Inspection on 05/12/08 for Sunbury Lodge

This is the latest available inspection report for this service, carried out on 5th December 2008.

CSCI found this care home to be providing an Good service.

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

Other inspections for this house

Sunbury Lodge 20/12/05

Sunbury Lodge 02/08/05

Sunbury Lodge 03/02/05

Sunbury Lodge 12/08/04

Sunbury Lodge 03/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Tudor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Sunbury Lodge 1 Sunbury Street Woolwich London SE18 5NA Lead Inspector Maria Kinson Unannounced Inspection 09:35 5th and 22 December 2008 nd X10015.doc Version 1.40 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 Sunbury Lodge DS0000006861.V374274.R02.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 Older People. 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. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunbury Lodge Address 1 Sunbury Street Woolwich London SE18 5NA 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) 020 8854 8254 020 8855 7511 mary.oconnor@kcht.org.uk www.kcht.org Kent Community Housing Trust Ms Mary O’Connor Care Home 47 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20), Old age, not falling within any of places other category (0) Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories 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: Old age, not falling within any other category - Code OP Mental Disorder, excluding learning disability or Dementia - Code MD (maximum number of places: 20) The maximum number of service users who can be accommodated is: 47 29/12/2006 2. Date of last inspection Brief Description of the Service: Sunbury Lodge is a former purpose built local authority home. Accommodation is provided on two floors and is built around an enclosed garden. The home is located in a quiet residential road opposite a park. It is within walking distance of Woolwich town centre and bus routes. Kent Community Housing Trust is the Registered Provider for the home. The home is registered to provide care and accommodation for 47 older people. 20 beds can be used for older people with a mental disorder. The fees charged by the home range from £429.57- £545.00 per week. This does not include additional charges such as hairdressing, toiletries, newspapers and magazines, and holidays. This information was supplied to the commission on the 09/03/09. Sunbury Lodge DS0000006861.V374274.R02.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. The last key inspection of this service was undertaken in December 2006. In the period since the last inspection the home applied for a variation to increase the number of beds for people with a mental health disorder from 10 to 20. The application was approved. Prior to the inspection we reviewed all of the information that we had received about the service. This includes complaints, concerns, notifications and the annual quality assurance assessment (AQAA) form. The AQAA is a selfassessment form that registered services have to complete once a year. We sent surveys to some of the people that use or visit the home to obtain feedback about the service. We received eighteen responses, eight from residents, seven from staff, one from a relative and two from local health care professionals. We also spoke to five residents, four members of staff and one visiting social care professional during the inspection. We have included some of the comments that we received about the home in this report. This inspection was carried out over two days in December 2008. On day one we talked to residents and staff, observed staff supporting and communicating with residents and visitors, sampled some of the care records, looked at the environment and assessed the management of medicines. On the second day we talked to the manager and looked at some of the records that were kept in the home. There were forty residents living in the home at the time of the inspection and three people were in hospital. There were four vacant rooms. What the service does well: Information about the service was displayed in the reception area where residents, relatives and visitors could see it. Staff carried out an assessment to establish what support people would require if they decided to live in the home. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 6 Staff worked in partnership with other health care professionals and sought advice if necessary. Residents were encouraged to maintain their independence and were treated as individuals. One health care professional said, “Sunbury Lodge has a tolerant and caring attitude”. Our observations indicate that this is an accurate reflection of the staff team. Residents told us that staff maintained their privacy and listened to their views. The range and choice of activities provided in the home was good and there were regular outings to places of interest. Visiting times were flexible. Food was nicely presented and people were given adequate support and time to eat. Complaints were logged and investigated. Residents knew who to speak to if they were unhappy and how to make a complaint. Staff said they would report allegations to the manager or senior staff. The home was clean, tidy and well maintained. The home has a stable team of staff. This provides good continuity of care for residents. Good records were kept about people’s money and valuables. The manager was respected and trusted by staff. Staff felt valued and supported. What has improved since the last inspection? Senior staff had attended training about the administration of insulin but still need to be assessed as competent before they can undertake this task. As an interim measure the manager had arranged for district nurses to support residents to take their insulin. Good records were kept about homely remedy medicines and medicines that were no longer required were crossed through. Action was taken to address the maintenance issues that we identified during the previous inspection. Parts of the home had been redecorated and some new carpets and furniture had been purchased. The home had recruited some new staff. The number of permanent staff had increased. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 7 The maintenance employee carried out regular checks to ensure that window restrictors were in place and working properly. 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. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 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 Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People had access to written information about the service and could visit or spend time in the home before making a decision to move in. Staff obtained and recorded information about the support that people would require if they decided to live in the home. EVIDENCE: A copy of the ‘Service user Guide’ and the previous inspection report was displayed near the visitor’s book and the registration certificate and public liability insurance certificate were displayed in the main corridor. Residents said they received adequate information about the service and some people told us that they visited the home before they moved in. One person visited the home on the day of the inspection. The person was accompanied by a relative and was shown around the home by a member of staff. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 10 The company employs a dedicated assessor. The assessor was responsible for assessing prospective resident’s needs and handing this information over to the homes staff. The assessor also arranged visits and was a point of contact for questions. Assessments were carried out very quickly because the assessor had no other commitments. Staff undertook their own assessment if the assessor was not available or if they had concerns about a placement. We looked at the assessment records for three people that had moved into the home in the period since the last inspection. One person was an emergency admission. Staff carried out a thorough assessment on the day that the person moved into the home. The second resident moved from another home that was out of the area to be near their family. Although staff were not able to carry out a pre admission assessment they did obtain a copy of the care plan from the previous home and a copy of the assessment that was carried out by the funding authority. These documents provided adequate information about the persons care needs. The third resident was assessed before they moved into the home. The assessment provided comprehensive information about the person’s health, personal and social care needs and information about medication and potential risks. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provided clear instruction and guidance about how staff could meet residents care needs. Staff communicated effectively and were tolerant and caring. Staff worked in partnership with other professionals to identify and resolve health issues. EVIDENCE: The company had recently introduced some new documentation. We looked at the records for two people with a mental health disorder and one older person that had difficulty communicating following an illness. All of the residents had lived in the home for 6 months-1.5 years. Staff had developed an individual care plan for each resident. Plans provided information about the action that staff should take to meet people’s needs and Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 12 about peoples preferred routines, likes and dislikes. There were prompts for staff about maintaining people’s independence and encouraging people to make choices. There was clear information for staff about how to manage specific behaviours and records were kept about the frequency of these episodes. Information in care plans about signs of relapse for people with mental health problems was not always very clear. For instance one care plan for a person with schizophrenia said staff should call the CPN if the person became unwell. The care plan did not state how staff would know the person was unwell. We recommend that staff receive further mental health training. See standard 30. There was evidence in the records that care plans were followed by staff. For instance one person liked to have a bath in the evening. The records indicated that the resident had a bath at 7:30pm, 8pm and 8:30pm in recent weeks. The files included information about risks that staff had identified and the action that they should take to protect the resident and other people. We saw risk assessments for people who required support to move, who smoked and who had challenging behaviour. Risk assessments were easy to follow and understand and were updated regularly. Information was recorded in the daily care records about the support that staff provided. We saw that one resident who felt unwell was given coffee and toast in bed and staff spent time talking to and preparing tea and biscuits for another resident that was restless during the night. Care plans were reviewed and updated regularly. The GP visited regularly and people were referred to other professionals if necessary. Some of the residents had seen a Physiotherapist, Psychiatrist, Nurse Practitioner and Chiropodist in recent weeks. We spoke to one social care professional that was visiting the home and received written feedback about the service from two health care professionals that were in regular contact with the home. The feedback that we received about the home was very positive. People told us that staff sought advice if necessary and always “follow up ongoing investigations and treatment”. They said staff had the right skills and experience to meet people’s health needs and the home has “a caring and tolerant attitude”. We looked at the medication supply and records for three residents. All medicines were in stock. Good records were kept about the amount and type of medicines that were supplied to or bought into the home. There were no gaps on any of the charts that we looked at and