Inspection on 11/09/06 for Sutherland Court

This inspection was carried out on 11th September 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sutherland Court 06/11/09

Sutherland Court 17/08/07

Sutherland Court 06/02/06

Sutherland Court 14/11/05

Sutherland Court 09/02/05

Sutherland Court 14/09/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Snydale Care Home

Whitwood House

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

CARE HOME ADULTS 18-65 Sutherland Court Upper Sutherland Road Lightcliffe Halifax West Yorkshire HX3 8NT Lead Inspector Lynda Jones Unannounced Inspection 11th September 2006 10:00 Sutherland Court DS0000001073.V311616.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 Sutherland Court DS0000001073.V311616.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. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sutherland Court Address Upper Sutherland Road Lightcliffe Halifax West Yorkshire HX3 8NT 01422 203584 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) St Anne’s Community Services Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (7), Physical disability (7), of places Physical disability over 65 years of age (7) Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2006 Brief Description of the Service: Sutherland Court is a care home providing care and support for seven people with learning disabilities. The home is owned and managed by St Anne’s Shelter and Housing Action. The home is in the Lightcliffe area of Halifax, close to shops and other local amenities. The home can be easily accessed by public transport. The house is a large bungalow with two separate living areas. There is internal access to all parts of the house but as the facilities are replicated in both parts of the house the two sides tend to function as separate units. All of the bedrooms are single and each has a wash hand basin. Toilet and bathing facilities are in close proximity. The house is surrounded by a well-kept, enclosed garden. Fees are £452.90 pw; this includes accommodation and all meals. People living at the home buy their own personal toiletries. The fee includes a contribution of £19.00 for use of the homes transport. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgement categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk Sutherland Court was first registered in March 1993 as a care home with nursing, providing accommodation, care and support for seven people with learning and physical disabilities. The same group of men have lived there since the home was first established. The home was set up to provide nursing care for people who moved from Stansfield Hall Hospital and was staffed by a team of nurses and support assistants. Over recent years the abilities of the people living there have developed and their needs have changed. Earlier in 2006 the needs of each person were re-assessed and the findings indicated that the group of men living at the home no longer required nursing care. The registration of the home was changed on 1/8/06; the home is now staffed by a team of support workers and no longer provides nursing care. This visit to the home took place over 4 hours. A pre inspection questionnaire was sent to the home before the visit took place. This provided useful information about Sutherland Court, which has been used in the preparation of this report. During the site visit, discussion took place with the manager and staff on duty. Records were looked at in the office and care practices were observed during the visit. The shared areas, bathrooms and some of the bedrooms were seen. Comment cards were sent to relatives of service users asking for their views about the home. Three relatives provided their views on the home. Service users themselves are unable to complete comment cards because of the complex nature of their disabilities. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The pen pictures and support summaries have greatly improved. Some good information is recorded about the sort of life experiences residents have had, about methods of communication, how to recognise signs of distress and agitation and what action to take to reduce this. The recording against personal objectives has improved. There is now clear, quantifiable evidence showing action taken and progress towards meeting goals. All relatives were invited to comment on the service provided by completing a satisfaction survey about the home. Relatives were invited to join residents and staff at a garden party at the home where they could raise any concerns about the proposed change in the homes registration. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 7 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. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 8 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 Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 9 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): 2,3,5. Quality in this outcome area is good.This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are provided with information about the home to help them decide if it can meet their needs. Appropriate assessments are carried out and everyone has a contract, which tells them about the terms and conditions of residence and fees. EVIDENCE: The organization has an admissions procedure. Most of the men who live at Sutherland Court have been resident there since 1995 when the home first opened, so there has been limited opportunity for the staff to use the procedure. One person has recently begun to stay at the home for weekends and respite periods. Evidence shows that a detailed assessment of his needs was carried out before he took up residence. He was invited to visit the home with a family member and his advocate. He was given the opportunity to meet the other residents and staff and to stay for meals before eventually staying overnight. The records indicate that every effort was made to get to know him; to understand his support needs, his interests and his likes and dislikes and to make sure he felt comfortable in his surroundings before moving in. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 10 A statement of purpose and service user guide is available and everyone has a copy of a license agreement, which includes details of the terms and conditions of residence. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 11 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): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual plans and appropriate assessment of risks makes sure the health and welfare of residents are met. EVIDENCE: A personal plan is in place for everyone living at the home. The plans have been developed in partnership with residents, their relatives and other key providers of support that they come into contact with in their daily lives. Some very good quality pen pictures and individual support summaries have been written. The pen pictures provide information about resident’s families, their life experiences, their strengths and their likes and dislikes. The support summaries are sensitively written and in plain language, they provide an excellent working tool for staff and could be used in an emergency by people who are not familiar with the full content of care plans. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 12 One individual who does not live at the home permanently does not currently have a personal plan at Sutherland Court, his plan relates in the main to his activities at the resource centre, which he attends during the week. This needs to be shared with the home so that staff are working jointly towards supporting him on common objectives. This was discussed during the visit to the home; the manager is aware of this issue and is addressing the matter. Each care plan includes a comprehensive risk assessment. It is regularly updated and includes details of any action needed to respond to changes in the assessment. The management of risk takes into account the specialist needs of people who use the service, balanced with their need for independence and choice. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to take part in appropriate activities both in the home and in the community on a regular basis. EVIDENCE: The home has a set number of hours each week to provide leisure activities for all of the residents. During August, the allotted number of leisure hours was not always achieved. The manager said that this was now back on target and had been met the week prior to this visit. Each person’s goals and interests are set out in their personal plan. The records indicate that residents are involved in meaningful daytime activities, which suit their interests and capabilities. Two people go to the local college, one person is attending a reminiscence group covering memories of Brighouse, and another person whose personal objective is to improve skills in food preparation is planning to start a cookery course at college. One individual, who stays at Sutherland Court at weekends and for periods of respite, attends Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 14 a community resource centre during the week then returns to his family home. At weekends he takes part in planned leisure activities with other residents of Sutherland Court. A significant improvement was noted on this visit in the monitoring of personal objectives, the records clearly show all of the actions that are taking place to support residents towards achieving their goals. The method of recording is good; it allows progress to measured clearly. The staff have worked hard in this area. The records show that residents are using facilities that are available in the local community. People go swimming; use the hydrotherapy pool and snoezelen and go out to the cinema and pub. Most people go out for meals fairly regularly. Everyone has had the opportunity to have a holiday or to go for days out this year, if that is their preference. Wherever possible residents are involved in the domestic routines of the home. They are consulted about the meals they prefer, objects of reference are used to assist one person in making a choice about meals. The staff know individuals very well and they have a good understanding of what people prefer to eat. The menu is varied and consideration is given to healthy eating options. The meals are balanced and cultural and dietary needs are catered for. Halal meals are currently bought in already prepared, ready for cooking. There are plans to change this and prepare these meals at home in future. Residents have the opportunity to develop and maintain important personal and family links. Friends and family are always made welcome at the home; this was confirmed in the comment cards received from relatives. The staff support residents to send greetings cards to members of the families on special occasions. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide sensitive and flexible personal support. The health of residents is assessed and reviewed to make sure that individual needs are not overlooked. Appropriate procedures are in place for the, receipt, storage, administration and disposal of medication. EVIDENCE: Systems are in place to ensure that residents receive effective personal and healthcare support. The personal plans clearly record individual needs in these areas and detail how these are to be met. The support summaries provide information about how much prompting people need with their personal care. Where this is provided by staff, there is sufficient information to ensure that personal care can to be provided consistently, in a way that suits each resident. Some very good information is provided about methods of communication and what certain sounds may be indicative of. There are clear instructions for staff about the importance of Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 16 speaking calmly and clearly to one resident with a limited vocabulary. Valuable information is recorded about indicators of pain and distress expressed by individuals who do not communicate verbally and about distraction techniques that can be used to calm situations. There has been a big improvement in these records since the last inspection. Each individual has a personal health action plan. A system of OK Health Checks is in use, the records examined were found to be up to date. Each personal files includes details of all contacts with health care providers, records show the reasons for contact and the outcomes of all appointments. Everyone living at the home has access to all NHS healthcare facilities in the local community, regular appointments are seen as important and systems are in place to ensure they are not missed. Medication systems at the home are well managed. All staff have recently received training from Boots on the monitored dose system that is used at the home. Staff who are new to medication administration have received supervision in this area from the manager, some staff that do not work full time are not yet administering medication. Sutherland Court DS0000001073.V311616.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are protected from abuse and have their rights protected. EVIDENCE: The service has a complaints procedure that is up to date and clearly written. According to the information provided by the manager there have been no complaints over the last twelve months. Two out of three relatives said they did not know about the complaints procedure, they also went on to say that they had never needed to complain. It would be useful to take steps to remind people about the procedure. St Anne’s regularly arranges training of staff in areas of protection. The records show that this training is regularly updated. From speaking to staff it is apparent that they are aware of their responsibilities in this area. Sutherland Court DS0000001073.V311616.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): 24,25,26,27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, wellmaintained and comfortable environment. EVIDENCE: The bungalow at Sutherland court was purpose built to provide accommodation for this group of residents. It is close to community facilities and services in Lightcliffe. The home is well maintained; any repairs that are needed are promptly dealt with. The attractive gardens around the property are well kept, a range of chairs, tables and sunshades are available outdoors. The garden is safe and staff said it was really well used during the summer months. The home is fully accessible throughout. The home is well lit, clean and tidy and smells fresh. The house is divided into two separate living units. Each side of the house has a lounge, dining and bathing facilities. A corridor connects both areas but they tend to function as two separate houses. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 19 All of the bedrooms are single and each one is individually furnished and decorated to meet the needs and tastes of each resident. There is plenty of evidence to show that everyone has lots of their own personal possessions around them. People are free to use their rooms at any time of the day if they wish. There are sufficient bathrooms for the number of people living at Sutherland Court and these are equipped with specialist bathing facilities to meet people’s needs. There are sufficient toilets to enable immediate access. There is a policy on infection control and this is adhered to. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is currently adequately staffed in terms of staff numbers. Continuity of care will be improved when a permanent team is established. EVIDENCE: On 1/8/06 Sutherland Court ceased to provide nursing care. The nursing staff that were in post have moved to work in other St Anne’s homes. The home is now staffed by support workers, some of whom worked at the home prior to the change in the registration. Additional support workers have been recruited to make up the homes required staff compliment. Not all of the new staff are in post, as some of the required checks have not yet been completed. The Provider Relationship Manager for the Commission for Social Care Inspection examined a sample of St Anne’s staff files in April 2006. Recruitment practices were generally found to be good, with references and Criminal Records Bureau checks taken up before new staff start work. At the time of this visit to the home the shortfall in staffing hours was covered in three ways, existing staff were working additional hours, St Anne’s bank staff were providing cover and agency staff were also covering some of the shifts. The manager said that the same bank staff and agency staff were used as far as possible because they knew the residents well and were familiar with Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 21 their support needs. The manager felt that this arrangement was working well and it allowed time to “stagger” the start dates of new staff, making their introduction to the home more manageable. All of the new staff that had already commenced employment had been supernumerary to the rota when they first started work, so that they could get to know people. Everyone undertakes an “in house” induction during the first six weeks of employment. Two relatives raised concerns about the loss of familiar staff. They said the care provided at the home had always been good and they hoped that this would continue in the future. The period of change had been unsettling and they said they were looking forward to having a team of permanent staff at the home. This was discussed with the manager who understood the issues raised. He said he had spent time meeting and talking to relatives about the changes at the home. He assured relatives that he was always contactable and was at the home most days if they wanted to talk about any concerns they had. The manager provided details of all of the training that staff have attended and details of updates of all mandatory training courses. Plans are in place for induction training for all staff that are new to the service. Staff who have started work recently are scheduled to take part in LDAF (Learning Disability Award Framework) training in the coming weeks. All staff receive regular supervision from the manager. Staff on duty said they were well supported by the manager. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 22 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is qualified and competent to run the home. The management of the home is based on respect and openness. The views of relatives and other care providers about the way the home is run are welcomed. EVIDENCE: The manager of the home is not yet registered with the Commission for Social Care Inspection in respect of Sutherland Court. He has made an application to be registered and this is being processed. The manager has the required qualifications and is competent to run the home. He is a qualified nurse with several years experience of working with people with learning disabilities. He has worked in various homes managed by St Anne’s in the Calderdale area over the past thirteen years, providing care and support for people with learning disabilities, complex health care needs and challenging behaviours. He moved to this post in May 2006 from a management position in another St Anne’s home. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 23 The manager is person centred in his approach, he offers support and encouragement to staff and provides the team with regular supervision. He works to continuously improve the service and to provide an increased quality of life for residents. The service has a comprehensive set of policies and procedures, which are reviewed regularly. Details of implementation and review dates were provided with the pre inspection questionnaire. Systems are in place to ensure that staff follow procedures during their practice. There is a health and safety policy in place. The home has a good record of meeting relevant health and safety requirements, regular checks are carried out around the home, any repairs are reported to St Anne’s and promptly dealt with. Relatives and other representatives of residents are consulted about the way the home is run. “Satisfaction Surveys” can be found in the entrance area and visitors to the home are asked to complete them. The surveys were recently sent out to relatives because of the change in the service, five responses had been received up to this visit taking place. These indicate that relatives are quite happy with the quality of the service provided. One relative raised an issue about an aspect of care practice, which was addressed immediately. The manager is available most days at the home, he is very open and actively welcomes comments about the way the home is run and any improvements that can be made. Within the service there is a good understanding of equality and diversity issues, there is evidence that staff are able to translate this into positive outcomes for people who use the service. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 3 3 X Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA14 YA22 Good Practice Recommendations A copy of the personal plan should be obtained in respect of the person who resides at the home on a temporary basis. The manager needs to ensure that the requisite number of hours are allocated for leisure activities. The manager needs to ensure that all of the relatives know about the homes complaints procedure. Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Sutherland Court DS0000001073.V311616.R01.S.doc Version 5.2 Page 27 - 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. 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