Inspection on 18/01/06 for Sunnydene

This inspection was carried out on 18th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sunnydene 20/09/06

Sunnydene 13/07/05

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 Announced Inspection 18th January 2006 14:15 Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sunnydene Address 5 Mill Hill Lostwithiel Cornwall PL22 0HB 01208 872602 01208 872602 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) Royal Mencap (Housing & Support Services) Ms Nadia Brown Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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 13th July 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 DS0000009227.V264159.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over eight and a quarter hours and was announced. The inspector was able to speak to some service users, and the staff members on duty. The inspector examined the business, staff, care records, and toured the building. What the service does well: What has improved since the last inspection? What they could do better: Although care planning is generally to a good standard, a requirement set at the last inspection, for one user to have a care plan has not been completed. This must be completed without delay so it is documented what care this person requires. Two improvements are required to the building to assist service users with mobility problems. The route from the rear to the front of the building must be paved particularly as this is a fire exit route. The upstairs shower is currently not in use as it is potentially dangerous to people with mobility problems. This must be modified as a matter of priority. Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 Page 6 One member of staff requires a Protection of Vulnerable Adults (POVA) check. This must be obtained as a matter of priority and the person must not work unsupervised until a suitable disclosure is obtained. A requirement from the previous report requiring the registered provider to take suitable steps to minimise the risk of Legionella has only partly been completed. This must be finalised and suitable control measures put in place. 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 DS0000009227.V264159.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 The registered manager provides suitable information to assist service users and their representatives to make an informed choice about moving to the home. The registered provider has a suitable pre admission assessment procedure. Suitable links are maintained between staff in the home and other external professionals to ensure service user needs are met. Service users are issued with a suitable license /tenancy agreement. EVIDENCE: The inspector observed a suitable statement of purpose and service user guide. The service user guide is issued to service users. However due to many of the users poor literacy skills, it is suggested a copy of the service user guide is also issued to next of kin / service user representatives. A copy of the pre admission assessment procedure was available for inspection. This is satisfactory. There have been no new admissions since the previous inspection. The registered manager said the staff team have developed suitable links with external professionals such as community nurses, general practitioners and social workers. Suitable records are maintained regarding medical appointments. The registered manager said staff have access to comprehensive training provided by Mencap, for example to National Vocational Qualifications. Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 Page 9 Service users either have an assured tenancy agreement or a licence agreement. As a license agreement offers significantly less security of tenure, the registered manager is advised to liaise with the housing association to ascertain if the issuing of this was correct. Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9,10 All service users (except for one) have a care plan and a risk assessment. There are suitable arrangements for service user participation and consultation. Information regarding service users is treated 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 last year still does not have a care plan. This was notified in the last inspection report. It is not satisfactory this requirement is still outstanding, and the care plan must be developed as a matter of priority. Other care plans are currently being updated. These should be finalised and made available to the staff team. Service users said staff regularly consult with them about major decisions regarding the home and their care. There is evidence of regular residents meetings. Service users are involved in cooking, and day-to-day tasks. There is evidence that regular resident meetings occur. Appropriate systems are in place so information is stored confidentially. Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 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 the following standard(s): 11, 12, 16, 17 Suitable opportunities are available for service users for personal development. Service users have a wide range of day activities available. Service users’ rights are respected and responsibilities are recognised in their daily lives. Meals available for service users are appropriate. EVIDENCE: The registered manager said service users have appropriate opportunities for their own personal development. For example staff work to assist service users to develop new skills such as cooking etc. Other professionals, such as behavioural nurses, work with service users to maintain and develop social, emotional and communication skills. Staff are working to learn the Makaton communication system to assist communication with one service user. Service users attend religious services if they wish. The registered manager said service users are given suitable opportunities to participate in the community, for example sheltered work placements or attending college courses. There are also suitable leisure opportunities such as service users being able to attend leisure centres, pubs, cinemas and clubs. All Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 Page 12 service users have comprehensive day activity plans. Service users all had at least one holiday in the last year. Daily routines are flexible and tailored according to individual needs. Independence and choices are encouraged. Service users stated they felt very much at home and are supported appropriately by staff. Service users have a lock on their bedroom doors and are supplied with a key to their bedroom, and to the front door. Satisfactory records are kept of food eaten by service users. Service users cook for themselves with staff support where this is necessary. Special diets are catered for where this is necessary. Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 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 the following standard(s): 18, 19, 21 Service users receive personal care in a manner, which respects their privacy and dignity. There are appropriate links with relevant professionals so service users physical and emotional health needs are met. Ageing, illness and death of service users is handled appropriately. EVIDENCE: Service users said they were happy with how personal care and support is provided. The inspector observed staff working with service users in an appropriate manner. Care interventions are appropriately documented in care plans for all except one service user (see NMS 6). Since the last inspection there have been no major accidents which have resulted in hospital admission. Accident and incident records are appropriately maintained. Staff stated links with general practitioners, and other professionals such as social workers are satisfactory. Suitable records are maintained regarding hospital and other health care appointments. The registered provider has developed a policy regarding ageing, illness, death and dying. Although basic, this is satisfactory. Service user care plans satisfactorily address issues regarding ageing, and service users receive appropriate care and support in this area. Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 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 the following standard(s): 23 The registered provider has suitable adult protection policy, which is effectively implemented. One member of staff however requires a Protection of Vulnerable Adults (POVA) check. EVIDENCE: Mencap has an appropriate adult protection policy. Some staff have covered social services training regarding abuse. Mencap also provides training regarding abuse as part of induction and foundation training. One member of staff does not have a POVA check and this must be obtained as a priority. Until disclosure is obtained the member of staff must receive appropriate levels of supervision as outlined in the current guidance. Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 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 the following standard(s): Sunnydene generally provides a suitable environment for people living there. However improvement is required to make the upstairs shower, and path at the side of the building, more accessible for people with mobility problems. The home is clean and hygienic. EVIDENCE: The building was inspected. The home is generally well maintained, pleasantly decorated and well furnished. However some of the external decorations will soon require some attention. For example some of the woodwork needs repainting before rot sets in. The pathway from the rear of the building around to the front needs to be paved. Service users with mobility problems use this route in the event of a fire. The upstairs shower has a large lip, which makes it unsafe for people with mobility problems to use. This issue must be addressed. The building was clean and hygienic on the day of the inspection. Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Staffing levels appear to be appropriate to meet the needs of service users so service users can feel assured their needs will be met. Recruitment procedures and checks are generally satisfactory. Staff training is satisfactory. EVIDENCE: Rotas suggest there are appropriate numbers of staff on duty i.e. two staff first thing in the morning, evenings and at weekends. The registered provider has a suitable strategy to ensure 50 of staff are qualified to have a National Vocational Qualification in care. The registered persons have a suitable recruitment procedure, and generally appropriate recruitment information has been obtained for staff. However one member of staff has not received a Protection of Vulnerable Adults check, and this must be obtained as a matter of priority. Several staff files were inspected. Staff appear to have received training, which is required by regulation (e.g. fire, manual handling, first aid, food handling, infection control). Training records however need tidying, as audit is currently difficult. Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40, 41, 42, 43 The registered persons ensure the effective management of the home, and suitable systems are in place to evidence this. However suitable control measures to prevent Legionella must be put in place. EVIDENCE: Mencap has suitable quality assurance policies in place. The registered persons facilitated a survey of the views of various stakeholders regarding how the service is managed. The survey ascertained the views of service users, staff, external professionals etc. Responses were very positive. Mencap has a suitable range of policies and procedures. Although suitable records are generally maintained, systems for recording information regarding service users should be rationalised. For example each service user has 3 files, and this could be simplified. Mencap has a suitable health and safety policy. Suitable procedures are in place to test fire prevention, gas and electrical equipment, and there is satisfactory evidence that testing is completed. For example portable appliance Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 Page 18 testing was completed in August 2005, and gas appliances were tested in June 2005. Although a risk assessment has partly been completed regarding the prevention of Legionella, this needs to be completed and suitable control measures put in place. The previous requirement is subsequently renotified. Summaries of budgets and expenditure were inspected. These show the home is financially viable. Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 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 3 3 3 X 3 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sunnydene Score 3 3 X 3 Standard No 37 38 39 40 41 42 43 Score X X 3 3 3 2 3 DS0000009227.V264159.R01.S.doc Version 5.0 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 YA6 Regulation 15 Requirement Timescale for action 01/03/06 2 YA24 2 YA24 3 YA23YA34 3. YA42 All service users must have a care plan, which is reviewed regularly. (Deadline of 01/09/05 not met Second Notification.) 16, 23 The upstairs shower must be adapted to improve accessibility for people with mobility problems. 16, 23 The pathway at the side of the building must be paved. This is used as a fire escape route by people with mobility problems 12, 13,19, All staff must receive a 37 Protection of Vulnerable Adults check. Appropriate levels of supervision must take place, in line with the current guidance, until the disclosure is returned. 12, 13, 23 Suitable measures must be taken to prevent health and safety risks to staff and service users. I.e.: 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. DS0000009227.V264159.R01.S.doc 01/09/06 01/09/06 01/03/06 01/05/06 Sunnydene Version 5.0 Page 21 (Deadline of 01/09/05 not met Second Notification.) 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 Refer to Standard YA1 YA5 Good Practice Recommendations A copy of the service user guide should be issued to service users’ next of kin / representatives The registered manager should check with the housing association that the issuing of a licence agreement to one service user was correct. Other service users have been issued with a tenancy agreement offering more security of tenure. Reorganise staff training files Rationalise and reorganise service user files. The outside of the building needs painting. 3 4 5 YA35 YA41 YA24 Sunnydene DS0000009227.V264159.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection St Austell Office 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. 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