Inspection on 14/09/09 for Sussex House

This inspection was carried out on 14th September 2009.

CQC found this care home to be providing an Good service.

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

Sussex House 15/09/08

Sussex House 03/07/07

Sussex House 04/07/06

Sussex House 08/02/06

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Sussex House 36 Princes Road Cleethorpes North East Lincs DN35 8AW Lead Inspector Stephen Robertshaw Key Unannounced Inspection 14th September 2009 09:00 Sussex House DS0000064150.V377681.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. Sussex House DS0000064150.V377681.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 Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Sussex House Address 36 Princes Road Cleethorpes North East Lincs DN35 8AW 01472 694574 F/P 01472 694574 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) Amina Teja Mr Altaf Hirji, Mrs Nimet Hirji Mrs Anne Hanslip Care Home 24 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (24) Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 2008 Brief Description of the Service: Sussex House is a 24-bedded care home providing for the needs of people with mental health problems. The home does not offer nursing care. Individuals health needs are met with the assistance of other health care professionals for example general practitioners, community psychiatric nurses and district nurses. The home will take permanent residents and those needing short- term and respite care. The building is old and has been extended on several occasions. There is no scope for further development. The accommodation is provided over two floors. There is a passenger lift to the first floor. Sussex House is close to the centre of Cleethorpes and is within five minutes walk of the train station and the beach. Local amenities include shops, public houses, GP surgeries and parks. Regular public transport is easily accessible from the home and is also available to the adjoining town of Grimsby. Information about the home and its services can be found in the statement of purpose and service user guide, Both these documents are available from the manager of the home. The fees for the services provided by the home are £361 per week. The home does not currently charge third party top-up fees. People that live at the home are expected to pay for hairdressing, private chiropody treatments, toiletries and newspapers/magazines for themselves. More up to date information on fees and charges can be obtained from the manager of the home. The quality rating for this service is 2* star. This means the people who use this service experience good quality outcomes. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit took place over 1 day on the 14th September 2009. The Commissions visit to the service was unannounced and we were in the home for approximately six hours. At the time of the visit there were eighteen people living at the home. The site visit and other information gathered since the last inspection have contributed towards this report. This includes the homes Annual Quality Assurance Assessment. During the visit to the home we also spoke with seven of the people that use the service, the manager and deputy manager of the home, four care workers, the cook to help to find out how the home was run and if the people who lived there were satisfied with the care that they received at Sussex House. We also case tracked three people that live at the home. This included looking at all of the written information in the home that was about them and their care. The Commission also looked around the home and the grounds to see what the environment was like for the people that live there. What the service does well: What has improved since the last inspection? Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 6 The care staff receive the right training and supervision to make sure that they have the skills and knowledge to safely look after the people that live at the home. The care plans in the home are much better. This means that they tell the staff how individuals want to be supported with their needs when they are living at the home. 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. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 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 Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 and 5 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. This means that the people that use the service have their needs fully assessed before they are admitted to the home. EVIDENCE: At the time of the Commissions visit to Sussex House there were eighteen people living at the home. The Commission looked at all of the assessment of need information for four of the people that use the service. All of these included a copy of their local authority assessment of need and a preadmission assessment of need that had been completed by the home. The homes pre-admission assessments of need are usually completed by the manager of the home or her deputy. The information in the homes assessment of need was very basic and generic in nature, they did not give any idea of how individuals needs affected their daily lives. However, both the manager and deputy manager of the home stated that a new pre-admission assessment was going to be introduced to prospective new admissions to the home. They Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 9 stated that these would be more personal centered and this would make it easier to develop person centered care to the people that use the service. All of the people that were spoken to by the Commission were aware that an assessment of their needs had taken place and that there care plans had been developed from them The Commission spoke to several people that use the service to determine their thoughts on their admission to the home. One person said that they had chosen to live at the home because of the ‘friendly atmosphere’; another person said ‘the staff and everyone here are friendly, this is my home’. Care files observed by the Commission for both self-funding and publicly funded residents included a contract for their residency and a statement of their terms and conditions. The staff training records and interviews with staff supported the evidence that the staff have all of the necessary knowledge and skills to be able to deliver care to the people that use the service in a safe and professional manner. Information from the services Annual Quality Assurance Assessment completed direct observations and interviews with the management and staff indicated that all the people living in the home are white/British. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 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. This means that the individual care plans in the home support the needs of the people that use the service. EVIDENCE: The Commission looked at all of the individual care plans for three of the people that use the service. The methodology used was a physical examination of care plans, interviews of care staff and people that use the service and direct observation on the day of the site visit. Since the last inspection new documentation to record care needs had been introduced. The care plans were very much improved and demonstrated that Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 11 the home is working in a personal centered way. The care plans were very descriptive and clearly detailed how people wanted to be supported with their individual needs. The individual plans were supported where appropriate by written risk assessments some of these had been developed through multi agency teams. Records in the home demonstrated that the care plans and risk assessments are evaluated on a minimum of a monthly basis. This helps to make sure that they are still appropriate to the individual needs of the people that use the service. There was also evidence to support that the care plans are updated as people’s needs changed. The risk assessments help to support the people that live at the home to live as independently as possible, and also identify the level of support that they require to access the local community or public transport. All the residents spoken to confirmed that they were aware of their care programmes and risk assessments. However most of the people said they weren’t that interested in them and knew that ‘I am well looked after her’. Direct observations on the day of the site visit also supported the evidence that people are encouraged and supported to make decisions for themselves throughout their daily lives at the home. This included what time to rise from and retire to bed, what to eat and where to eat it and whether or not to become involved in any activities that are made available to them. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 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. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12,13,15,16 and 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. This means that people that use the service are supported and encouraged to maintain and develop their personal lifestyles while they live at the home. EVIDENCE: The care staff that were interviewed by the Commission stated that people’s routines in the home are planned around the individual’s needs and wishes. All the people spoken to by the Commission stated that they felt that the care staff listened to them. Direct observations on the day of the site visit and interviews with the people that use the service and the care staff demonstrated that the care staff had a good knowledge of individual needs of the people that Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 13 use the service and this included their likes and dislikes, religious belies and personal hobbies and interests People spoken to by the Commission said that they are able to choose how to spend their days at the home, what clothes to wear and whether or not to join in activities in the home or in the community. A visitor to the home on the day of the Commissions visit was observed to be treated in a warm and friendly manner and it appeared that they were very comfortable with the staff team. The home employs a part time an activity co-ordinator and they are responsible for arranging the activity and entertainment programme. Direct observations of the activities that are available at the home showed that the activities have improved in the frequency and the nature of he services that are provided. One person in the home has sight problems and care staff and other people that use the service were observed supporting them with activities that were suitable to them. The current activity programme in the home included bingo, quizzes, games, nail care and occasional outside entertainers. One person said ‘last week we had a singer in here, I like it when come in to sing with us’ and another person said ‘I don’t like to get involved in activities, they always ask me, but I don’t very often get involved’. The records for the activities could be improved to show how people participated in the activities and say why they didn’t want to be involved in them. The home provides three meals a day and a light supper. Prior to the inspection taking place the proprietor of the service stated that a choice of food was now available at all meal times. However there wasn’t a choice of meal on the menu, however the cook stated that if anyone wanted anything different from the main course then a suitable alternative would be provided for them. People spoken to by the Commission confirmed that if they didn’t want what was on the menu they told the cook and then they would be given something else to eat. One person said ‘the food is excellent here and you always get enough’, another person said ‘I like the meals here’. The Commission looked around the kitchen. It was very clean and was well stocked. The cook stated that additional supplies were being stored at the home in case of supply problems due to a threatened flu pandemic. The local authority environmental health department had recently awarded the kitchen a four star rating. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 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. This that people that use the service can be confident that their personal health care will be supported while they live at the home. EVIDENCE: The Commission looked at the care files for three of the people that were living at the home. These records included their personal and healthcare needs being supported by the home or through their health care partners in the community. All the people that live at Sussex House were registered with a General Practitioner and the health care records also showed that individuals had access to chiropodists, dentists and optician services. The care plans also demonstrated where necessary people were accompanied to attend health care Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 15 appointments in the community. However some of the health care records recorded interventions including blood tests but failed to record any outcomes or treatment that may have been required. The people that use the service that were spoken to by the Commission confirmed that when they were seen at the home by a visiting healthcare professional they are always seen in private unless they requested a member of staff to support them. The home uses a Monitored Dosage System for medication. Staff training records showed that the only people that administer prescribed medication in the home had received appropriate training to safely do this. This was also confirmed in the Commissions interviews with the care staff. Policies and procedures are in place for the safe administration of prescribed drugs in the home. At the time of the site visit there were no controlled medications in the home. The medication systems were examined at this visit. The medication was being managed appropriately and the records were up to date and were accurately recorded. The medication records could improve with the introduction of people’s photographs with their medication records. This would be seen as good practice and would ensure that the right person received the medication that was prescribed for them. This would benefit new staff or agency staff if they were supporting the care being provided in the home. There was list of the names of staff that are authorised to administer medication in the home and specimen signatures had been obtained. This makes it easier to identify who has administered the medication at any time. People spoken to by the Commission confirmed that spoken to confirmed that care was always provided at the home in a way that respected their privacy, dignity and respect. Direct observations on the day of the site visit helped to support the evidence that the staff have very good professional working relationships with the people that they are responsible for. One person said ‘you couldn’t ask for better staff’. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 16 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 and 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. This means that the people that live at Sussex House are protected from abusive situations at the home. EVIDENCE: The home had not recorded any complaints about the service since the last inspection of the service. No complaints had been sent directly to the Commission in relation to Sussex House. The home has an appropriate complaints policy and procedure and people spoken to by us said that they knew how to make a complaint about the service if they had one and also said that they were confident that their views would be listened to and be acted on. One person said ‘I like it here I don’t have any complaints’. A recent admission to the home did not feel comfortable there and his views were listened to and he was moved to alternative accommodation. The homes records and the Commissions records showed that the home had no safeguarding adults referrals made about its services since the last inspection. The service did however have policies and procedures to cover adult protection and the prevention of abuse and whistle blowing processes. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 17 Staff training records showed that the staff receive safeguarding adults training including training provided through the local authority. Staff spoken to by the Commission were all aware of safeguarding issues and how to report any allegations or suspicions of abuse. The homes employment polices and procedures also support the well being of the people that use the service. This includes making sure that everyone has a new Criminal Records check before they have any contact with the people that use the service. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 18 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): 24,25,27,29 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This means that the environment of the home is suitable to meet the needs of the people that use the service, however there are some areas of the home that need to be improved to create a homely and warm environment. EVIDENCE: The Commission made a tour of the premises and the grounds as part of the site visit. The home was free from any offensive odours. The domestic staff do a very good job at maintaining a clean and safe environment for the people that use the service to live in. A handy men is employed on a part-time basis to support the home with its general repairs and refurbishment. There have been some positive changes in the environment since the last inspection, Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 19 however it would appear that the amount of maintenance that the home requires inside and out would be too much for one person to undertake. The manager of the service stated that the provider of the service has suggested that a team of people is introduced to the home over a short period of time in order to complete all of the tasks that need to be done. The external doors of the home have now all been replaced and most of the windows in the home have also been replaced. The manager of the home stated that the maintenance plan for the home includes the remainder of the old windows. This will help to improve appearance to the exterior of the building. It will also help to provide a more homely appearance and environment. The manager of the home also stated that it is the managements plan to develop the gardens to the front and side of the building to create an area that is safe for the people that use the service to access. The communal and corridor areas of the home the décor were showing signs of wear and tear. It is important that these areas are improved to provide a homely and comfortable environment for the people that use the service to live in. The manager stated that the provider was considering how to improve these areas and work would soon begin on them. Three people invited the Commission to look around their individual rooms. All