Inspection on 04/07/06 for Sussex House

This inspection was carried out on 4th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 21 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 03/07/07

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 Stephen Robertshaw Unannounced Inspection 4th July 2006 09:30 Sussex House DS0000064150.V304154.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.V304154.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.V304154.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 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 (24) of places Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2006 Brief Description of the Service: Sussex House is a residential care home registered for 24 service users in the category of mental disorder. 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. The home have applied to the Commission to vary their registration as approximately 50 of the service users are now close to or over 65 years old and wish to remain in the home were they believe their needs are being well met. Two new proprietors have been approved by the Commission to support the current proprietor in the management, administration and running of the home. The proprietors have applied to the Commission to be re-registered for the care of service users over the age of 65 with mental health problems due to the increasing ages of the current service users. The current fees for the home are £329. There are no top up fees at the home. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of the site visit there were nineteen service users living at the home. The site visit was unannounced and took place on the 4th July 2006. The inspector was at the home for approximately seven hours. The evidence for this report was gathered through talking with ten of the service users, two visitors, three staff, the manager the home and from the returned preinspection questionnaire, contact with service users’ social workers and through returned staff and service user questionnaires. The pre-inspection questionnaire had been returned to the Commission before the site visit took place. The service users’ experiences at the home appeared to be very positive saying that all of their needs could be met there and it provided a homely and friendly environment. What the service does well: What has improved since the last inspection? Much of the home had been redecorated. Some service users had their bedrooms completely redecorated and new carpets fitted. They said that this made them feel it was ‘more like home’. The home’s statement of purpose and service user guide had been updated to include the details of all of the home’s proprietors. This means that the service users or their carers have access to the proprietors if they wish to contact them. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 6 The dining tables had been supplied with new tablecloths and these appeared to be better condition than the ones previously in use at the home and this results in service users experience at mealtimes being more pleasurable. The frequency for staff supervision has improved. This means that the manager of the home can make sure that the staff understand and provide what support each of the service users need at the home. 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. Sussex House DS0000064150.V304154.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.V304154.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 The quality outcomes in this area are adequate. This judgement has been made through evidence gained both during and before the visit to the service. This means that the service users have their needs assessed before they are admitted in to the home but greater detail could be included to identify how individual needs affect service users’ lives. EVIDENCE: The home’s statement of purpose and service user’s guide include all of the relevant information and they have been updated to include the details of the new proprietors that have joined the management team of the home. At the time of the site visit there were nineteen service users living at the home and the inspector case tracked the care of three of the service users. All of the files seen included a full assessment of their needs completed before they were admitted in to the home. The assessment of the service users needs were a combination of the homes pre-admission assessment and where appropriate care management assessments and care plans. The home’s preadmission assessments have improved in quality and content since the last inspection. However they still need to be developed further to identify how individual service users’ needs effect their daily lives and the support that they require to allow them to lead a safe, meaningful and stimulating life. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 9 Where risks were identified to service users or others through their behaviours there were clear risk assessment and management plans in place and these were reviewed on a regular basis where appropriate through multi-disciplinary teams. The care management assessment of needs and care plans were generally in position in individual care files and were up to date. The inspector spoke with ten of the service users and two visitors to the home they all confirmed the evidence that the home can meet the assessed needs of the service users. One service user stated that Sussex House ‘was like home’ and was ‘the best place I have ever lived’. Observation of the service users and staff at the home supported the evidence that they have good working relationships between them. Service users said that the staff are able to meet all of their needs and they were very responsive to the service users. Sussex House does not provide intermediate care to the service user group. Respite care service users that are