Inspection on 06/02/06 for Sutherland Court

This inspection was carried out on 6th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 1 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 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 6th February 2006 09:30 Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 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.V265890.R01.S.doc Version 5.1 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.V265890.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sutherland Court Address Upper Sutherland Road Lightcliffe Halifax West Yorkshire HX3 8NT 01422 203584 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.V265890.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2005 Brief Description of the Service: Sutherland Court is a care home providing nursing care and support. The home can accommodate 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. Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk The last inspection of the home was unannounced and took place on 14 November 2005. There have been no further visits until this inspection. As a number of standards were assessed at the last inspection this report should be considered together with the last inspection report. This was an unannounced inspection carried out by one inspector over a 3.0hour period. The main purpose of the inspection was to make sure that the home continues to provide a good standard of care for the people who live there. The methods used at this inspection included looking at care records & talking to the acting manager. This is not a particularly positive report. From observing staff interacting with service users it is apparent that relationships at the home are good and it is evident that the staff know and understand people very well. However, the records are poor and fail to demonstrate that service users are being given sufficient support to meet their personal objectives. What the service does well: What has improved since the last inspection? The organisation of information in service user files has improved. Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 Page 6 Staff training information has improved. A matrix has been completed making it is easy to see what training has taken place and where updates are required. 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.V265890.R01.S.doc Version 5.1 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.V265890.R01.S.doc Version 5.1 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): EVIDENCE: Not assessed on this inspection. See last report. Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 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 The personal plans that were examined were not satisfactory and require urgent attention. There is very little evidence that service users are supported to achieve their personal goals. EVIDENCE: The introduction to the National Minimum Standards in Care Homes for Younger Adults with regard to care plans states, “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 do not reflect the needs, aspirations and goals of service users. Since the last inspection all of the files holding the personal plans are better organised. Each one now follows the same format making it easier to access information. Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 Page 10 It was difficult to tell when the last review of the plans had taken place and when the next review was due. The acting manager said one plan was due for review in February 2006 but no date had been set & there was no evidence that any preparatory work had taken place. The recording made against the goals was extremely poor, there appeared to be a lack of evidence to show that objectives had been achieved. On one plan, which appeared to have been reviewed in July 05, six objectives were listed. These included attending a college course, purchasing shopping/toiletries, being supported to go out for a walk, making a drink independently, going on holiday and attending local events. The service user had not attended a college course. A note made in December 05 indicated that the course was full and further enquiries should be made in January 06. It was not clear whether this had been done. Shopping for toiletries – the records suggested that this had occurred once in December 05. Going for a walk – according to the records, this activity had taken place on four occasions. On three of these occasions the service user was accompanied by relatives, not staff from the home. Making a drink independently – as there was no monitoring sheet for this activity there is no evidence that it ever took place. To have a holiday – a note made in December 05 said this had been deferred due to staffing problems. An entry in January indicated that a holiday had been booked for March. To attend local events – The notes indicated that the service user had attended Xmas parties in Halifax. There were no further details. A second plan examined suggested that very little had been attempted to support the service user. The records appeared to show that the last review took place in August 04. The acting manager said the next one was due in March 06. These records were unclear. One objective was to develop an evening activity plan. Seven entries had been made in 14 months. The last entry, made in December 05 said “activities carried out inconsistently due possibly to high turnover of staff & not working with full quota of staff”. Another objective dated September 04 was to establish links with a volunteer advocate. An entry in the records indicated that this was first achieved in December 05. Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 Page 11 An objective to visit the leisure centre was dated August 04. A visit took place in May 05 but the centre was deemed to be too noisy. No further entries were made. There was no evidence of any attempt to consider any alternatives One objective was to improve fluid intake. No reason was given, no direction was offered. This should not be a personal objective. If there were concerns about this service users fluid intake these should be part of the healthcare plan and should be monitored appropriately. The poor plans, poor records and lack of achievement suggest a lack of regard and respect for service users. The staff have a collective responsibility to ensure that the needs, aspirations and goals of each service user are reflected in the plans and that they support people to achieve their personal goals. Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 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): 17 A good choice of food is available. Service users are encouraged and enabled to decide what they would like to eat. EVIDENCE: The acting manager said the menus for the evening meals for the week were usually decided on a Sunday. Each side of the house plans their own menu and the meals are prepared in the two separate kitchens. The staff know service users well, they know what foods people like and dislike and they cater accordingly. There is no set menu at lunchtime, a choice is available to service users. The staff were said to encourage service users to indicate what they would like to eat by showing people pictures of different food and by offering different options of food at lunchtimes. The acting manager said that service users have their own distinctive ways of letting the staff know if they like or dislike certain meals. The shopping is done locally each week. One or two service users usually accompany staff to the shops. Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 Page 13 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 Personal support needs are not recorded in sufficient detail. Personal needs of service users are sometimes not met; this appears to be due to poor communication in the staff team. EVIDENCE: There is still 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. The acting manager said that this information was available in a file that is used by bank staff and agency staff. This would be better placed with the personal files. The records show that the health action plans for individual service users have been reviewed. Records of routine appointments with opticians, dentists, chiropodists and other health care providers were available. It was of some concern to see that a member of staff had noted in the daily records that one individual had been unable shave one day as there were no Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 Page 14 razor blades available. This suggests poor planning and failure to meet the needs of the service user. This is not acceptable. Another of the daily records indicated that one service user needed to purchase new pyjamas and trousers because his clothes had holes in due to shuffling on the floor. The acting manager disputed this and said that new clothes had been bought. If this is the case, there is a problem with communication in the staff team. A further example of poor communication came from another recent entry in the notes. Family members expressed concern about the specialist boots worn by one person, they thought they were quite worn and mentioned this to staff. A note was left for a member of staff to contact the orthotic department at the hospital. An entry in the service users personal file indicated that new boots had been supplied in October. The acting manager also said that this service user had a spare pair of boots in his room. It was not clear why all of the staff were not aware of this, no explanation was offered. At the last inspection inspectors expressed concern about service users not being weighed regularly. This has apparently been remedied, however service users who need to use specialist scales have to go to another St Anne’s home in Huddersfield every month for this to take place. Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 Page 15 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 All staff receive adult protection training and to make sure they are aware of their responsibility to ensure that service users are appropriately safeguarded. EVIDENCE: The acting manager reports that all relatives of service users’ have details of the complaints procedure. No complaints have been received. Since the last inspection, six staff have attended a training course on adult protection issues. St Anne’s regularly provides updates of this training to ensure that all staff are aware of their responsibilities in this area. Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 Page 16 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): EVIDENCE: Not assessed on this inspection. See previous reports. Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 Page 17 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): EVIDENCE: Not assessed on this inspection. See last report. Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 Page 18 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 The home would benefit from a settled period of leadership and management. EVIDENCE: There is no registered manager at the home at present. The registered manager left the home in June 2005. There is an acting manager who is a qualified nurse with several years experience of working with people with learning disabilities. He was originally recruited as the deputy manager of the home. The home had a period last year between July and October when the acting manager was seconded to work in another St Anne’s home. Sutherland Court would benefit from a settled period of management. This report indicates that there are a number of areas that need to be improved. Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 Page 19 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 X 3 X 4 X 5 X 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 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 X X X 1 X X X X X X Sutherland Court DS0000001073.V265890.R01.S.doc Version 5.1 Page 20 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 YA6 Regulation 15 (1) Requirement An up to date comprehensive, person centred plan must be in place for all service users. Previous timescale of 31/1/06 not met. Timescale for action 30/04/06 2 6 15(2) 3 4 18 37 12 8 The plan must be reviewed 30/04/06 regularly and must be updated to reflect the changing needs of service users. The plan must include details of 30/04/06 how personal care needs are to be met. Arrangements must be made to 30/04/06 register a manager for the home. 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.V265890.R01.S.doc Version 5.1 Page 21 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.V265890.R01.S.doc Version 5.1 Page 22 - 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!