of the bedrooms that were seen were clean and tidy and had been furnished to their own tastes and preferences. This included personal photographs, pictures, ornaments and small pieces of furniture. The manager said that as bedrooms were being redecorated people were given choices in relation to what colour they wanted the room to be and how they wanted it to be decorated. One person told the Commission ‘I chose the colour for my room and the quilt’. The manager of the home stated that the bath hoist is regularly serviced and maintained and was in working order, care staff also supported this and direct observation by the Commission showed that the bath hoist was now working correctly and was being maintained and serviced. The service only has one mobile hoist to help to move and handling individuals with mobility problems. Since the last inspection this piece of equipment had been repaired and was being regularly serviced and maintained to make sure that it was fit and safe to use. There were still plans in the home to convert pone of the homes bathrooms to a wet room. This would allow people to have a greater choice in the way that they wished for their personal hygiene needs to be met. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 20 The home provides accommodation to the people that use the service over two floors. The second floor can be accessed by stairs and a passenger lift. The maintenance records showed that the lift is regularly maintained and serviced to make sure that it is safe and fit for use. Direct observations and the people spoken to by the Commission supported the evidence that the home was always clean and tidy. The homes laundry had been fitted with a new washing machine and dryer. These were observed to be appropriate to the needs of the home. One of the homes toilet floors was badly marked and needed to be replaced to create a safe environment. The manger of the home stated that she was aware of this and quotes were being obtained to replace the floor covering. The home has a very clear and descriptive asbestos management plan. The assessment shows that the asbestos is not a risk to the people that live and work in the service but state that it should not be disturbed. Overall the general environment of the home has improved, however there is much more required to create a homely environment for the people that use the service. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 21 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): 32,33,34,36 and 36 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. This means that the care staff have all of the training and supervision that they need to provide them with the skills and knowledge to safely care for the people that use the service. EVIDENCE: The manager of the home stated that the Residential Forum Guidance is used to calculate the weekly staffing hours for the service. At the time of the site visit there were eighteen people living at the home and the staffing hours that were being provided were appropriate to the needs of the people involved with the service. The people that use the service were very positive about the skills of the staff when they spoke about them. One person said ‘the staff are the best’ another person said’ they help me to do things I couldn’t do by myself’. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 22 Direct observations on the day of the inspection helped to support the evidence that the staff have very good professional working relationships with the people that use the service and the staff have a good and clear understanding of all of the individual needs of the people that use the service. The staffing at the home is fairly consistent with very few people leaving the service and new people starting. Care staff that were spoken to by the Commission said staffing levels in the home were generally satisfactory and that they had time to carry out their roles and responsibilities. On the day of the inspection a member of staff was sick and did not arrive for their morning shift. Another member of staff was approached and came in to the home to help cover the shift. Staff spoken to by the Commission stated that this was the usual practice and only in exceptional circumstances were staffing level low. The manager of the home stated that for a period due to staff sickness and holidays agency staff were used to support the care being provided at the home. She stated that this was not the best use of resources however it meant that health and safety in the home could be supported. The home remains committed to providing National Vocational Qualification training for staff. There are fifteen care staff working at the home. Thirteen of the homes care staff have completed NVQ qualifications in care. This equates to approximately 87 of the staff. The staff should be commended on this achievement. The homes Annual Quality Assurance Assessment also supported this information. The manager of the home stated that staff can also access NVQ 3 in care when they have completed NVQ 2. Staff spoken to by the Commission also confirmed their NVQ status. The staff were very well presented and they all appeared to be very smart in their uniforms. However this may not continue in the future as the management of the home no longer provide uniforms to the staff group, they are expected to pay for their own. As tunics become worn and need replacing there may be some reluctance to do this as the staff have to pay for them themselves. It also means that people may not have clean uniforms as they don’t have a change of uniform and have to wash their only tunic before it is used again. This can cause problems on quick turn around shifts. This could also have an effect of the homes infection control policies and procedures. Following the draft report being issued the proprietor of the service stated that the service supports the staff team to pay for their uniforms over a period of time to ease any financial pressure that this may place on them. The Commission observed the employment records for two of the care staff. Both of these only included one reference. However enhanced Criminal record checks had been obtained. The Commission stated to the manager that the missing references should be followed up and a record should be placed on the staff files to say why they had not been obtained. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 23 New staff are provided with an induction that is tailored towards the needs of the service and the manager also had access to an induction programme which meets the Skills for Care Common Induction Standards specification. Staff training record and interviews with staff showed that they were generally up to date with essential safe care training including moving and handling and health and safety training. The training provided for the staff working at the home is much improved. There was evidence to support that all of the staff had received their mandatory training and specialist training to meet the needs of the people that use the service. This included challenging behaviours and deprivation of liberty. Staff spoken to by the Commission stated that they had received all of the training that was identified on their files. Interviews with the care staff and the management of the service supported the evidence that they all had a clear understanding of the mental health needs of the people that use the service. A staff supervision programme was in place. Management and staff confirmed that everyone working in the home have regular formal recorded supervision to make sure that they have the knowledge and skills to safely care for the people that use the service. To support this system regular staff meetings are held at the home to raise new ideas, policies and procedures, legislation. Staff spoken to by the Commission said that this was a good way for them to get new information. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 24 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): 37,39,41 and 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. This means that the management of the service understands and supports the needs of the people that live and work at the home. EVIDENCE: The manager of the service is a qualified nurse and has many years experience of working in the home. The manager of Sussex house is close to completing the Registered Managers Award. The manager stated that this should be Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 25 completed by November 2009. The deputy manager of the home had already completed the NVQ 4 registered manager Award. The proprietors of the service meet with the manager every month and record any outcomes of the visits. Records of these visits to the home were observed by the Commission. Care Staff spoken to by the Commission continue to confirm the evidence that the moral in the home was very good and said that there was a good team approach to the safe delivery of care at the home. People that use the service were very positive in relation to the skills, knowledge and abilities of the management and the care staff and the manager. One person said ‘the matron is always around and always talks to us, she is very nice’. The home has a policy and procedure for quality assurance and monitoring. This seemed to have improved since previous inspections of the service. Surveys had been sent out to people that use the service and to the care staff. These returned questionnaires had been evaluated and action plans had been developed to support the quality assurance programme. The Commission reaffirmed to the manager of the service the importance of the home having an effective quality assurance system to help with the identification of any improvements that are needed to improve the quality of life for the people that are living in the home. This included surveying outside professionals for their opinions of how services are provided through the home. The Commission also suggested that future questionnaires should use more open questions and not rely on tick box answers that do not necessarily identify individual problems. Current certificates were in place for the fire, gas, portable electrical appliances, passenger lift and fixed electrical systems. The manager of the home needs to make sure that all documents completed in the home that relate to the people that use the service, or the running of the business include full dates and are signed by the people that have completed the documents. The Annual Quality Assurance Assessment that was returned to the Commission was very thoroughly completed and included clear information as to how the service saw how it provided services to people that live at the home. Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 26 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 3 3 3 4 3 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 2 25 3 26 X 27 2 28 3 29 3 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X 2 3 X Version 5.3 Page 27 Sussex House DS0000064150.V377681.R01.S.doc 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. 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. Refer to Standard YA2 Good Practice Recommendations The registered person should make sure that all future admissions to the home have a full and comprehensive assessment of their needs. This will help to make sure that the service has the ability to support all of their individual needs in a safe way. The registered person should make sure that there is a choice of food available at all meal times and the people that use the service are aware of these choices. The registered person as a matter of good practice should introduce a photograph to the medical records. This will help to make sure that the right person receives the medication that is prescribed for them The registered provider should make sure that the renovation and maintenance programme of the home is DS0000064150.V377681.R01.S.doc Version 5.3 Page 28 2. YA17 3. YA20 4. YA22 Sussex House 5. YA37 continued to provide a safe and comfortable environment for the people that use the service. The registered person must ensure that the manager of the home has achieved the registered managers award or equivalent. The registered person should make sure that all documents that are completed by the service are fully signed and dated to help to identify who completed the records and when. 6. YA41 Sussex House DS0000064150.V377681.R01.S.doc Version 5.3 Page 29 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@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. 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. 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