admitted in to the home are only admitted after their needs are recognised as being able to be met at the home and that they are within the homes registration with the Commission. Service users confirmed to the inspector that they had been given the opportunity to visit the home before they were admitted to see if it suited their needs. One service user stated that ‘my social worker and family looked at the home for me, I didn’t want to visit because I was not well enough’. The home’s policies and procedures and statement of purpose identify that the service users have a ‘settling in period’ of up to three months at the home. This allows them time to decide if the home is going to be right for them and to make sure that the service users gets along with the other service user living at the home. All of the case files seen by the inspector included terms and conditions of service users placements at the home provided through their placing authority and also terms and conditions provided through Sussex House itself. The management of the home have made an application to the Commission to alter their current registration to older people with mental health problems due to the increasing ages of the current service users. Sussex House DS0000064150.V304154.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 The outcomes in this area are adequate. This judgement has been made through evidence gained both during and before the visit to the service. This means that the service users’ care needs are identified and a care plan is usually developed from their assessment of need. This needs to be improved to include care plans for all service users including those at the home for respite care. EVIDENCE: The inspector observed the care files for three of the service users living at the home. Two of the service users were in long-term care and the third service user was at the home for a period of respite care. The service users that were at the home on a permanent basis had care plans that were clearly associated to the needs identified in their original assessments. The service user that was placed at the home for respite care did not have a care plan that had been developed by the home, but the file did include a care plan form the placing authority. The inspector contacted the social worker that had made the placement and they stated that they were sure that the home Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 11 was able to meet the needs of the service and on their visits to the home they were very happy with the care that they observed being given to the service users. The social worker said that the home kept them up to date with the service users progress and how the care management care plan was being worked with. The placing social worker stated that the placement was made in an emergency and that the home may not have had the opportunity to develop their own care plan. The service users are encouraged to maintain and develop their personal lifestyles at the home. This is supported through their ability to make choices in what they become involved in on a daily basis and times to rise from and retire to bed. Service users spoken to by the inspector stated that they were not forced to do anything that they didn’t want to do. One service user said to the inspector, “We can choose to do what we want at Sussex House, sometimes it is quiet and boring but other times there are lots of things you can choose to do.” Service user meetings are held at the home to allow the service users to make their opinions known in relation to the services provided through the home. These meetings are only attended by a small number of the residents however they are infrequent and should be held on a more regular basis. The home has an activity co-ordinator and they speak with individual service users to identify what hobbies and interests they have and what activities they would like at the home. Service users manage their own finances unless their care plan recognises that they have a representative that supports them with their finances. The individual care plans were supported where appropriate by risk assessments that had been developed through multi-disciplinary teams. The plans minimise any risks that the service users may pose to either themselves or others. Service users spoken to by the inspector were aware of their care plans and risk assessments. Service users are encouraged and supported by the home to access mainstream activities in the community. The staff at the home that work with the service users maintain confidentiality in relation to the care that they provide. Staff interviewed by the inspector were aware of the limitations of confidentiality and when this could be breached including when information received by them could place service users or others at risk. Service users families consulted by the inspector were not invited to meetings where decisions are made in relation to the care of their relatives. Sussex House DS0000064150.V304154.