Inspection on 17/08/07 for Sutherland Court

This inspection was carried out on 17th August 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sutherland Court 06/11/09

Sutherland Court 11/09/06

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 Key Unannounced Inspection 17th August 2007 09:15 Sutherland Court DS0000001073.V342588.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.V342588.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.V342588.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) areaoffice@st-annes.org.uk www.st-annes.org.uk St Anne’s Community Services Mr Gerard Wainwright 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.V342588.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Learning disability over 65 years of age - Code LD(E) Physical disability - Code PD Physical disability over 65 years of age - Code PD(E) 2. The maximum number of service users who can be accommodated is: 7 11th September 2006 2. Date of last inspection Brief Description of the Service: Sutherland Court is registered to provide nursing care and accommodation for seven adults with a learning disability. St Anne’s Community Services, a charitable organisation, manages the home. The home is in the Lightcliffe area of Halifax, it is on a bus route and close to shops and other local amenities. Accommodation is provided in two large adjoining bungalows. 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 near to the bedrooms and the lounges. The house is surrounded by a well-kept, enclosed garden. Fees are £452.90 per week; 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 home’s transport. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection of the home took place on 11 September 2006. We have not made any visits to the home since then. This inspection was carried out to assess the quality of care provided to people living at the home. The inspection took place over approximately 2.5 hours. During the visit I talked to the manager, looked at various records and looked round the home. The manager completed a self-assessment form before the visit took place and the information provided has been used in this report. Surveys were sent to the relatives of people who live there, to an advocate who acts on behalf of one person and to the local GP practice; these provide an opportunity for people to share their views of the service with us. Six completed surveys were returned to us. Comments made in the surveys are shared with St Anne’s without revealing the identity of those completing them. What the service does well: Sutherland Court is a friendly, very well managed home that is run in the best interests of the people living there. Relatives of the people who live there value the work of the staff. The approach of the team is focused on the needs of the people who live there. The staff provide appropriate support to individuals and encourage people to be as independent as possible. These are some of the comments that people made about Sutherland Court in the surveys they returned to us: “Great care was taken to discuss and take on board his needs, likes and dislikes and details about daily routines before he moved in” “Every person is treated as an individual and with respect” “From what we have seen, they do the best they can for residents” “They keep in touch and look after our relative” “ I have arrived unexpected and found everything as I would expect” Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 6 “ I can’t fault them” What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sutherland Court DS0000001073.V342588.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 Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,5. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service are appropriately assessed before they move into the home; this is to make sure that their needs can be met. EVIDENCE: Most of the men who live at Sutherland Court have been resident there since 1993 when the home first opened, so there has been limited opportunity for the staff to use the admissions procedure. One person has been staying at the home for weekends and short breaks since last year. The records show that a detailed assessment of his needs was carried out to make sure Sutherland Court was suitable for him. He visited the home a few times before he first stayed overnight; this gave him the opportunity to meet the other people who live there and the staff. The records show 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. This is supported by the comments we received in the surveys. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 9 A Statement of Purpose and Service User Guide is available and everyone has a copy of a licence agreement, which includes details of the terms and conditions of residence. This means that everyone is provided with information about their rights and responsibilities. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Personal plans and appropriate assessment of risks makes sure people’s health and welfare needs are met. EVIDENCE: Everyone has a personal support plan which shows step by step what their needs are and how their care and support should be delivered. The detail included in the plans helps to ensure that staff are consistent in their approach and that they assist people in a way that suits them best. Some people don’t like changes to their routine and this is important to them. The plans are regularly reviewed. This makes sure that the changing needs of people living at the home are continually met. I looked at two plans and both were found to contain good detail about how to support people to meet their health, personal and social care needs. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 11 The records show that genuine attempts are made to consult people about the sort of support they need. Relatives told us that they are invited to attend review meetings and they feel that their views are taken on board. In the surveys they said people’s needs are being met and they felt that people are receiving the support that they required. Some excellent work has been carried out to produce “Listen to me” workbooks which help to identify individual needs and choices. Staff are skilled at communicating with people who live there, they understand what certain behaviours might mean and have recorded this information. This is helpful because some people are unable to tell staff how they are feeling. Everyone is encouraged to be as independent as possible and to develop new skills. People are also supported to take reasonable risks. The records show that risks are assessed appropriately and detailed information is available showing what steps staff should take to minimize risks. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People have plenty of opportunities to take part in a range of leisure and social activities. EVIDENCE: There has been an increase in the amount of activities people are involved in outside the home in the last 12 months. This means that everyone has access to a range of leisure and social activities that they enjoy. The sorts of activities that people enjoy or want to try are highlighted in their personal planning meetings. This means that staff can then support people to work towards their personal objectives. Each person has a leisure diary where details are kept of all the things they have done. A daily record is also kept which shows how people have spent their day. These records help staff to see what progress is being made towards objectives. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 13 Everyone makes regular use of local community facilities such as cafes, pubs, local shops, library and health care practice. People are encouraged to keep in contact with their families. The manager said every effort is made to create an inviting and friendly atmosphere and to be welcoming to the families and friends of people who live there. In the surveys, relatives said the staff are polite and friendly and they are made to feel welcome. A number of parties and events have been held over the year to which friends and family have been invited. The manager acknowledged that the friendships people have tend to be with staff and other people who they share the house with. He felt that people would benefit from increased opportunities to develop relationships beyond this and identified this as an area that could be improved upon. People are helped to eat a healthy diet and there is plenty of choice available at mealtimes. Efforts are made to make sure that the menus reflect personal choice and preferences. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People’s health care needs are assessed and reviewed regularly to make sure that individual needs are not overlooked. Personal care is given in accordance with individual preferences. EVIDENCE: Everyone has an annual “OK Health Check”, this is a recognised tool to help ensure that people’s healthcare needs are identified .It is reviewed every year to make sure that everyone is receiving the service and support that they need. Everyone also has a healthcare action plan showing what their personal needs are and how these will be met on a day-to-day basis. The records show details of all contacts with health care providers and the outcome of all appointments. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 15 There are individual support guidelines for everyone’s personal support needs. These are well written and easy to follow and should ensure that people receive support in a way that best suits them. The staff who give out medication have all received relevant training. They check all medication that comes into the home carefully and make sure it is safely stored. People have all the specialist adaptations and equipment they require to make sure they are safe and comfortable at all times. All personal care is given in private, and people are treated with dignity at all times. Relatives told us they are always kept informed about important issues such as accidents and outcomes of doctor’s appointments etc. They said the staff are good at keeping in touch with them. Sutherland Court DS0000001073.V342588.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People are protected by the procedures and practices in the home and they are safeguarded from harm. EVIDENCE: The home has a complaints procedure, which is included in the service user guide. It provides information about the procedure to follow and the correct contact details. Everyone who completed a survey told us they knew how to make a complaint. One person said when a concern was raised with the manager it was addressed straight away and fully discussed with the family. The manager said staff have regular training on adult protection issues. There is a ‘whistle blowing’ procedure for staff, which gives details of their responsibilities to report any instances of bad practices observed or suspected. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,29,30. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People live in a safe, well-maintained and comfortable environment with specialist equipment to meet their needs. EVIDENCE: Sutherland Court is purpose built to provide accommodation for people with learning disabilities and physical disabilities. It comprises of two interconnecting semi detached bungalows. 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. The home is fully accessible for wheelchair users and there are adaptations to meet the mobility and personal care needs of the people living there. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 18 All of the bedrooms are single and each one is individually furnished. People are free to use their rooms at any time of the day if they wish. The bathrooms are equipped with specialist bathing facilities to meet people’s needs. All parts of the house are well maintained, clean, tidy and well lit. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People’s needs are met by a well-supported and competent staff team. People who live there are protected by the thorough recruitment practices. EVIDENCE: Last year the home ceased to provide nursing care. It is now staffed by a team of support workers, some worked at the home prior to the change in the registration. Additional support workers were being recruited at the time of the last visit in September 2006. The home is now appropriately staffed to meet the needs of the people who live there. The staff team work flexibly to meet the people’s social, recreational and personal needs. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 20 All of the new staff have had appropriate induction training and all have received training in areas such as moving and handling, food hygiene, fire safety. This will equip them to carry out their work safely. New staff are now on the Learning Disabilities Award Framework (LDAF) training. Once they have completed their three month probationary period they will have the opportunity to undertake NVQ level 3. This makes sure that people living at the home are cared for by suitably trained and qualified staff. People who completed the surveys said they felt that the staff had the right skills and experience to look after people properly. All of the people living at the home are protected by the home’s recruitment procedure. All staff are subject to the necessary Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. An application form is completed and two written references are taken up before an offer of employment is made. This is to make sure that prospective staff are suitable for this type of work and to make sure the people who live there are safe. All staff have access to regular supervision from the manager and deputy manager, they also have an annual appraisal. This helps to make sure their training and development continues to meet the individual and joint needs of the people who live there. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People live in a well run and well managed service. People’s health and welfare are protected by the home’s health and safety practices. EVIDENCE: The manager is registered with the Commission. He 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 Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 22 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. The management team make every effort to ensure that the home is run in a way that reflects the needs of the people who live there. Relatives and other representatives of residents are consulted about the way the home is run. “Satisfaction Surveys” are sent out periodically throughout the year to relatives and health and social care providers asking for their views on the service provided. In the self-assessment completed by the manager, he said there have been many changes in the last twelve months. He hopes that having a full staff team will lead to improvements in the running of the home which will directly benefit the people who live there. There is a commitment to health and safety and safe working practices in the home. Policies and procedures are in place to make sure the health, safety and welfare of people who live there is promoted and protected. Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 23 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 X 4 4 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 X 26 X 27 3 28 X 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 4 3 3 X 3 X Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 24 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. 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. Refer to Standard Good Practice Recommendations Sutherland Court DS0000001073.V342588.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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