which promote quality and consistency of care. The protection and best interests of service users is maintained through the effective and up to date records kept by the home. Health and safety within the home is well managed to promote the safety and welfare of both service users and staff. EVIDENCE: The inspector met with the registered home managers and the assistant manager. All were open and cooperative in their approach, contributing towards a balanced inspection. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 21 Health and safety within the home is being well managed, with all members of staff sharing areas of responsibility. Fire alarms, test and procedures are all completed as required and this evident in the recording. Fire drills are completed twice yearly. It is considered good practice to undertake more regular practice drills to make sure staff and service users are familiar with the procedures in the event of a fire. Redditch Fire Protection service inspected and serviced the home’s equipment on 28/7/05 Cleaning products are locked in the laundry at all times, and all staff have a separate key to access the laundry. Three service users smoke in the designated area of the home. The smoking policy identifies the designated smoking area and risk assessments identify the risks and protocols, which are included in individual care plans. Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 2 x 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score 3 x 3 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sunnycroft Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 3 x E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 23 No 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 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. 1. 2. 3. Refer to Standard YA28 YA28 YA30 Good Practice Recommendations Consideration to be given to the provision of an area for service users to have visitors in private Consideration to be given to the provision of staff facilities It is advised that disposable towels and soap dispensers are supplied in all toilets and bathrooms (restated from previous inspection). Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 24 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Sunnycroft E52 S18487 Sunnycroft V240866 090805.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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