Inspection on 03/07/07 for Sussex House

This inspection was carried out on 3rd July 2007.

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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sussex House 14/09/09

Sussex House 15/09/08

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 09/07/2008.

CARE HOME ADULTS 18-65 Sussex House 36 Princes Road Cleethorpes North East Lincs DN35 8AW Lead Inspector Ms Matun Wawryk Unannounced Inspection 3rd July 2007 09:30 Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 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 Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 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. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 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.V345021.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staff receive the appropriate training to meet the needs of service users that have mental health problems that are under 65 and also training to meet the mental health needs of over 65s 10th April 2007 Date of last inspection 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. Service users’ 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 service users 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. Information given by the manager at the visit on the 3rd July 2007 indicates the home charges £345 per week. The home does not currently charge third party top-up fees. Service users are expected to pay for hairdressing, private chiropody treatments, toiletries and newspapers/magazines. More up to date information on fees and charges can be obtained from the manager of the home. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the homes first key inspection of 2007/08. The site visit took place over 1 day in July 2007, Mrs Matun Wawryk carried out the visit. At the time of the visit there were twenty-one people living at the home. Prior to visiting the home the inspector sent out survey questionnaires to a number of residents, staff and six professional staff to try and establish whether the residents’ needs were being met. Eight residents and seven staff returned a questionnaire at the time this report was written. Some of the comments received by these people have been included in the report. During the visit the inspector spoke to six residents, the manager, three care workers, the cook and one visiting relative to find out how the home was run and if the people who lived there were satisfied with the care and facilities provided. The inspector also looked around the home and looked at lots of records, for example; resident care plans and risk assessments, daily records, supervision schedules, menus, and other records relating to the running of the home. Information received by the Commission over the last few months was also considered in forming a judgement about the overall standards of care within the home. What the service does well: There was a very relaxed and homely atmosphere in the home, residents were observed to be very settled and comfortable in their surroundings. All of the residents who returned a questionnaire and those spoken to said they were satisfied with the overall care provided at the home. One resident said ‘ cannot fault the place’; another resident said ‘Sussex House is a very good care home, excellent meals, very clean’. Residents said they had good access to professional medical support when needed. Residents also said that they were able to access external services such as chiropodist and opticians as needed. Residents said they were offered a good choice of meals and that they enjoyed the quality of food. Specific wishes were catered for and residents said they had plenty to eat and drink throughout the day. Comments from residents included ‘excellent food’, ‘the food is lovely’. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 6 Residents said their family and friends were made to feel welcome by staff when visiting the home and that they can visit when they please. One visiting relative said they were always made welcome when visiting the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 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.V345021.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have their needs assessed prior to admission to the home to ensure staff can meet their needs. The admission process was through with staff ensuring that new residents are made to feel welcome and secure. EVIDENCE: At the time of the site visit there were twenty-one people living at the home. Three residents files were looked at, the manager had obtained a copy of the local authority assessment/care plan for two people. An internal needs assessment had been completed for the third person. The assessment had not been signed by the person completing it and was very basic. Internal needs assessments are completed by the manager and care manager. The care manager had not received any specific training in how to complete needs assessments. It is important that this training is now provided to ensure staff have the necessary skills and knowledge to undertake this role competently. There was nothing to show that resident’s or their Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 9 representatives were formally advised that the home could meet their needs, this must now happen for new admissions. Some people spoken to were aware that an assessment of their needs had taken place and that a care plan had been formulated to meet their needs. Staff in interview confirmed that they understood the admission process and were aware of the importance of ensuring new residents were made to feel welcome and secure. The majority of residents spoken to said they had received sufficient information about the home to help them make an informed choice about the service before accepting the placement offer. Some residents said they had chosen the home for reasons such as: the friendly atmosphere, the location and the friendliness shown by the staff. One person said ‘ I was brought here by my social worker to see the home and talk to the staff before I made the decision to stay’, it’s the best home I’ve been in’. The manager should consider looking at the admissions process as part of the homes quality assurance programme to determine the level of resident satisfaction with their experiences of these processes within the home. This will