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 The quality outcomes in this area are good. This judgement has been made through evidence gained both during and before the visit to the service. This means that the service users are encouraged and supported to maintain and develop their personal lifestyles at the home. EVIDENCE: The home has a good history of reintegrating service users back to living in the community with appropriate support. Staff training is linked in to the needs of the service user group. Evidence seen in the service users’ case files and discussions with service users supported the fact that the service users are encouraged to maintain and develop their social emotional, communication and independent living skills while resident at the home. The staff stated that they support service users to access training and education in the community. None of the service users spoken to by the inspector were currently involved in any training or education in the Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 13 community but some did confirm that they had previously been involved in training and education at local venues but no longer wished to attend them. Care plans showed the support individual service users required to access the local and wider communities. Service users stated that staff support them to access the community if they don’t feel that they can do this for themselves. The home appears to have good relationship with its neighbours and a summer fete is planned in the grounds of the home in the near future. The neighbours had been invited to this as well as the wider community. Most group activities outside of the home use public transport or taxis as the hoe does not have its own transport. Family members spoken to by the inspector stated that ‘the home always keeps us informed of any changes in’ the service users health and invites them to any reviews of their care and that they could always see their family in private. The carers said that they are always made to feel welcome when they visit the home and that the staff were always friendly and patient and understood the needs of the service users. The daily routines in the home are very flexible. This includes what and where to eat, and times to rise from and retire to bed. Staff were observed knocking on service users doors and awaiting permission before entering them. Service user case files identified their preferred term of address and service users spoken to by the inspector confirmed that the staff always refer to them in the way that they want. They also confirmed that they have open access to all parts of the home and its grounds. Since the last inspection there have been two anonymous complaints in relation to the meals that are provide at the home. None of these complaints were upheld. On the day of the inspection a nutritious meal was provided and the inspector ate with the service users. Service users confirmed that if they didn’t like the main meal provided then an alternative would be provided for them. One service user said that the meals at the home were ‘like eating at a top class hotel’. There were no complaints from any of the service users in relation to the quality of meals that are provided at the home. The mealtime was observed to be unrushed and relaxed. Service users confirmed that this was the usual practice in the home. Sussex House DS0000064150.V304154.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 The outcomes in this area are good. This judgement was made through evidence gained both during and before the visit to the service. This means that the service user personal and healthcare needs are generally met at the home but the staff training records need to clearly identify that they receive the training to meet the care needs of the service users. EVIDENCE: The service users spoken to by the inspector stated that the staff support them with all of their personal and healthcare needs at the home. The service users confirmed to the inspector that when they are seen at the home by visiting Healthcare professionals they are always seen in private unless they request a member of staff to support them. One of the service user case files seen by the inspector recognised the homes frequent contact with healthcare professionals and a lack of positive response due to the ladies mental health problems being attributed to all of her ‘health problems’. Regardless of this the staff at the home where persistent in an attempt to ensure that the service users received the appropriate support and care to meet her needs. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 15 Visitors to the home informed the inspector that when their family members healthcare needs changed they were informed and kept up to date with any developments. The times for getting up from and retiring to bed, and bath times are all in conjunction with the service users’ wishes. The staff were observed working with the service users in a professional and friendly manner. Their training records did not clearly identify that the staff received the appropriate training to make sure that the service user needs could be met in the home. There is a keyworker system at the home and the service users that were spoken to by the inspector were aware of who their keyworker was. When questioned about keyworkers one-service users said ‘ they are your special worker who understands you and helps you get the things that you need’ . Service users’ individual care files identified when they had any contact with professional healthcare workers. All of the staff that administer medication to the service users have received accredited medication training. This practice minimises any risk of service users being given the wrong medication. The inspector observed medication being given out and all appropriate legislation and good working practices were followed. The medication records for three of the service users were observed by the inspector and they were all up to date and were accurately recorded. All of the care files observed by the inspector included the service users last wishes in the event of their deaths. