Care Home: Sunrise Operations Hale Barns Limited (Assisted Living)

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What the care home does well People enquiring about using this service can be confident that their needs will be thoroughly assessed to determine if the home will be a suitable place for them to live. Following the assessment process an Individual Service Plan is developed with the person. This document details the care and support that will be provided according to the person’s personal preferences. A Wellness CoCoordinator meets with individuals each month to discuss how their needs are being met and to agree if any changes are needed. This process ensures that people are listened to and that their support is provided in a person-centred manner. Staff work hard to ensure that people maintain the lifestyles that they enjoyed prior to moving into the home. People meet with the Activity Co-ordinator every month to ensure that events and activities are designed around the personal interests of the people accommodated. The people we spoke to said that they enjoyed the activities and events, particularly the trips out. People using the service praised the restaurant-style dining service. They valued the choice of meals that they are afforded and the opportunity to express views and suggestions that are included on the menu. Mealtimes are flexible and provide people with the opportunity to socialise in a relaxed environment.Sunrise Operations Hale Barns Limited (Assisted Living)DS0000073260.V378138.R01.S.docVersion 5.2Policies and procedures are in place for investigating concerns and complaints and staff have been trained to take appropriate action if they suspect someone to be at risk of harm. The home has been designed and furnished to a very high standard. We found the environment to be clean, hygienic and well maintained. A rigorous health and safety programme is in place to make sure that a safe environment is provided for people using the service. One person showed us her suite. She said that the facilities provided enabled her be independent and to invite friends for a cup of tea and a chat. Robust recruitment procedures are in place to check that staff have the required personal qualities, skills and experience to work in the home. An ongoing programme of training is designed to ensure that staff continually update their working skills. The organisation places high importance on providing a quality service. Performance and outcomes are regularly monitored and assessed and action is taken to continually make improvements where necessary. What has improved since the last inspection? This section is not applicable as this was the service’s first key inspection. What the care home could do better: We made one requirement and four good practice recommendations during this key inspection of the home. Written information supplied to people interested in using this service should be updated to accurately reflect the current status of the manager. The Statement of Purpose and Residents Handbook referred to the manager as being registered with the Care Quality Commission, although the manager had not submitted her application to be registered with us. Similarly, people enquiring about the service may find it useful to be informed of our website, where they can access inspection reports for this home. Care records should record the choices and decisions that people make about their care and support. This provides evidence that staff have considered the risks and have taken action that is in the best interests of the individual. One of the care records we examined told us that the person had lost 5kg in weight in one month. We asked the manager to look into this. The outcomeSunrise Operations Hale Barns Limited (Assisted Living)DS0000073260.V378138.R01.S.doc Version 5.2 was that a different set of scales had been used to weigh the person and the reading was inaccurate. This should have been questioned at the time the weight was recorded. Changes in the health and welfare of people using the service, such as significant weight loss, should be promptly investigated to ensure that they are not at risk of becoming ill. We recommend that the location of oxygen cylinders held in the building should be recorded in the folder that is made available to the emergency services. This will ensure that they have important information relating to people needing evacuation in the event of a fire. Key inspection report CARE HOMES FOR OLDER PEOPLE Sunrise Operations Hale Barns Limited (Assisted Living) 295 Hale Road Hale Barns Altrincham Cheshire WA15 8SN Lead Inspector Val Bell Key Unannounced Inspection 09:00 21 and 28th October 2009 st DS0000073260.V378138.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunrise Operations Hale Barns Limited (Assisted Living) 295 Hale Road Hale Barns Altrincham Cheshire WA15 8SN 0161 980 9500 0161 980 9501 Address 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) www.sunrise-care.co.uk Sunrise Senior Living Ltd Post vacant Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP. The maximum number of service users who can be accommodated is: 60. New service Date of last inspection Brief Description of the Service: Sunrise Operations – Assisted Living is registered to provide accommodation and care for up to 60 older persons. Within this number, the provider also offers accommodation and nursing care for up to 20 older people. The home is situated on a main road on the outskirts of the village of Hale Barns. It is close to local facilities, bus routes and motorways. Accommodation is provided in 53 suites, which vary in size and design. Each suite has en-suite facilities and a small kitchen area for making drinks and snacks. Access to the accommodation above ground level is provided by two passenger lifts and a staircase. The home is accessible to people who use a wheelchair. There are a choice of lounges, an activity room and a restaurant style dining area. An attractive and enclosed garden provides opportunities for people to exercise or relax. Fees for this service are based on a person’s needs and preferred choice of accommodation. The scale of charges are itemised in the Resident Handbook, which can be obtained by contacting the manager at the home. Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was a key inspection of a new service, which included two visits to the home. The visits were unannounced which means the manager was not informed beforehand that we were coming to inspect. During the visits we spent time talking to people living in the home, a visiting relative, the chef, members of staff on duty and the manager. An Annual Quality Assurance Assessment (AQAA), which is a self-assessment document, had been completed and returned to the Commission prior to our visit. We sent satisfaction surveys to a number of people living in the home. