Inspection on 13/07/05 for Sunnydene

This inspection was carried out on 13th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sunnydene 20/09/06

Sunnydene 18/01/06

Sunnydene 17/01/05

Sunnydene 30/06/04

Sunnydene 18/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Sunnydene 5 Mill Hill Lostwithiel Cornwall PL22 0HB Lead Inspector Ian Wright Unannounced 13 July 2005 1600 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. Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sunnydene Address 5 Mill Hill Lostwithiel Cornwall PL22 0HB 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) 01208 872602 01208 872602 Royal Mencap Society Ms Nadia Brown Care Home 8 Category(ies) of Learning Disability (8) registration, with number of places Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include up to 8 adults with a learning disability (LD) Total number of service users not to exceed a maximum of 8 Date of last inspection 17.1.2005 Brief Description of the Service: Sunnydene is situated in Lostwithiel. The home provides care and support for 8 adults with learning disabilities. The home is a large detached property with pleasant grounds. Currently all service users have their own bedrooms, although one bedroom is registered for two service users. The home has a large lounge, dining room, kitchen and appropriate bathroom and toilet facilities. Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over three hours. The inspection was carried out on an unannounced basis. The inspector was able to speak to the majority of service users, and the staff members on duty. The inspector examined the medication system, care records, and inspected the building. What the service does well: What has improved since the last inspection? What they could do better: Although pre admission assessments and care planning is generally completed appropriately, written documentation is inadequate for one service user. Pre admission assessments must be improved for people admitted in future (for example in line with Mencap procedures). A care plan for one service user must be completed as a matter of urgency. Failure to complete pre admission assessments and provide a care plan could be an indicator, for example, that staff have not assessed whether they can meet service user needs appropriately. Some health and safety precautions are not being completed appropriately. These include testing the fire alarm system, completing health and safety risk Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 6 assessments, and the testing of portable electrical appliances. Failure to implement these measures could put staff and service users at risk. The inspector has requested prompt action is taken to correct these deficits. 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. Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 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 Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 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) 1,2,3,4, The registered manager provides suitable information to assist service users and their representatives to make an informed choice about moving to the home, although this is required to be issued to service users. Documentation regarding pre admission assessments must be improved so the registered persons can demonstrate an appropriate assessment and resettlement process. Suitable links are maintained between staff in the home and other external professionals to ensure service user needs are met. EVIDENCE: The inspector observed a suitable statement of purpose and service user guide. The registered manager said service user guides had been issued but had been returned in case they got lost. The inspector suggests these are reissued, and a note of their issue is made in service user files. Service users and / or their representatives will then have appropriate information regarding the level of service they can expect/ how to make a complaint etc. A service user was admitted in the last year. The registered manager said the service user visited the home during the day, and also for at least one overnight stay. However written documentation was very limited. The registered manager said the staff team have developed suitable links with external professionals such as community nurses, general practitioners and social workers. The staff group keep excellent records of all medical Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 9 appointments. The registered manager said staff have access to comprehensive training provided by Mencap, for example National Vocational Qualifications. Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 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 standard(s) 6,7,8,9,10 Care planning is generally appropriate, and each service user has an appropriate risk assessment. However one service user requires a care plan and this must be developed as a priority so the registered manager can evidence the service users needs are being met appropriately. Service users appear to be supported to maximise their independence, and take suitable risks. Suitable strategies are in place to minimise risks which may cause harm to service users. Appropriate strategies are in place to consult and involve service users. Information is stored confidentially. EVIDENCE: Generally service users have an appropriate care plan and risk assessments and these are reviewed regularly. However a service user who moved to the home this year did not have a care plan. Service users said staff regularly consult with them about major decisions regarding the home and their care. Service users are involved in cooking, and day to day tasks in the home. There is evidence that regular resident meetings Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 11 occur. Staff are currently learning signs for the Makaton communication system. Appropriate systems are in place so information is stored confidentially. Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15 Suitable opportunities are provided for service users to be part of the community, and they have a wide range of day activities available. Contact with service users family and friends is encouraged. EVIDENCE: Service users said they are given suitable opportunities to participate in the community for example using local facilities such as colleges, sheltered work placements, leisure centres, pubs and clubs. Some service users use public transport. Mencap also provides a multi purpose vehicle and this is used to assist service users to participate in their activity programmes, and social trips. Service users said they have appropriate opportunities to maintain links with their families and friends. Visiting arrangements are appropriate. Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 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) 20 The registered manager ensures an appropriate medication system is in operation so service users can be assured their medication is managed correctly. EVIDENCE: The registered provider has a suitable policy regarding the storage and handling of medication. An appropriate medication system is in operation, storage is appropriate and satisfactory records are maintained. The registered manager said all staff, except for one recent recruit, have received formal training regarding medication. Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 14 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 The registered provider has a suitable complaints policy. EVIDENCE: The registered provider has developed an appropriate complaints procedure, and a user friendly version is issued to service users. Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 15 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) 24-30 The home is a suitable environment for service users accommodated there. EVIDENCE: The building was inspected. The home offers a pleasant and homely environment for service users. The home was clean and hygienic on the day of the inspection. Service user bedrooms are pleasantly decorated according to individual tastes. Locks are fitted to all bedroom doors, and service users are issued with a key where this is appropriate (i.e. as long as there are no health and safety risks to the user concerned). Appropriate environmental adaptations are in place. Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 16 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, 36 Staff are clear regarding their roles and responsibilities. Staffing levels appear to be appropriate to meet the needs of service users so service users can feel assured their needs will be met. Appropriate supervision arrangements are in place. EVIDENCE: All staff are issued with a job description when they commence employment. Staff appear to have a clear understanding of their roles. The registered manager said the majority of staff have completed at least NVQ 2 in care. A copy of NVQ certificates should be placed on individual staff files. Rotas suggest there are appropriate numbers of staff on duty i.e. two staff on duty throughout the waking day. However there are currently a number of vacant posts totalling 75 hours. Difficulties in recruitment have resulted in considerable pressure on the staff team including difficulty for the registered manager to fulfil some of her obligations. Staff have however admirably completed a significant number of additional shifts to ensure the home is appropriately staffed. The registered provider should consider the use of agency staff in these situations to avoid overstretching the staff team. The registered manager and her deputy ensure the appropriate day to day supervision of staff, and ensure staff are formally supervised on a monthly basis. Written records of supervision are maintained. Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 17 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, 39, 40, 42 The registered manager is competent to manage the home. Service users benefit from a positive management culture, and the staff team appears to work well together. Policies, procedures, and records kept were observed to be suitable. Improvements are required to health and safety precautions. EVIDENCE: The registered manager has suitable experience, knowledge and skills to manage the home. The manager appears very committed to meeting the needs of service users. The registered manager works alongside the staff team. There is appropriate evidence of regular staff meetings. Staff contribute to the staff meeting agenda, and are involved in the decision making regarding how the home is run. The staff team have a satisfactory approach to quality assurance. Service users and other stakeholders such as external professionals involved in the care of people living in the home, have completed satisfaction surveys. People Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 18 appeared to be satisfied by the service provided from the questionnaires completed. There are regular residents meetings, and established contacts with relatives of service users. Care plans are reviewed regularly, and formal care reviews are held at least annually. The inspector could not find a copy of a Mencap quality assurance policy. A copy of the quality assurance policy is requested; and if the registered provider does not have a policy, one should be developed. Otherwise, Mencap generally appears to have a suitable range of policies and procedures. Although Mencap has a suitable health and safety policy, the inspector had some concerns regarding its implementation: • The fire alarm system call points are only being tested monthly rather than weekly. • Portable electrical appliances have not been tested since May 2004 • No risk assessment has been completed regarding the prevention of Legionella- and control measures in place may subsequently not be adequate. • Health and safety risk assessments have still not been completed despite this first being required by the Commission by 1.9.04 The inspector acknowledges the staff team have been particularly overstretched recently. However the registered persons must ensure action is taken to rectify these deficits. Other health and safety measures were satisfactory. These include appropriate fire training for staff, satisfactory testing of other fire equipment and testing of the electrical hardwire circuit. Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 19 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 2 2 3 3 x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score 3 x 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sunnydene Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x 1 x D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4, 5 Requirement Timescale for action 1.9.05 2. 42 13 3. 21 12 4. 2 14 5. 6. 6 42 15 12, Service users and /or their representatives must be issued with a copy of the service user guide The registered manager is required to carry out health and safety risk assessments and review these at least annually. A copy of these must now be sent to CSCI by the Timescale for action date (Timescale of 1.3.05 not met Third Notification) The registered provider is required to expand the home’s death and dying policy to cover the care of service users who are ageing or ill, with reference to the national minimum standard. 3rd Notification.). The registered manager must document any pre admission assessments appropriately for any future assessments (e.g. using the Mencap proceedure) , and this documentation must be available for inspection. All service users must have a care plan, which is reviewed regularly. 13, 23 Suitable measures must be taken to prevent health and D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc 1.9.05 1.1.06 1.9.05 1.9.05 1.9.05 Page 21 Sunnydene Version 1.30 safety risks to staff and service users. For example: · Fire prevention equipment must be tested at suitable intervals as recommended by the fire officer. · Portable electrical appliances must be tested at suitable intervals as recommended by the environmental health officer (health and safety) · Health and safety risk assessments must be completed. These must be reviewed at intervals prescribed by the environmental health officer (health and safety). A copy of these must be forwarded to the Commission for Social Care Inspection. . A suitable risk assessment must be completed regarding the prevention of Legionella- and suitable control measures must be in place. Advice from the environmental health officer should be sought as necessary. 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 33 32 39 Good Practice Recommendations The registered provider should consider the use of agency staff where there are a significant number of vacancies to avoid overstretching the staff team A copy NVQ of certificates should be placed on individual staff files. A copy of Mencaps Quality Assurance policy should be provided to the Commission for Social Care Inspection. If such a policy does not exist the registered provider must develop an appropriate policy. D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 22 Sunnydene Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Sunnydene D52-D04 S9227 Sunnydene V227176 130705 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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