Inspection on 30/05/07 for Sutton Lodge Nursing Home

This is the latest available inspection report for this service, carried out on 30th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 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

Sutton Lodge Nursing Home 28/06/05

Sutton Lodge Nursing Home 28/10/04

Sutton Lodge Nursing Home 01/06/04

Similar services:

The Shelley

Thorndene

Springfield House

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Bethany Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 17/12/2008.

CARE HOMES FOR OLDER PEOPLE Sutton Lodge Nursing Home 87 Oatlands Drive Weybridge Surrey KT13 9LN Lead Inspector Lesley Garrett Unannounced Inspection 30th May 2007 10:00 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 DS0000017647.V335296.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. DS0000017647.V335296.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sutton Lodge Nursing Home Address 87 Oatlands Drive Weybridge Surrey KT13 9LN 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) 01932 222184 01932 252597 toutj@bupa.com www.bupa.com BUPA Care Homes (BNH) Limited Ms Jacqueline Anne Tout Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0) DS0000017647.V335296.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing: 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 Physical disability over 65 years of age - PD(E) 2. Physical disability - PD. The maximum number of service users to be accommodated is 28. Date of last inspection 26th September 2005 Brief Description of the Service: Sutton Lodge is a private care home that provides nursing care, owned and managed by BUPA. Service provision is predominantly for older people from the age of sixty years, with five places for physically disabled adults from the age of forty years. This Edwardian house has been tastefully converted and extended over the years to provide a comfortable, welcoming home with modern equipment and facilities. There are car parking facilities to the front of the premises and an enclosed, mature furnished garden to the rear. The home is conveniently located near to shops and all community amenities in the small town of Weybridge. Bedroom accommodation is arranged on the ground, first and second floors, accessible by a passenger lift. Most bedrooms have en-suite facilities and are predominantly single rooms. The home has comfortable spacious lounges and a separate dining room. A conservatory affords an additional sitting area overlooking the garden. A full time nurse manager and deputy are employed. The fees for this service range from £895 to £1200 per week. DS0000017647.V335296.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 0945 and was in the service for three hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. We looked at the home’s records and completed a tour of the building. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. What the service does well: The manager has only been registered with the Commission since April 2007 has written a training plan for the home and she will deliver some of this training with the help of a senior carer. She told us that she has an open door policy and during a tour of the building many service users stopped her to talk and the inspector noticed good interaction. The home has a low turnover of staff and the manager said they rarely need to use agency staff so service users have a good rapport with the staff as they are able to get to know one another well. There is an ongoing maintenance programme and the manager said that all the old divan beds would eventually be replaced with more suitable profiling ones, which will meet the needs of the service users. DS0000017647.V335296.R02.S.doc Version 5.2 Page 6 From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000017647.V335296.R02.S.doc Version 5.2 Page 7 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 DS0000017647.V335296.R02.S.doc Version 5.2 Page 8 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): 3&6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. All people who use the service have a pre-admission assessment and are confident that their needs will be met. The home does not provide intermediate care beds. EVIDENCE: The manager stated that both her and the deputy do all the pre-admission assessments prior to service users moving to the home. She also explained that service users also visit the home and can spend some time at the service to allow an assessment to take place. We sampled two individual plans of care and they both contained the assessment and care plans are generated from this assessment. DS0000017647.V335296.R02.S.doc Version 5.2 Page 9 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 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users have individual plans, which reflect the care and support they require and their health care needs are fully met. The medication policies and procedures that are in place and implemented by staff protect service users. The privacy and dignity of the service users is respected. EVIDENCE: We sampled two individual plans of care and found them to contain a good variety of individual plans and risk assessments. They were all reviewed every month and changes made where necessary with risk assessments also in place. The plans also contained daily notes and information regarding other visiting professionals. We observed evidence that both service users and their representatives had also been consulted. BUPA have introduced this care planning system recently called QUEST and all service users in the home have this system for their individual plans of care. DS0000017647.V335296.R02.S.doc Version 5.2 Page 10 The manager stated that the home has good support from the local general practitioner (G.P.). They visit the home every week and in between if necessary. The manager stated that there is also good health care support from other practitioners, which include the Macmillan nurses, physiotherapist, dietician, opticians, chiropody and the speech and language therapist. The manager stated that the home has the support of a local pharmacy for all their medication needs. We observed that blister packs are used and their supplies are delivered every month. The medication is stored in the clinical room and all medication policies and procedures are available for the nurses. The manager said that arrangements are in place with a clinical waste company for the removal and destruction of unused medicines. The manager told us that privacy and dignity is a topic discussed on induction for all new staff. We observed staff knocking on bedroom doors prior to entering and speaking appropriately to the service users. We observed in the individual plans of care that the preferred name of the service user was documented and the manager said this question is often asked during the preadmission assessment. The manager said that all people who use the service have the opportunity to see visitors and visiting professionals in private. DS0000017647.V335296.R02.S.doc Version 5.2 Page 11 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 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Social and recreational activities meet the people who use the service expectations and they receive a varied diet according to their assessed requirements and choice. EVIDENCE: The manager stated that the home employs an activities organiser who works Monday to Thursday and on Friday’s carers are allocated to this role. There is an activity programme displayed and is available to all people who use the service in their bedrooms. A variety of activities take place, which include ‘resident’s individual time’ and group activities. A comment received stated ‘there is a published activities programme and there is always something to do’. On the day of the site visit we observed the service users with the hairdresser and enjoying sherry or tea and coffee. They sitting and talking with the hairdresser and activities organiser. The manager stated that they go out in a mini bus twice a month to visit local places of interest. The manger told us that the home has the benefit of volunteers who will visit the service users and sit and talk and will also help on the organised visits DS0000017647.V335296.R02.S.doc Version 5.2 Page 12 away from the home. Comments were received by us and said ‘the family get invitations to many pleasant social activities’. The manager stated that choices are given to all service users, which include when to get up and go to bed. On the day of the site visit we observed staff giving menu choices for the days meal. One service user stated ‘I enjoy sitting in this quite lounge during the day’. He told us he chose to sit there so he could enjoy his paper. The home employs a full time chef and menus were sent to us prior to the site visit. The manager explained that the chefs who work for BUPA write the menu plans using a points system to ensure that all service users get a nutritious well balanced diet. One service user stated that ‘the food had improved recently’. The home had an environmental health visit in July 2006 and no requirements were made. DS0000017647.V335296.R02.S.doc Version 5.2 Page 13 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 & 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who use the service are protected by the homes complaints policies and safeguarding procedures. EVIDENCE: The manager stated that the home keeps a complaints log and she had received two complaints since the last inspection, which have both been resolved. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. Survey forms returned to us all stated that they knew how to make a complaint and one survey stated they would go to see the manager if there was a problem. We observed that the home has the local authorities procedures for safeguarding adults and the manager stated that the home follows these procedures. The manager stated that the home has had no referrals under these procedures since the last inspection. Documentation observed by us demonstrated that staff has had training in safeguarding adults and this takes place regularly. DS0000017647.V335296.R02.S.doc Version 5.2 Page 14 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 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service live in a well-maintained environment, which was clean and hygienic. EVIDENCE: During a tour of the building it was observed that rooms have been personalised and the communal areas are well decorated. It was observed that there was a good selection of hoists and variable height beds, which meets the needs of the people who use them. All bedrooms with the exception of two have en-suite facilities and communal bathrooms are also available. The manager employs a full time maintenance person who is responsible for the repairs and painting of the home. DS0000017647.V335296.R02.S.doc Version 5.2 Page 15 Service users have access to a safe well maintained garden, which the manager said in good weather is well used and table, chairs and shade was available for their use. We met the laundress and found the laundry neat and tidy. She had knowledge of infection control procedures and had received training. There was adequate facilities for washing hands around the home with gel hand rub available for all staff. DS0000017647.V335296.R02.S.doc Version 5.2 Page 16 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 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of people who use the service. EVIDENCE: In conversation with the manager and observation of the staff rota it was apparent that the home has sufficient numbers of staff to meet the needs of the people who use the service. The manager stated that the home rarely uses agency staff and that all night staff are waking. A survey form returned to us stated ‘a skilled, experienced, caring team with good leadership from management’. A healthcare professionals comment was that ‘the staff team was stable’. The manager stated that staff are encouraged to participate in the national vocational qualification (NVQ) training available and more than 50 of the staff have this qualification at level 2 or 3. We sampled two staff recruitment folders and found that all the necessary documentation to enable the home to employ staff were in place. A pre-inspection questionnaire was returned to us, which showed us the training that has taken place in the last twelve months. The manager stated DS0000017647.V335296.R02.S.doc Version 5.2 Page 17 that herself and a carer are now responsible for all the training. Mandatory training had also taken place and this included moving and handling, food hygiene and safeguarding adults. DS0000017647.V335296.R02.S.doc Version 5.2 Page 18 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 33 35 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness, and has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The manager has been registered since April 2007 and has completed at least half of her registered managers award, which she hopes will be fully completed before the end of the year. A deputy manager supports her and they work closely together. The manager stated she has an open door policy and during the site visit we observed staff coming into the office for advice and during the tour of the building she demonstrated a good knowledge of the service users. DS0000017647.V335296.R02.S.doc Version 5.2 Page 19 A survey form returned to us stated ‘the manager is always available if you need to discuss something’. The manager completes regular quality checks in the home and this month has been concentrating on the menus. Along with the chef they are looking at the summer menus in consultation with the service users. BUPA sends a yearly customer survey to all homes and this has just been completed and the manager has the results. She has to complete an action plan from the results and feed the results back to the service users. It will be a recommendation at the end of the report for the home to also survey other visiting professionals and stakeholders to the home. The manager stated that resident and relative meetings are held regularly and minutes kept. The managers stated that no service user manages their own finances but the home provides a personal allowance account. All transactions are documented and individual records and all receipts are kept. The homes administrator manages this account. All necessary health and safety checks have taken place and we looked at the records provided on the pre-inspections questionnaire and also spoke to the manager. All certificates are current and the manager identified no health and safety issues during the site visit. The home has a health and safety committee which meets every three months and minutes are kept of these meetings. DS0000017647.V335296.R02.S.doc Version 5.2 Page 20 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 X X 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 X X 4 DS0000017647.V335296.R02.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP33 Good Practice Recommendations It is recommended that the home seek the views of all stakeholders to the home to include visiting professionals and relatives or representatives. 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