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken. What the service does well: People enquiring about using this service can be confident that their needs will be thoroughly assessed to determine if the home will be a suitable place for them to live. Following the assessment process an Individual Service Plan is developed with the person. This document details the care and support that will be provided according to the person’s personal preferences. A Wellness CoCoordinator meets with individuals each month to discuss how their needs are being met and to agree if any changes are needed. This process ensures that people are listened to and that their support is provided in a person-centred manner. Staff work hard to ensure that people maintain the lifestyles that they enjoyed prior to moving into the home. People meet with the Activity Co-ordinator every month to ensure that events and activities are designed around the personal interests of the people accommodated. The people we spoke to said that they enjoyed the activities and events, particularly the trips out. People using the service praised the restaurant-style dining service. They valued the choice of meals that they are afforded and the opportunity to express views and suggestions that are included on the menu. Mealtimes are flexible and provide people with the opportunity to socialise in a relaxed environment. Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.2 Page 6 Policies and procedures are in place for investigating concerns and complaints and staff have been trained to take appropriate action if they suspect someone to be at risk of harm. The home has been designed and furnished to a very high standard. We found the environment to be clean, hygienic and well maintained. A rigorous health and safety programme is in place to make sure that a safe environment is provided for people using the service. One person showed us her suite. She said that the facilities provided enabled her be independent and to invite friends for a cup of tea and a chat. Robust recruitment procedures are in place to check that staff have the required personal qualities, skills and experience to work in the home. An ongoing programme of training is designed to ensure that staff continually update their working skills. The organisation places high importance on providing a quality service. Performance and outcomes are regularly monitored and assessed and action is taken to continually make improvements where necessary. What has improved since the last inspection? What they could do better: We made one requirement and four good practice recommendations during this key inspection of the home. Written information supplied to people interested in using this service should be updated to accurately reflect the current status of the manager. The Statement of Purpose and Residents Handbook referred to the manager as being registered with the Care Quality Commission, although the manager had not submitted her application to be registered with us. Similarly, people enquiring about the service may find it useful to be informed of our website, where they can access inspection reports for this home. Care records should record the choices and decisions that people make about their care and support. This provides evidence that staff have considered the risks and have taken action that is in the best interests of the individual. One of the care records we examined told us that the person had lost 5kg in weight in one month. We asked the manager to look into this. The outcome Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.2 Page 7 was that a different set of scales had been used to weigh the person and the reading was inaccurate. This should have been questioned at the time the weight was recorded. Changes in the health and welfare of people using the service, such as significant weight loss, should be promptly investigated to ensure that they are not at risk of becoming ill. We recommend that the location of oxygen cylinders held in the building should be recorded in the folder that is made available to the emergency services. This will ensure that they have important information relating to people needing evacuation in the event of a fire. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People considering moving into the home received sufficient information to help them make a decision and staff received enough information to understand and respond to the person’s needs. EVIDENCE: We examined the information that is provided to people when they enquire about using this service. This is in the form of two documents called a Statement of Purpose and Resident Handbook and Information Guide. Both Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 10 documents give people good information and this enables them to decide if the home will be a good place for them to live. There were some details that we felt could be improved. Both documents referred to the current person running the home as the registered manager. The person-in-charge is currently in the process of preparing an application to become the registered manager. Until the registration process is complete the documents should not refer to her as being registered with us. In the section on quality assurance in the Statement of Purpose, the reader is informed that they can access copies of our inspection reports on the home’s community notice board and from our website. It would be helpful if the Commission’s web address was included. We looked at care records belonging to three people using this service. Their needs had been thoroughly assessed and risks associated with the safe delivery of care and support had been appropriately assessed. Clear guidance had been written down to inform staff what they must do to keep people safe from harm. This robust process of needs and risk assessment ensures that people can be confident that staff will provide the right level of support to meet their individual needs. Sunrise Operations does not offer an intermediate care service. Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of dignity, respect and privacy are put into practice so people living in the home can be confident they will be well cared for. EVIDENCE: We looked at the care plans belonging to three people accommodated in the home. Staff call these documents Individual Service Plans or ISP’s. The three we examined contained clear information about what staff would do to meet each person’s needs. There was a plan in place for each need that had been identified in the original assessment. Sunrise Operations had a good system in Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 12 place to monitor each person’s progress and wellbeing. A wellness nurse had the responsibility of meeting with each person every month to review their personal and healthcare needs and to make sure that they were receiving the right amount of support in accordance with their preferences. This system was generally working well. However, one of the records detailed a weight loss of 5kg between August and September and there was no evidence to demonstrate that this had been investigated. We asked the manager to look into this. The outcome was that the September weight had been taken from a different set of weighing scales and was inaccurate. However, we were concerned that this had not been looked into when the person’s weight had been recorded in September. A perceived weight loss of 5kg is a significant amount that potentially placed the health and welfare of the person at serious risk. The manager said that she would remind staff that prompt action must be taken to investigate and monitor changes in peoples’ health and welfare. We found two further shortfalls in the ISP’s. Daily records detailed a medication error that had not been communicated to the management. Errors in the administration of medication are incidents that must be reported to us under Regulation 37 of The Care Homes Regulations 2001. We asked the manager to send us written notification of this incident. The second shortfall related to an omission in recording. One of the ISP’s recorded that the person had a lump behind their ear, yet this person had not seen their doctor for three days. The manager told us that the person had chosen to wait until the doctor attended the home on a routine visit. This person’s decision and a risk assessment should have been written in the ISP to provide evidence that staff had acted in the person’s best interests. We looked at the system for administering medication to people using this service. We found medication records to be accurate and all medicines were securely stored. A robust system of weekly audits meant that medicines in the custody of the home were being handled safely. We spoke to a number of people during our two visits to the home. Each person confirmed that staff treated them with dignity and respect and that their support was provided in private. A relative of a person who had used this service said that staff had helped her mother to settle in well during her stay in the home. She said she had always found staff to be courteous and helpful. Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service are enjoying a good quality of life that meets their expectations of the support they receive. EVIDENCE: Calendars detailing planned activities for the month had been posted on notice-boards and in the lifts. Copies of the calendars had also been delivered to each person using the service. A range of interesting and stimulating events were planned, including regular outings for shopping and visiting places of interest, clubs, hobbies, classes, visiting entertainers and family events and social evenings. Several people told us that they enjoy these events, especially the day trips. One person commented that there does not seem to be much going on at weekends. We asked about this and the manager told us that a Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 14 weekend driver is currently being recruited to ensure that outings can be provided on these days. The home had a minibus for outings and this had the facility to safely accommodate people with physical disabilities. We spoke to the Activity Co-ordinator. He told us that he holds monthly meetings with people using the service and that the activity calendar had been developed from listening to peoples’ views and suggestions. It was particularly pleasing to find that people using the service were supported to maintain their preferred lifestyles by continuing to participate in community activities that they enjoyed prior to moving into the home. Regular family events encouraged people to maintain and further develop their relationships with relatives and friends. Three meals a day were provided in the restaurant-style dining area and menus offered a choice of courses, including a vegetarian option. A complimentary glass of wine was offered with the midday and evening meals. Mealtimes were flexible as follows: breakfast 07:00 to 09:30, lunch 12:00 to 14:00 and evening meal 17:00 to 19:00. Menus provided evidence that meals were nutritionally balanced and varied. Omelettes, jacket potatoes and sandwiches were available as alternatives to the main courses. A family dining room was available if people wished to eat with their friends and relatives. Hot and cold drinks were available from the ‘Bistro’ at any time for people living in the home and their visitors. People using the service praised the quality of the catering. One person said, ‘We meet with the chef every month and our suggestions are taken into account when planning the menu.’ The chef had a thorough understanding of individual’s nutritional needs, including the provision of a range of special diets. Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are good systems in place for people to express their concerns and be listened to, to protect their rights and to safeguard them from harm. EVIDENCE: Sunrise Operations had a complaints policy and procedures were in place to ensure that action was taken to resolve peoples’ concerns. A summary of the complaints procedure was supplied to people as an attachment to the Statement of Purpose, which they received on admission to the home. People told us that they knew who to speak to if they had any concerns and they were confident that staff would take appropriate action to resolve any issues they had. No complaints had been received about this service. There was a notice-board in the reception area containing a large number of written compliments about staff from visitors and people using the service. Robust procedures were in place to safeguard people using the service from harm. Staff told us that they had received training in the recognition of abuse Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 16 and they knew what they must do if a person using the service was found to be at risk of abuse. There had been no safeguarding incidents recorded in the home since it opened. Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service are provided with a safe and comfortable home that is well maintained and decorated and furnished to a very high standard. EVIDENCE: We looked round the home to assess cleanliness, hygiene, health and safety and maintenance of the facilities provided. Furniture, fittings and furnishings were of a very high standard and the home was clean, hygienic and maintained on a regular basis. Systems were in place to control the spread of Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 18 infection and staff had access to protective equipment such as gloves and aprons. Alcohol based hand rub dispensers had been provided at all hand wash basins to minimise the spread of harmful bacteria. The people accommodated had been provided with en-suite bathing and toilet facilities along with a kitchen area and the facilities to make drinks and snacks. One of the people accommodated told us that this enabled her to maintain her independence. She said, ‘I can invite a friend back to my room for a cup of tea and a chat.’ In addition to private bathing facilities people had the option to have assisted bathing in one of the spa bathrooms. Each floor was equipped with a ‘resident’s laundry room’ where people using the service could attend to washing, drying and ironing their personal clothing. Alternatively, people could choose to have their laundry undertaken by the housekeeping team. An attractive enclosed garden area, with ample seating and shaded areas, provided people with opportunities for fresh air and exercise. Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service receive care and support from staff that have the skills and integrity to meet their needs in a safe manner. EVIDENCE: There were sufficient nursing and support staff on duty on the two days we visited the home and the current weeks rota provided evidence that these staffing levels were being maintained. Over 50 of support staff had achieved a National Vocational Qualification in Care at level 2 or 3. We looked at the recruitment records for five members of staff that had been employed since the home was registered. The required pre-employment documents had been obtained and saved in their personnel files. This provided evidence of a robust recruitment system that ensured that new staff were suitable to work with people living in the home. Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 20 Staff spoken to confirmed that they had access to regular and relevant training and development records provided further evidence of this. Records stated that staff had undergone an induction process following their appointment. However, there was no written evidence that the content of the induction programme was consistent with that specified by ‘Skills for Care’. By the time of our second visit this had been addressed by obtaining training and development portfolios for each member of staff, in which the exact content of all training could be recorded. Staff confirmed that they received regular supervision and ongoing support from the manager and they were confident that they could request more training if they felt they needed it. Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This service is managed well and a high level of consultation means that people using the service can contribute to its development. EVIDENCE: The registered manager for this service resigned in July 2009. A suitably experienced manager had been appointed to be in day-to-day charge of the Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 22 home and she was in the process of applying for registration with the Care Quality Commission. People living in the home praised the manager and a visitor to the home commented that the manager was good at communicating and making sure that people’s needs were being met. Staff told us that they had a good relationship with the manager and that she was supportive and treated them fairly. Regulation 37 of the Care Homes Regulations 2001 requires services to notify us of incidents that affect the welfare of people using the service. During our visits we found evidence of three incidents that we had not been notified about. These related to a death, a medication error and a person being referred for treatment to a hospital’s accident and emergency department. This home had a comprehensive system of monitoring and assessing the quality of the service provided. This included regular audits of systems, policies and procedures and accessing the views of people using the service and their representatives. Regular meetings were being held with people living in the home, both individually and as a group. A senior member of the organisation visited the home each month to assess the quality of the service and their findings and action points to be addressed had been recorded. At the time of our visits people living in the home were managing their own personal finances. There was a system in place to assist people with managing small amounts of personal spending money if this was their choice or if they lacked capacity. An accounting system for this purpose was in place and it was proposed that records would be audited on a regular basis. We examined a sample of health and safety records and found these to be accurate and up to date. We recommended that a record of the location of oxygen clylinders in the building is held in the folder that is used by the emergency services. Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 OP31 Regulation 37 Requirement The registered person must ensure that the Care Quality Commission is notified about significant incidents that affect the people using this service. This will provide evidence that the correct action is being taken to keep people safe from harm. Timescale for action 21/11/09 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 OP1 Good Practice Recommendations The Statement of Purpose and Resident Handbook should be updated to include accurate information about the status of the manager and the web address of the Care Quality Commission. This will ensure that people are given accurate and up to date information about the home before deciding if the service will be able to meet their needs. Care records should accurately record an individual’s DS0000073260.V378138.R01.S.doc Version 5.3 Page 25 2. OP7 Sunrise Operations Hale Barns Limited (Assisted Living) choices and decisions and any associated risks to provide evidence that staff have acted in the person’s best interests. 3. OP8 Changes in a person’s health and welfare should be promptly investigated to provide evidence that the person has not been placed at risk of harm. A record of the location of oxygen cylinders held in the building should be kept in the folder used by the emergency services. 4. OP38 Sunrise Operations Hale Barns Limited (Assisted Living) DS0000073260.V378138.R01.S.doc Version 5.3 Page 26 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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