Inspection on 14/11/05 for Sutherland Court

This inspection was carried out on 14th November 2005.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sutherland Court 06/11/09

Sutherland Court 17/08/07

Sutherland Court 11/09/06

Sutherland Court 06/02/06

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 14th November 2005 1:00 Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sutherland Court Address Upper Sutherland Road Lightcliffe Halifax West Yorkshire HX3 8NT 01422 203584 01484 559936 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.V272250.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2005 Brief Description of the Service: Sutherland Court is a care home providing nursing care and support for seven men with physical and 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. One side accommodates three men; four men live in the other side of the house. 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. Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out by two inspectors and took place over 2.45 hours. Staff training records, medication records, service user plans and personal money records were examined. Discussion took place with the manager who was on duty. What the service does well: What has improved since the last inspection? What they could do better: Personal plans must be improved. The plans that were examined did not reflect the current needs, aspirations and goals of service users. Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 6 New service agreements must be in place and plans must be updated when reviews have taken place. The records, which chart the progress service users make towards achieving their personal objectives need to be improved. Records should include information about the preferred daily routines of individuals, their methods of communication and information about the way they prefer to receive personal care and support. Healthcare records need to be improved to show how individual needs are monitored and how these needs are to be met. The men who live at Sutherland Court should be able to be weighed in their own home. Individual activities should take place when scheduled for service users. 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.V272250.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. An appropriate admissions procedure is available. EVIDENCE: The organization has everything in place to meet these standards, however as all of the men who live at Sutherland Court have been resident there since 1995 when the home first opened, there has been no opportunity for the staff to use the admissions procedure. 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.V272250.R01.S.doc Version 5.0 Page 9 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. The personal plans that were examined were not satisfactory and require urgent attention. EVIDENCE: The key to providing an individually appropriate lifestyle is the service user plan; this should put the service user at the centre of the service delivered by the home. The plan should reflect the needs, aspirations and goals of each individual. It should set out the services that will be provided by the home to meet each person’s needs and should reflect the developments and changes in the lives of each individual. The plans that were examined at Sutherland Court were unsatisfactory. Three reviews of plans took place in July 2005; a manager from another St Anne’s home chaired the review meetings. Revised service agreements arising from the reviews have still not been forwarded to the home. The plans that were examined did not reflect the current needs, aspirations and goals of the three service users. This is not acceptable. Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 10 Some of the objectives listed on plans should be part of the day to day care provided at the home, for example, “to promote continence”, “to improve mobility”, “to improve leisure activities”. “To have quality time with staff taking part in activity”. These should be part of the general expectations of the service provided and not objectives that individuals should need to strive for. Other objectives had not been recorded against, for example, to attend hydrotherapy sessions – no record of this since April 05; to go 10 pin bowling – no record of this since July 05; to go to snoezelen – no record of this activity since June 05. It was not clear whether these had ceased to be objectives. One person is expecting to move out of the home into alternative accommodation in the very near future, this will be a major change for this individual. The records failed to show that any planning or preparation for the move had taken place. Discussion took place with the manager about some entries in the daily records. Two recent entries relating to one individual referred to “time out” being given. There were no accompanying behavioural guidelines to explain what this meant, how it took place, how long it lasted. The records show that on these two occasions it followed “episodes of aggression and self injurious behaviour”. The manager said that “time out” in this instance meant that the individual concerned “went to his room to chill out”. It is not clear whether this person went to his room voluntarily. In relation to the service user plan standard 6.5 of the National Minimum Standards states; “The plan establishes individualised procedures for service users likely to be aggressive or cause harm or self harm, focusing on positive behaviours, ability and willingness”. Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Activities have not always been taking place as planned. Service users are supported to keep in contact with their families and friends. EVIDENCE: Service users usually receive support from staff employed by Social Services, to take part in leisure activities. Two staff are usually allocated to the home to provide this service. This arrangement has not been satisfactory in recent months, the home has not been in receipt of all of the hours allotted by Social Services and as a consequence some activities for service users have not taken place. The manager reported that this situation had been resolved very recently by a change in the staffing arrangements. It is expected that all activities will now take place as planned. This will be reviewed at the next inspection. The manager said that all service users are supported to maintain links with their families and friends. Relatives are welcome to take part in personal planning meetings and are kept informed of accidents and any concerns about the well being of service users. Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 12 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 Personal support needs are not recorded in sufficient detail. The records suggest that health care needs are not always met. EVIDENCE: There is insufficient information recorded about the preferred daily routines of individuals, their methods of communication and about the way they prefer to receive personal care and support. It would not be possible for a different group of staff to provide care and support with any continuity if they had to rely on what is currently recorded. Records relating to healthcare were found to be unsatisfactory. One person failed to attend a chiropody appointment in April 05 because there were not enough staff available to accompany him. There was no evidence to show that this had been followed up. It was not possible to tell from the records whether a dentist’s appointment, due in April 05, had been attended. On another personal file it was noted that follow up dental appointments had been made for two dates in March 05, again it was not possible to tell whether these had been attended. There was also no evidence that an optician’s appointment due in August 05 had been followed up. The records indicate that service users are not being weighed regularly. Inspectors noted the concerns recorded by one member of staff regarding the Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 13 visible weight lost by one person living at the home. This individual had not been weighed for six months. There is an urgent need for suitable scales to weigh people at Sutherland Court. At the present time the men who live at the home have to go to another St Anne’s home in central Halifax to be weighed, using scales that are appropriate for them to use. This could be the reason why people are not being weighed regularly. Medication records are well maintained. Details are recorded about how people prefer to take their medication. There were good guidelines for the use of PRN (as required) medication. Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this inspection. EVIDENCE: Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed in detail on this inspection. EVIDENCE: Since the last inspection a new lounge and hallway carpet has been fitted. One bedroom has new laminate flooring and new furniture has been bought for one of the lounges. Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 The staff recruitment process is thorough. Staff training records need updating. EVIDENCE: St Anne’s operates a thorough recruitment process. References are always taken up and CRB checks are carried out for all new staff before employment commences. The home employs eight qualified nurses, including the manager. Five care staff are in post, three have completed LDAF training, two have completed NVQ level 3. The recruitment of two additional care staff is underway. The manager reported that there are always three staff on duty throughout the day. At night there is one person on waking duty with one person “sleeping in”. It was noted that staff supervision and appraisal meetings were booked in advance and appeared on the staff rota. Staff training records are not up to date. It would be helpful if the manager completed a training matrix, which would show at a glance, which training had been undertaken and whether any training needed to be updated. Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38 Record keeping has suffered because of changes in management of the home over recent months. With a full staff team and full time manager this situation should be resolved. EVIDENCE: The registered manager left the home in June 2005. Between July and October the deputy manager was seconded to work in another St Anne’s home and took over as acting manager on his return in October 2005. During his absence, the manager of a nearby St Anne’s home provided managerial support. The manager is aware that some of the records at the home need to be improved. He had already identified a number of the issues raised in this report. Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sutherland Court Score 1 1 3 X Standard No 37 38 39 40 41 42 43 Score 2 2 X X X X X DS0000001073.V272250.R01.S.doc Version 5.0 Page 19 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. 1 Standard YA6 Regulation 15 (1) 15(2)(b) Requirement An up to date comprehensive, person centred plan must be in place for all service users. This must include a behaviour management plan. The plan must show how the service user’s needs in respect of health and welfare are to be met. The home must make appropriate provision to ensure that service users are weighed regularly Timescale for action 31/01/06 2 YA19 15(1) 31/01/06 3 YA19 12(3) 31/12/05 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 YA14 Good Practice Recommendations Arrangements should be made to ensure that all service users have opportunities to take part in leisure activities. Sutherland Court DS0000001073.V272250.R01.S.doc Version 5.0 Page 20 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.V272250.R01.S.doc Version 5.0 Page 21 - 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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