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality outcomes in this area are adequate. This judgement has been made through evidence gained both during and before the visit to the service. This means that the service users are able to raise any concerns about the care or services available to them at the home, however relatives were not clear of the procedure to follow. EVIDENCE: The home has a clear complaints policy and procedure. Service users spoken to by the inspector were aware of how to make a complaint if they needed to and they showed confidence that they believed that the complaint would be dealt with appropriately. In the last twelve months there have been two referrals to the protection of vulnerable adults team. Both referrals were anonymous. The first report was that the manager of the home was never available and the quality of the meals provided at the home were of a poor quality. The investigation supported the manager of the home and her working practices and also supported the quality of the meals that are provided. The complaint was not upheld. The second referral was still under investigation at the time of the inspection so this will be reported in the next inspection report. Some of the concerns raised by the complainant are similar to the complaints made in the first POVA investigation. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 17 Service users relatives comment cards returned to the inspector showed that they are not aware of how to make complaints to the home. Staff receive adult protection training that is provided through the local authority. Staff also confirmed to the inspector that protection of vulnerable adults training is included as part of their NVQ’s in care. The staff interviewed by the inspector were aware of what could constitute suspected abuse and the process of how to appropriately report their suspicions. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 The quality outcomes in this area are poor. This judgement has been made through evidence gained both during and before the visit to the service. This means that in general the homes environment is appropriate to the service users there is still room for improvement. EVIDENCE: The home has existing recommendations and requirements for the environment that are outstanding from previous inspections. The extractor fan in the smoking lounge is in urgent need of repair or replacement. When working it is so loud the television cannot be heard and therefore the service users usually switch it off. This means that the smoke from their cigarettes hangs around as a ‘fog’ in the room. The fire door in the main lounge still has not been repaired. The outer frame of the door is considerably rotted. The registered person must make sure with the fire service that this exit is safe to use and appropriate repairs or replacement must be made within a short period of time. The additional handrail that was recommended has not been included in the stairway down to the cellar. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 19 The carpet cleaner in the home was broken. As there are service users living at the home with continence problems it is important that the carpet shampooer is either repaired or replaced to ensure the service users are free from infection. The outside of the home requires painting. The paint has peeled of much of the woodwork. The lighting in the home could be improved. The dining room lighting is poor and is not domestic in character. The lighting is provided in this area by strip lights. The glass light shade in from one of the lights in the main lounge was missing as it had been broken. The bathrooms of the home had all been fitted with new liquid soap dispensers and the bathrooms and toilets were very clean and free of any offensive odours. The home has a small team f domestic staff and they work very hard to maintain the quality and freshness of the environment. The home does not have a dedicated budget for the maintenance and renewal of the facilities provided at the home. The manager stated to the inspector that as part of the homes quality assurance and monitoring programme she was developing questionnaires for the service users and their families in relation to the refurbishment and redecoration of the home. All of the service user rooms are on the ground floor with the exception of two rooms on the first floor. Only one of these was occupied at the time of the inspection The bathrooms, toilet and communal areas are all close to the service users individual rooms. The inspector was invited to see five of the service users’ bedrooms. These had all been decorated and furnished to their own tastes and preferences. This supported the evidence that the service users are provided with choice in relation to how they had their individual rooms and what they included for example small items of furniture, personal photographs, pictures and ornaments . The home does not have CCTV. Therefore the service users’ privacy is not compromised either inside or outside of the home. The quality of the furnishings in the dining area and the smoking room are adequate. The homes maintenance and renewal plan should identify the timescale for when these areas will be improved. Service users said to the inspector that the dining chairs were ‘uncomfortable’. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 20 The mobility aides in the home were evidenced to be serviced and maintained on a regular basis. The laundry facilities are kept clean and tidy and the washing machine is programmable to disinfection and sluicing standards. The home also has a manual sluice but this is rarely used. Infection control policies and procedures in the home ensure the safety of the service users. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 The outcomes in this area are poor. This judgement has been made though evidence gained both during and before the visit to the service. This means that the staff have good working relationships with the service users and understand their needs however they are not provided with the recommended minimum formal recorded supervision. EVIDENCE: The staff at the home clearly understand the needs of the service users. Interviews with the staff and observation of their personal and training files showed that they receive the appropriate mandatory training, and specialist training in relation to the needs of the service users. The manager of the home states that the residential forum is used to determine the staffing levels for the home. The pre-inspection questionnaire completed by the manager showed the staffing hours provided and these did not equate to the recognised formula and showed a severe shortfall in the staffing hours that are required at the home. It would appear that the hours to be taken in to consideration for the layout of the building and the special needs of service users were not included in the homes calculations. Service users and relatives comment cards stated that ‘sufficient’ staff numbers are always available at the home. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 22 Staff stated to the inspector that the manager was always available to offer them advice outside of their routine supervision. Frequency of staff formal recorded supervision has improved at the home since the last inspection however the staff are still not receiving the recommended minimum of supervision per year. This is an outstanding requirement and must be improved to make sure that the staff have the support that they require to meet the needs of the service users. There are no volunteers working at the home. All care staff working at the home had recently received their annual appraisal of their work with the homes manager. Interviews with staff and discussions with service users and visitors supported that the staff have the competencies and qualities to meet the needs of the service users. The manager does not have a formal system to identify when staff are required to undertake mandatory training. The manager should develop a training matrix so that she can instantly identify when updated training is required for individual members of her staff. The staff recruitment procedures for the home follow all of the appropriate legislation and guidelines and includes equal opportunities and appropriate security vetting. Staff training records observed by the inspector showed that they had undertaken recognised induction training. Regular staff meetings are held at the home. The records for these meetings were observed by the inspector. These meetings give the staff the opportunity to offer their opinions and views in relation to the care and services provided through the home. General staff meetings are held on a weekly basis. The records from one of these meetings recognised that a new hot water boiler was needed and it was replaced immediately following the meeting. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 and 43 The quality outcomes in this area are poor. This judgement was made through evidence gained both during and before the visit to this service. This means that the management of the home supports the needs of the service users however there is no evidence of the homes financial viability or the continuation of service provision. EVIDENCE: The manager of the home is a qualified nurse. She is currently working towards the Registered Managers Award. This is now being undertaken with a different external training agency due to the lack of support offered to the manager by the previous provider. Some of the delay can also be attributed to the time taken up by the manager’s business administration duties at the home. The managers attitude towards the RMA appears to be much more confident and committed to the course. The manager maintains her nursing registration by joining in with the training provided to the staff group. She is a qualified SRN and SEN. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 24 Much of the manager’s time is taken up with the administration of the home and this impinges on her contact with service users and staff. The manager’s office is very small and does not allow the room and quiet required for completing some of her tasks. Therefore at times she works at home to complete the administration tasks for Sussex House. The staff’s weekly wages continue to be manually calculated on a weekly basis. For the manager to complete this for all of the staff working under her can take up to two days of her working week. The manager does not receive any formal supervision provided through the external management team. This must be introduced to identify any training or support that she may require to effectively manage and run the home. The home did not have a business and financial plan that was open to inspection. Therefore it was not possible to validate the financial viability of the service. This also makes it difficult for the manager of the home to budget for any renewal and refurbishment that is required in the home as there is no dedicated budget for this. The two anonymous complaints to the home both refer to the manager never being available. Discussions with service users and visitors to the home and contact with outside professionals supported the manager of the home saying that she was available and that her approach was open, positive and inclusive for the service users. Service user meetings are held at the home to identify what their opinions are in relation to the services that they receive or would like to receive. These meetings are infrequent and would benefit from being on a more regular basis. The home has a quality assurance and monitoring system. This system is a bought in package. Questionnaires are sent out to service users and outside professionals. When these are returned they should be appraised and an action plan should be developed form the findings and these records should be published. The inspector observed the home’s policies and procedures. These provided evidence that they are evaluated on an annual basis to make sure that the still met the needs of the service users and the service itself. All of the records required by regulation were up to date and were accurately recorded. The fire fighting appliances in the home were well monitored and are serviced on an annual basis. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 25 Service user stated that when they use the call bell system the staff are always quick to respond. The service records were available for the system and supported the evidence that they are well maintained. There were appropriate maintenance records for the lift maintenance, and the electrical installations safety certificate and gas safety certificates were up to date. The home also has appropriate contracts to deal with the disposal of their controlled waste. Appropriate insurance cover was also identified to be in position for the home. The external management of the home do not undertake regular regulation 26 visits to the home. The registered person must make arrangements for the safe disposal of sanitary and continence wear at the home. Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 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 3 2 1 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 1 33 1 34 3 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 2 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 1 3 1 3 3 1 1 Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 27 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 YA2 Regulation 14.1a Requirement Timescale for action 30/08/06 2. YA2 14.1b 3. YA6 15.1 The registered person must ensure that the homes preadmission assessments needs to include more information to clearly identify the service users needs and how they will be met at the home. These must also be included for all service users admitted to the home for respite care. The registered person must 30/08/06 ensure that when service users are funded through care management then the care management assessment of care needs and care plan is available at the home. The registered person must 30/08/06 ensure that all of the service users living at the home have individual plans for the care and services to be provided by the home and these are agreed by the service user or their representative. The registered person must ensure that service users families/carers (where appropriate) are invited to DS0000064150.V304154.R01.S.doc 4. YA6 15.1c,d 30/08/06 Sussex House Version 5.2 Page 28 attend the reviews of their care at the home to offer their support and personal opinions. 5. YA24 YA42 23.2p The registered person must ensure that the extractor fan in the smoking lounge is repaired or replaced. The registered person must ensure that the fire door in the lounge is assessed by the fire service in relation to its safety and appropriate repairs or replacement must be carried out. The registered person must ensure that a second handrail is fitted to the stairs leading down to the cellar to ensure the health and safety of the people using them. The registered person must ensure that a minimum of 50 of the care staff have achieved NVQ 2 or equivalent. (Previous timescale of 31/07/06 was not met). The registered person must ensure that the manager of the home maintains a training matrix that clearly identifies the training requirements of the staff. The registered person must ensure that the residential formula is used appropriately to calculate the hours required for staff to be on duty at the home. The registered person must ensure that all care staff receive formal recorded supervision a minimum of the DS0000064150.V304154.R01.S.doc 30/09/06 6. YA24 YA42 23.2b 23.4b 30/07/06 7. YA24 YA42 13.4 a 30/09/06 8. YA32 19.5b 30/11/06 9. YA32 19.5b 30/10/06 10. YA33 18.1a 20/07/06 11. YA36 19.5a,b,c,d 30/12/06 Sussex House Version 5.2 Page 29 recommended six times per year. (Previous timescale of 01/05/06 was not met). 12. YA37 9.2a,b i, ii, 3i The registered person must make sure that the manager of the home receives the appropriate supervision and support required out to run and manage the home in the best interests of the service users. 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 was not met). The registered person must ensure that the home has an effective quality assurance and monitoring system that supports the needs of the service users living at the home. (Previous timescale of 01/06/06 was not met). The registered person must ensure the safe disposal of sanitary and continence wear at the home. 30/12/06 13. YA37 9.2bi 30/11/06 14. YA39 24.1a,b 30/11/06 15. YA42 13.3 16.2k 30/08/06 16. YA43 25.1.2a,b,c, The registered person must 30/08/06 d ensure that the home has an up 25.3a,b, c to date business and financial plan that supports the financial viability of the service 26.1 The registered person must ensure that regulation 26 visits to the home are carried out on a monthly basis. 30/08/06 17. YA43 18. YA43 23.2b,d 25.3a,b,c The registered person must 30/08/06 ensure that the home has an up to date refurbishment and DS0000064150.V304154.R01.S.doc Version 5.2 Page 30 Sussex House renewal plan and has a dedicated budget for this. 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 YA8 Good Practice Recommendations The registered person should ensure that service user meetings are held more regularly at the home and that the meetings are recorded. The registered person should consider changing the dining chairs for a more comfortable substitute. The registered person should make visitors to the service aware of the homes the complaints policy and procedure. The registered person should make sure that the outside woodwork of the home is painted. The registered person should ensure that the home has appropriate cleaning equipment for the home including an appropriate carpet cleaner/shampooer) The registered person should consider changing the lighting that is provided in the dining area and repair the lighting in the lounge. 2. 3. 4. 5. YA17 YA22 YA24 YA24 6. YA28 Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sussex House DS0000064150.V304154.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!