staff inserted a code to explain why some medicines were not given or omitted. Records of administration were good overall, but the balance of one medicine was higher than it should be. There are two likely explanations for this. Either staff signed for a medicine that they did not give or some leftover medicine from the previous Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 13 month’s supply was not carried forward onto the new chart. See recommendation 1. Good records were kept about unwanted medicines that were sent for disposal. Medicines were stored securely and the temperature of the medication refrigerator was monitored. A list of ‘non prescription’ medicines that staff could give residents was agreed with the GP and good records were kept about the receipt and use of these medicines. Medicines that were subject to special storage conditions were kept in an appropriate cupboard and a register was kept about the use of these medicines. A medication profile had been developed for each resident. This provides useful information for staff and the GP about medicines that residents are taking and have taken in the past. The manager notified us about four medication errors that occurred in the home. The manager had tried to establish the cause of the errors and find ways of preventing a reoccurrence. We spoke to and observed senior staff administering medication in the dining area. The procedure was satisfactory but staff were distracted at times by residents or the telephone. The manager said she would arrange for care staff to take telephone messages during medication rounds. The manager had purchased red tabards for staff to wear when they were giving out medication. The writing on the tabard advised people not to disturb the staff member whilst they were administering medicines. We were told that staff had received training about giving insulin but had not been assessed as competent. District nurses were supporting residents to take their insulin. Communication between staff and residents was good. We observed two members of staff talking to residents that were very confused and in one instance agitated. Rather than correcting the residents account of events the staff members accepted the residents ‘reality’ and provided reassurance. Residents said staff were “caring” and listened to their views. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a varied programme of activities to meet people’s needs. Visiting hours were flexible and residents were able to choose how and where they spent their time. The menu was varied and people said they liked the food that was prepared in the home. EVIDENCE: The home has a dedicated activity coordinator that works 30 hours each week. We observed residents undertaking various activities in the activity room and some residents liked to spend their time in this room watching what other residents were doing. The activity programme was displayed. It included a wide range of activities such as exercises, games and crafts. The activity coordinator said the programme was a guide and was adapted to suit people’s needs. For instance if residents did not want to undertake the activity listed or expressed an interest in doing something different then this would be arranged. People confirmed that the home arranged regular activities that they could take part in. One resident said they were often asked if they wanted to take part but found it “too difficult”, due to their anxiety. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 15 The activity coordinator kept records about the activities that residents took part in and who attended the sessions. The records indicated that in recent weeks some of the residents played bingo and scrabble, went shopping or for a meal in a local pub, made Christmas place mats, attended reminiscence sessions, had a manicure or hand massage and attended a 25th wedding anniversary party. There were regular trips to local places of interests in the ‘bright days’ bus that visits all KCHT homes once a month. The home also has its own bus which it used to take eight of the residents on holiday to Camber Sands. We saw three visitors during the inspection. Residents said relatives could visit at anytime and it was clear that some relatives had established good relationships with staff. One relative provided written feedback about the service. They said they received adequate information from staff and were always told about important issues such as accidents and falls. There were regular residents meetings. We looked at the minutes from the meetings that were held in July and October 2008. The minutes indicated that there was lots of discussion about food and some residents put forward suggestions about places they would like to visit. We arrived as some of the residents were eating their breakfast and we joined some of the residents for lunch. The tables in the dining room were nicely laid out with tablecloths, flowers, jugs of juice and condiments. People were offered support to cut their food up if necessary and were given aids such as a plate guard to help them to be independent. Food was nicely presented and tasted good. We spoke to five residents during breakfast and lunch period and received written feedback about the food provided in the home. Residents said they “very happy with the food”, “we have good meals” and told us that “the cook is great. We looked at the menu and the record of resident’s choices sheet. The menu was varied and there was a good choice of food for residents to choose from. The menu includes dishes to meet people’s cultural needs such as Dahl curry, salt fish and plantain. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were procedures in place to investigate concerns and to protect people from abuse. EVIDENCE: A ‘Making your views known’ poster was displayed in the home. The poster explained what people should do if they were unhappy with the service and who they could speak to outside the home. The poster advised people that they could contact the Commission for Social Care Inspection (CSCI). Information about our contact details was out of date. The manager should update this information. Residents said they knew who to speak to if they were unhappy and how to make a complaint. We have not received any formal complaints about this home but one person did express concerns about the time it took the home to follow up a concern that was raised during a review meeting. Information that we received about this issue indicated that this was due to circumstances that were beyond the manager’s control. However the manager did not tell the person that raised the concern about the difficulties that she was experiencing. See recommendation 2. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 17 The home received six complaints in 2008. We looked at three complaints records. All of the complaints were investigated and dealt with promptly. The manager met one resident in an attempt to resolve their concerns. The home has a ‘Protection of Vulnerable Adults’ procedure which was reviewed and updated in April 2008. The procedure indicates that staff should notify CSCI and Social Services about allegations of abuse and must take action to protect the individual, where appropriate. Staff told us that they would report allegations and concerns to senior staff or the manager and some members of staff they would record what they saw or were told in the resident’s notes. All of the staff that we spoke with had attended safeguarding training. In the period since the last inspection the local authority investigated three concerns relating to the home. We were informed that staff dealt with one issue “promptly and sensitively” and the second allegation was not substantiated but some recommendations were made. One issue is still being investigated. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents liked their rooms and said the home was always fresh and clean. Staff could not weigh residents that were not able to stand because they did not have access to suitable equipment. EVIDENCE: In the period since the last inspection all of the communal rooms, the hairdressing, activities and medication room and some of the bedrooms were redecorated and the garden was repaved. Further work was planned. The maintenance person was responsible for undertaking routine repairs and health and safety checks. The home was well maintained overall but some of the paintwork in the corridors was damaged and there were several cigarette burn marks on the carpet and chairs in the smoking room. The wash basin in Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 19 the hairdressing room was stained. The manager should ensure that these issues are addressed in the redecoration/refurbishment schedule. See recommendation 3. Bedrooms were arranged to suit individual needs and some residents personalised their rooms by using some of their own furniture and displaying family photographs. One resident showed us their room which they said was “very comfortable” but the mattress on their bed was hard. This issue was discussed with the activity coordinator and manager. The manager agreed to see whether an alternative mattress could be provided for the resident. The communal areas were pleasantly decorated and furnished. The gardens were not in use but were tidy and well maintained. One staff member expressed concerns about the hoist which they said was not working. We talked to several staff and the manager about this issue and found that the hoist was broken for a short period but was now in working order. Some residents were not weighed because the home did not have weighing scales that were suitable for people that could not stand or weight bear. The home must find an alternative means of monitoring resident’s weight. See requirement 1. One person told us that their room was “always clean and tidy when I go to it” and other residents said the home was always clean and fresh. Hand washing facilities were good and clinical waste was stored appropriately. Kitchen cleaning schedules and temperature records were up to date. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a stable team of caring and competent staff. Recruitment practices were good but the home could undertake some further checks to protect residents. Staff had access to regular training but the training programme did not include specific sessions about mental health issues. EVIDENCE: There were seven staff and one team leader on duty when we arrived in the home. The off duty rosters that we looked at indicated that this was the usual number of staff for an early shift. There were five carers and a team leader on the afternoon shift and one team leader and two care staff on the night duty shift. The manager and assistant manager provide support during office hours and an ‘on call’ manager was available for advice at other times. Staff said there were usually enough staff to meet people’s needs and residents said staff were usually available when they required assistance. The home had recruited some new staff in the period since the last inspection but the use of temporary staff was largely unchanged. The manager told us that that the home used temporary staff on eighteen shifts during a three month period. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 21 Three members of staff had left during the past year. Retention of staff was good. Several members of staff told us that they enjoyed working in the home and were” pleased to be part of KCHT”, one new member of staff said her decision to work at Sunbury Lodge was “the best decision that I ever made”. Staff communicated effectively with residents. We looked at the recruitment files for three members of staff that were appointed in 2008. The files were well organised and easy to follow. All of the documents that must be kept in the home were present in the files but some references were not followed up to check that they were genuine. See recommendation 4. The company has a dedicated training department. The training department arranged a varied programme of training but the programme did not include specialist training for staff that support people with a mental health disorder. See requirement 2. Staff could attend local authority training courses and there was some flexibility for homes to arrange local training sessions to meet staff needs, if necessary. An individual record was kept about the training that staff attended. Seven members of staff completed a comment card about the home and we spoke to four members of staff during our visit. All of the staff that we spoke to said they received adequate information about residents needs and felt supported. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is led by an experienced and competent manager. Residents were treated as individuals and staff accepted people’s individual lifestyle preferences. There were good systems in place to identify and address concerns and to safeguard resident’s money. Health and safety issues were well managed but the fire door to the smoking room was often left open. This could compromise people’s safety. EVIDENCE: The manager has a Certificate in Management Studies and attained a National Vocational Qualification (NVQ) level four in care and the Registered Managers Award (RMA) in the period since the last inspection. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 23 Staff said the manager was approachable and easy to talk to. One member of staff said “her door is always open for staff to discuss work issues” and another member of staff told us that “management and senior staff are very supportive”. The manager communicates effectively with the commission. We were told about significant events and allegations and about any action that was taken in respect of these issues. There were various systems in place for monitoring the quality of care and services provided in the home and for obtaining feedback from residents and relatives. A senior manager visits the home once a month to assess the conduct of the service, complete an audit and talk to residents and staff. A different topic such as medication and complaints was audited during the visits. A corrective action plan was prepared to show what action the manager would take to address the matter, if concerns were identified during the audit. Satisfaction surveys were sent to relatives and residents once a year. The results from the recent survey were not available at the time of the inspection but the manager agreed to forward a copy to the inspector. In addition to residents meetings there was also an annual forum for residents and relatives. This meeting provides an opportunity for residents and relatives to raise concerns and question senior staff and the board of trustees. Records were kept about money and valuable items that were handed to staff for safekeeping. There was clear information about how money was used and receipts were kept for most purchases. Records were also kept about money that was returned to residents or relatives or was used to purchase items or services such as newspapers and hairdressing for residents. Money and valuables were stored securely. Some residents managed their own money with support from relatives or staff. The fire safety risk assessment was reviewed in 2008. The fire alarm system, emergency lighting and fire safety equipment were checked and serviced at regular intervals. There were regular fire drills to check that staff were familiar with the fire procedure. The smoking room door was propped open with an ash tray. The door must be kept closed to protect residents from secondary smoke and in the event of a fire to stop the blaze from spreading to other parts of the building. See requirement 3. Equipment was serviced regularly to ensure that it was working properly and safe for use. The maintenance employee carried out regular checks to monitor hot water temperatures and to ensure that window restrictors were in place. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 24 Potentially hazardous substances such as cleaning fluids were kept in a locked cupboard. Some work was required to comply with water fittings regulations. The manager should let us know when this work is complete. See recommendation 5. Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 25 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 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X 2 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP22 Regulation 23 Requirement The home must have suitable equipment to meet people’s needs. This includes equipment to weigh residents that are not able use weighing scales that you have to stand on. Staff must receive training appropriate to the work they perform. The training programme must include sessions that will help staff to support people with mental health needs. Ensure the door to the smoking room is kept closed. Timescale for action 25/05/09 2. OP30 18 22/06/09 3. OP38 13 06/04/09 Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP16 Good Practice Recommendations Leftover medication should be returned to the pharmacist or carried forward onto the new medication chart. Where there is a delay in responding to concerns the manager should send an interim letter or contact the person to explain the reason for the delay. The following issues should be included on and addressed in the 2009 work schedule: • The damaged paintwork in the corridors • The cigarette burn marks on the carpet and chairs in the smoking room • The stained wash basin the hairdressing room References that are not company stamped or on headed paper should be verified to ensure that they are genuine. The manager should provide written confirmation to CSCI about compliance with the Water Fittings regulations 1999. 3. OP19 4. 5. OP29 OP38 Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. Extracts may not be used or reproduced without the express permission of CSCI Sunbury Lodge DS0000006861.V374274.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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