help the manager to assess if the home and staff are achieving the aims and objectives for the service. The manager reported that both self-funding and publicly funded residents were given a contract/statement of terms and conditions and files examined contained a signed agreement. Residents can have a choice of staff gender when deciding whom they would like to deliver their care, as the home has one male care worker as well as female staff. The manager said that she would discuss this with prospective residents during the assessment process. Residents and one relative spoken to said they were satisfied with the care being given, they felt the staff had the right skills and experience to look after people living in the home and that they were able to meet the needs and expectations of those receiving care. Information from the Pre-Inspection Questionnaire completed in April 2007 and discussion with the staff and observation on the day indicates that all the residents living in the home are white/British. The manager said staff would be able to support individuals with specific cultural or diverse needs following a needs assessment being completed. And where necessary additional training and guidance would be provided to staff to enable them to be responsive to the resident’s needs. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s personal needs are met. Individual care plans were generally well developed and took account of the person’s needs and preferences. EVIDENCE: Case tracking took place for three residents. The methodology used was a physical examination of care plans; written surveys to resident’s, health and social care professionals and direct observation on the day. Since the last inspection new documentation to record peoples care needs (care plans) had been introduced. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 11 The manager reported that all the care plans had been rewritten since the last inspection in July 2006. Care plans examined generally contained sufficient information to tell staff what care people needed. Individual plans were supported by written risk assessments some of which had been developed through multi agency teams. Records showed staff completed monthly evaluations of care plans with the involvement of residents. Plans were updated as people’s needs changed. The manager confirmed Care programme Approach (CPA) reviews were up to date. However records did not evidence that everyone living in the home had had a formal internal review of their care plan, involving the person using the service and other interested parties (where appropriate). Arrangements must be put in place to ensure formal reviews are carried out at intervals specified in the persons care plan. All the residents spoken to confirmed that they were aware of their care programmes and risk assessments, with most saying that they had no interest in reading them. All the residents and those who returned a questionnaire said they liked living in the home and were satisfied with the standards of care provided, they considered that the staff listened to them and always treated them with dignity and respect. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 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): 12, 13, 14, 15, 16 and 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are enabled to keep in contact with family and friends and residents receive a healthy and varied diet according to their assessed needs and choices. Residents have access to activities, but further improvement is needed to ensure all residents have access to a range of meaningful and stimulation activities suited to their individual needs and aspirations. EVIDENCE: Staff said the routines of the home are planned around the resident’s needs and wishes. All the residents spoken to said that they felt staff listened to them and said they were able to exercise choice in aspects of their life and Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 13 daily routines. In discussion staff displayed a good knowledge of individual resident’s needs, likes/ dislikes, family support and records contained information about people’s and religious observances. Residents confirmed that they are able to choose how to spend their day, what clothes to wear and which visitors to receive. Residents said their family and friends were made to feel very welcome when visiting the home. This was confirmed in discussions with one relative. The relative said there were no restrictions on visiting times The home employs a part time an activity co-ordinator and this person is responsible for arranging the activity/ entertainment programme. Due to staffing difficulties this person has had to cover the care rota and this had has had a detrimental impact on the provision of activities in the home. The current activity programme included bingo, quizzes, games, nail care and occasional outside entertainers. Three residents spoken to said they were happy with the level of activities on offer in the home, two people said they sometimes got bored and one person said ‘there was little for them to do in the home’. Comments received indicate staff need to look in more detail at peoples social stimulation needs to ensure daily activities are tailored to the individual wishes, needs and capabilities of some resident’s. The manager stated that she was aware that activities provision in the home needed further development and confirmed that the activity co-ordinator was in the process of reviewing the programme. The home provides three meals a day and a light supper. The cook said there were no restrictions on what food could be ordered. A choice of food is not available at dinner, although the cook and staff said if someone did not like what was on the menu an alternative would be provided. All the residents spoken to and those who returned a survey confirmed that the home provided a good standard of meals, which the residents enjoy. Comments included ‘ the food is excellent’, another said ‘meals are plentiful and there is a good variety of food served by staff who are very good’ another person said ‘very satisfying meals’. The inspector noted that residents had to ask for salt and pepper on their meals. This matter was discussed with the manager, who stated said salt and pepper pots were not provided due to health reasons. This practice restricts the choice and independence of some residents and the manger should address this with the residents. The home caters for people on diabetic diets. The manager and cook both said other specific dietary needs would be accommodated where this was needed. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements for meeting the health care needs of residents are good and personal support is provided in a way, which respects the residents right to privacy and dignity. Some medication processes may put resident’s health and welfare at risk if not addressed. EVIDENCE: The residents spoken to stated the staff supported them with all of their personal and healthcare needs at the home. All the residents were registered with a GP and records showed residents had access to chiropodists, dentists and optician services, with records of their visits being written into their care plans. Where necessary residents were accompanied to attend outpatient’s appointments. Residents spoken to and those who returned a questionnaire said they are satisfied with the level of medical support given to them. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 15 Residents spoken to 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 and the manager reported that only staff who have completed medication training administer medication. The pre inspection states that procedures are in place for medication. Medication systems were examined at this visit. Generally medication was being managed appropriately however there were a number of areas where improvement was needed. Staff were sometimes handwriting medication (transcribing) on to the medication administration record (MAR), a second member of staff was not witnessing the entry to confirm the information was correct. In order to ensure proper safeguards are in place a second member of staff should witness all hand written annotations on the MAR. Staff were not always signing the MAR to confirm quantities of medication received into the home. It is important that staff fully complete the MAR record to ensure the safety of residents. Staff use an authorised code on the MAR when medication had not been administered. On several medication records an ‘o’ had been written in red ink, (‘o’ denotes medication not administered for other reasons). Care records did not reference specific reasons for none administration and the monthly evaluations of care plans did not give reasons for this. It is important that a clear reason is given so there is accurate information on how a person is taking their medication. The precriber who may wish to review the medication, may also use this information. The manager gave an assurance that she would address this matter with staff. There was list of the names of staff authorised to administered medication, but specimen signatures had not bee obtained, the manager was advised to obtain signatures. As a matter of good practice the inspector also advised that patient information leaflets of medication supplied be obtained from the dispensing chemist and that these be kept in the medication cupboard. This will provide staff with up to date information on medication prescribed for each resident. There were no controlled drugs in current use at the time of the visit. Medication was being stored in a trolley in one of the rooms. The room was very warm on the day of the inspection; staff were not monitoring the temperature of medication stored in this area. The manager is advised to routinely monitor the temperature of the medication trolley/storage area. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 16 Medicines must be stored at a temperature that does not exceed 25 degrees Celsius, the maximum temperature recommended by most manufacturers. A number of old medication records had been put in a draw. These are important documents and should be filled appropriately. The manager gave an assurance that she would address this with the person concerned. Others areas of medication management in relation to receipt, storage and stock control were appropriate and effective. Residents spoken to confirmed that care was provided in a way that respected their privacy and dignity. The inspector observed staff speaking to residents in an appropriate and caring way. Analysis of the surveys received together with discussions during the visit identified that everyone was very satisfied with the quality of care provided at the home and the attitude of the staff; comments included “ I am impressed with the carers at Sussex House’ another person said “all the staff are very kind and helpful’. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints system was in place and residents and staff can be assured complaints and concerns will be listened to and acted upon. A safeguarding procedure was in place supported by a staff-training programme. EVIDENCE: The Commission had not dealt with any complaints about the home since the last inspection carried out in April 2007. Following the June 2006 inspection the manager had revised the homes complaints and procedure and had given a copy of this to all the residents to ensure they were aware of the complaints process and to ensure they knew how to raised concerns and complaints. Staff spoken to said they had no complaints about the home and felt confident to raise issues of concern if they arose with the manager. All the residents spoken to and those who returned a questionnaire confirmed that they knew who to report concerns or complaints to. One visiting relative spoken to also said they were aware of the complaints process. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 18 Information from the Pre-Inspection Questionnaire and discussion with the manager indicated the home had policies and procedures to cover adult protection and prevention of abuse and whistle blowing. Training records identified most staff had had adult abuse training and further training was planned. All the residents spoken to said they felt ‘safe’ in the home. When asked about abuse, what it was and what they would do if they suspected or saw or suspected any abuse staff stated that they would report it to the manager or senior care worker. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The design and layout of the home enables residents to live in a clean home, although some redecoration and refurbishment is needed. Whilst these matters do not pose a health and safety risk they do not ensure residents live in an attractive home. EVIDENCE: Since the last inspection several bedrooms had been decorated and some beds had been replaced and chairs in the small sitting room had been replaced and new dinning room furniture and chairs had also been purchased. Staff commented that the dinning rooms chairs were not suitable for some residents. The inspector noted that some residents did appear to struggle a bit Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 20 when sitting and rising from the chairs for example; some residents had to support themselves using the tables when getting up from the chairs. Following issue of the draft report an assurance was given that higher chairs would be purchased for those people needing one. A tour of the home was carried out and all areas seen were clean and tidy and the home was free of any offensive smells and odours. All the residents spoken to said they home was kept clean. Eight residents returned a questionnaire in response to the question ‘is the home kept clean’, all of the residents said always or usually. Comments included ‘ the home is always clean’. Furnishings, fittings and décor in some areas of the home are showing signs of wear and tear. Carpets in a number of bedrooms were worn and marked and external windows needed painting. The front entrance needed redecoration and the hallway carpet was marked and damaged in places. Whilst these matters do not pose a health and safety risk they do not ensure residents live in an attractive home. The owner of the home submitted a renewal plan for the home following the last inspection. Because of this no requirements have been made about the homes environment. Implementation of this plan will be checked at the next visit. All bedrooms seen were clean and tidy and many people had furnished their rooms with a range of personal items, to reflect their own individual choice and taste. The pre inspection questionnaire states that a fire risk assessment is in place. During the tour of the home the inspector noted that a number of the bedroom doors did not close properly. The manager gave an assurance that she would take action to address these matters as soon as possible. Staff in interview confirmed adequate supplies of protective clothing. Equipment provision was also discussed and staff said there were appropriate mobility aides in the home to enable resident’s needs to be met. Records showed that equipment and aids are serviced and maintained to the appropriate standards to ensure their safe use. Two residents were unable to have a bath because a bath hoist was not fully operational. The manager stated that quotes had been obtained for replacement of this piece of equipment. Because of this a requirement has not been made The home is built on two floors with flat walkways inside and out, providing safe and secure footing for people with limited mobility. Access to the upper floor is by use of a passenger lift and staircase. Entrances to the small sitting room and downstairs bedroom corridor are rather tight for people using larger wheelchairs. Residents spoken to said they had not experienced any particular problems with their laundry, and all said cloths were washed and ironed appropriately. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 21 Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although residents are generally satisfied that the care provided meets their needs a review of staffing is needed to ensure staffing levels match the dependency levels and numbers of people living in the home. Staff received training opportunities and supervision, but further improvement is needed. EVIDENCE: The roles and responsibilities of staff are clearly defined and in discussion with the inspector staff demonstrated understanding of the management and reporting structures for the home. The manager of the home stated that the Residential Forum Guidance is used to calculate staffing hours. Based on the information set out in the pre inspection questionnaire completed in April 2007, the numbers of care hours Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 23 provided for twenty residents was 323 hours per week. At the time of the visit there were twenty-one people living in the home. The manger reported that three staff are normally on duty between 8am to 5pm, this is reduced to two staff between 5pm and 8pm. Two staff are on duty at night. This would indicate that the home provides 299 hours. This indicates a review of staffing was needed based on assessment of the dependency levels of people using the service, preferably using a recognised dependency tool; this will enable accurate judgements to be made about the homes staffing needs. In interview staff said staffing levels were generally satisfactory. Seven staff returned a survey. In response to the question ‘are there sufficient numbers of staff on duty to enable residents needs to be met’ six said yes and one person said no. Turnover was low with three staff having left the home in the last twelve months. Evidence from surveys and discussions with residents during the visit confirmed that they were generally satisfied with the care they received. Residents commented on how kind and supportive the staff were. One resident said ‘ I am very pleased with the care at the home, another person said ‘I am very happy with the staff. They make me laugh and always listen to me’. Comments from other residents included ‘staff to busy to sit and talk’, ‘ staff always busy’. The home remains committed to providing National Vocational Qualification training for staff. The pre inspection questionnaire indicated 50 of care staff are now trained at level 2 or above; which is a positive achievement and the manager said other staff had been enrolled to complete an award. The manger said the home had an equal opportunities policy and procedure, although the inspector did not examine this. Feedback from the manager, staff and information in personnel and training records showed the procedure is followed when employing new staff and throughout the homes working practices and staffs access to training. Employment records for three staff appointed since the last inspection were examined and these were found to be in good order. Files contained the relevant documentation to comply with Schedule 2 of the Care homes Regulations and showed staff had only commenced working in the home after relevant police checks and references had been obtained. New staff are provided with an induction and the manager had an induction programme which meets Skills for Care Common Induction Standards specification. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 24 Most staff were up to date with essential safe care training for example moving and handling and health and safety training. However records evidence gaps in the provision of fire safety training. It is important that this training is now provided to ensure the health and safety of both residents and staff. Records showed some staff had not received any specific mental health training related to the needs of people living in the home and staff spoken to did not have a developed understanding of Care Programme Approach (CPA) arrangements. This is needed to help care workers deliver up to date care methods and to ensure have a better understanding of the varied conditions common to people living in the home. Failure to provide this training may mean staff do not have all the knowledge and skills they need to meet the needs of residents and this could impact on the care they receive. The manager was aware of what aspects of the programme needed to be developed and reviewed. The manager stated that she hopes to accomplish this within the next few months. A staff supervision programme was in place and all staff had a named supervisor and there was evidence that supervision practice had improved since the last inspection. However there were gaps, examination of a sample of records showed not all staff were accessing the required amount of supervision sessions (six) within twelve months. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. A competent manager manages the home and management practice is based on openness and respect. Arrangements are in place to ensure people are consulted about the running of the home, although further improvement is needed. The management of health and safety was generally satisfactory but deficiencies in some areas may put residents and staff at risk if not addressed. EVIDENCE: The manager is a qualified nurse and has many years experience of working in the home and was in the process of working towards the Registered Managers Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 26 Award. The manager attributed the delay in achieving the award to the time taken up by administration duties at the home and because of problems with the training provider. The manager did not have an individual training record setting out what training she had had, it is important that one is now put in place. The owners of the home meet regularly with the manager and it was reported that action points are recorded. The manager was not able to show the inspector supervision records which reflect all aspects of practice, training and career development needs. It is important that the owner addresses these matters more formally with the manager. This will ensure the managers personal development and support needs are clearly identified and ensure plans are in place to address any identified needs. Staff confirmed that moral was good and commented that there was a good team approach to the care delivery at the home. Evidence from staff interviews and staff surveys indicated that staff consider the manager and senior staff to be approachable. Staff said they take issues raised seriously and take action to resolve matters where this is needed. The home had a brought in procedure for quality assurance and monitoring. This consisted of a self-assessment tick box system; the manager had completed a number of the sections but a few areas still needed to be assessed. All the areas seen in the manual had been assessed as met or exceeded. The manager reported that questionnaires had been issued to residents, but responses had not been collated and analysed. The manager also stated that questionnaires had also been sent out to staff but not many had been returned. It is important that survey information is collated so that where applicable areas needing improvement are identified and action plans put in place. It is important that the manager can demonstrated how the service is meeting the needs of residents. The manager now needs to produce an annual development plan, which identifies the quality areas of improvement from 2007/08 and clearly set out the standards to be achieved in this year and ensure this information is made available to residents, their relatives and relevant third parties. A summary of which must be included in the service user guide. A requirement detailed in the last inspection report concerning a need to make available a business and financial plan that was open to inspection had been met. Information given by the manager in the pre inspection questionnaire indicated that there are a range of policies and procedures in place for health and safety. Safe working practices are maintained by the provision of training to staff in Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 27 the form of moving and handling, basic food hygiene, basic first aid, infection control and fire safety. Training records evidenced that not all staff had current received fire safety training. It is important that this training is now provided to ensure staff know what is expected of them in the event of a fire in the home. Not all staff responsible for completing risk assessments including those for moving and handling had received relevant training. It is important that all staff responsible for completing risk assessments receive training, training must be relevant to the area of risk being assessed. This is needed to ensure staff understand how to identify and plan for any identified risks. The pre inspection questionnaire indicated that a fire risk assessment for the home was in place. During a tour of the home the inspector noted that a number of the residents bedroom doors did not close properly, this poses a risk to residents. An immediate requirement notice was not issued because the manager gave an assurance that she would take steps to address the problem. Records showed staff randomly monitored water temperatures form outlets at regular intervals. The provider information questionnaire indicated current certificates were in place for the gas, portable electrical appliances, passenger lift and fixed electrical systems. A record of all accidents was maintained in each residents care file. The manger was monitoring the number of accidents but there was nothing to show any analysis of these to identify patterns and trends. The manger is advised to audits all accidents on a regular basis in an attempt to eliminate or to reduce accident reoccurrence. Two residents had bed rails fitted and individual risk assessments had been completed. The risk assessments were very basic and did not highlight why there was a need for bedrails or the identified risks and how to eliminate or minimise these. There are significant risks associated with bedrail use. In order to ensure the health and welfare residents the manager was advised to review the risk assessments to ensure they address guidance issued by the MRHA and to ensure that regular checks and records of these are maintained. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 3 4 X 5 3 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 X 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 29 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 OP2 Regulation 18 Requirement Timescale for action 31/10/07 2 YA6 15.1c,d 3 YA14 16(m) The registered person must ensure a competent person who has received relevant training completes needs assessment. Assessment records must be complete, accurate and signed. The registered person must 30/11/07 ensure that service users families/carers (where appropriate) are invited to attend the reviews of their care at the home to offer their support and personal opinions. Timescale of 10/05/07 not met. The registered person must 30/10/07 ensure residents have the opportunity to exercise their choice in relation to leisure and social activities; that these choices are recorded and they are offered a range of stimulating activities both inside and out of the home to ensure residents do not get bored and to ensure they are able to take part in meaningful activities. DS0000064150.V345021.R01.S.doc Version 5.2 Page 30 Sussex House 4 YA33 18 (1) 5 YA35 YA32 18 6 YA36 19.5a,b,c,d 7 YA37 9.2bi 8 YA37 YA43 9.2a,b i, ii, 3i The registered person must carry out a review of people’s dependency levels and then review the staffing levels in the light of this review. Completing a full review of people’s dependency levels will enable more accurate judgements to be made about the homes staffing needs. The registered person must produce a written training plan that reflects the needs of older people and those mental health problems. The plan must detail, the training to be provided to staff and the dates of when this training will be provided. Providing staff with better training will ensure they have all the knowledge and skills they need to meet the needs of residents and this will have a positive impact on the care they receive. The registered person must ensure that all care staff receive formal recorded supervision a minimum of the recommended six times per year. (Previous timescale of 01/05/06 was and 10/05/07 not met). The registered person must ensure that the manager of the home has achieved the registered managers award or equivalent. (Previous timescale of 30/06/06 and 30/11/06 were not met). The owners of the home meet regularly with the manager. Its important that supervision records are DS0000064150.V345021.R01.S.doc 31/08/07 30/09/07 30/09/07 30/11/07 30/09/07 Sussex House Version 5.2 Page 31 9 YA39 24.1a,b maintained and these cover all aspects of practice, training and career development needs. The manager now needs to produce an annual development plan, which identifies the quality areas of improvement from 2007/08 and clearly set out the standards to be achieved in this year and ensure this information is made available to residents, their relatives and relevant third parties. A summary of which must be included in the service user guide. The registered person must ensure each member of staff is provided with fire safety training from a competent person. Trained staff will have a better understanding of what to do in the event of a fire and will know what they are responsible for. The registered person must ensure staff fully complete the medication administration record, this includes verifying the quantities of medication received into the home. Where staff are using an ‘o’ code to denote nonadministration of medication, care records should contain information about the specific reasons for this. This is needed to ensure the health and welfare of the person. The registered person must ensure action is taken to DS0000064150.V345021.R01.S.doc 31/10/07 10 OP38 24 (4)(d) 30/09/07 11 YA20 13 31/08/07 12 YA42 23 31/07/07 Sussex House Version 5.2 Page 32 13 YA42 13 ensure all the bedroom doors in the home close properly. It is important that all doors close properly to ensure the safety of residents in the event of a fire in the home. The registered person must 31/07/07 ensure detailed risk assessments are put in place for service users using bedrails. There are significant risks associated with bedrail use. In order to ensure the health and welfare of people, it is important that regular checks are carried out on these and that risk assessments clearly detail the identified risks and the specific actions staff must take to minimise these. 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 YA24 YA20 YA20 Good Practice Recommendations The registered person should make sure that the outside woodwork of the home is painted. The registered person should ensure a second member of staff should witness all hand written annotations on Medication Administration Record charts. The registered person should ensure staff routinely monitor the temperature of the medication cupboard. Medicines must be stored at a temperature that does not exceed 25 degrees Celsius, the maximum temperature recommended by most manufacturers. The registered person should obtain copies of specimen DS0000064150.V345021.R01.S.doc Version 5.2 Page 33 4 YA20 Sussex House 5 YA42 signatures of staff authorised to administer medication. The registered person should analyse accident reports to identify patterns and trends in an attempt to eliminate or to reduce accident reoccurrence. Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Sussex House DS0000064150.V345021.R01.S.doc Version 5.2 Page 35 - 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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