Inspection on 14/08/06 for Bernard Sunley Nursing Home

This inspection was carried out on 14th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Bernard Sunley Nursing Home 07/08/07

Bernard Sunley Nursing Home 22/08/05

Bernard Sunley Nursing Home 28/04/05

Bernard Sunley Nursing Home 06/09/04

Bernard Sunley Nursing Home 29/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bernard Sunley Nursing Home College Road Maybury Hill Woking Surrey GU22 8BT Lead Inspector Denise Debieux Key Unannounced Inspection 14th August 2006 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 Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bernard Sunley Nursing Home Address College Road Maybury Hill Woking Surrey GU22 8BT 01483 764300 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) manger@bs.fote.org.uk Friends of the Elderly Ms Cheryl Louise Greta Rothschild Care Home 60 Category(ies) of Dementia (35), Dementia - over 65 years of age registration, with number (35), Old age, not falling within any other of places category (60) Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 25 beds providing nursing care to elderly people over the age of 60 years Of the 60 residents accommodated, up to 35 may be within the category DE(E) or DE, over the age of 60 years. In respect of this service, residents may be admitted from the age of 60 YEARS AND OVER Level 4NVQ Management to be obtained by 2005 Date of last inspection 22nd August 2005 Brief Description of the Service: Bernard Sunley is a registered home providing nursing care services for up to 60 service users in the categories of old age and dementia. The home is owned and managed by Friends of the Elderly who are the registered provider. Bedrooms are arranged over two floors, which are lift accessible. Accommodation in the home includes a secure environment for those service users who are diagnosed with dementia. The home is located close to local shops and has good road links and offers car parking facilities. Fees range from £749 - £991 per week. This fee does not include newspapers, hairdressing, chiropody, pads, transport or arranged outings. This information was provided on 02/08/06. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over 9.5 hours and was carried out by Denise Débieux, Regulation Inspector. Miss Cheryl Rothschild (Registered Manager) was present as the representative for the establishment. A tour of the premises took place. Six of the fifty-two service users and four on-duty staff were spoken with during the visit. In addition, ten service user survey forms and four relatives’ survey forms were completed and handed in to the inspector on the day of this visit. Some of the comments made to the inspector and made on the survey forms are quoted in this report. The home had completed a pre-inspection questionnaire and service user care plans, staff recruitment records, health and safety check lists, menus, activity schedule, medication records and storage were all sampled. The lunchtime meal and medication round was observed and the home was toured. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this visit. What the service does well: What has improved since the last inspection? The ongoing maintenance, redecoration and refurbishment programme provides service users with a safe and comfortable environment in which to live. Since the last inspection the home have amended their statement of purpose and service users’ guide, amended their complaint’s and protection of vulnerable adults procedures, increased the number of care staff qualified to National Vocational Qualification (NVQ) level 2 in care and started to introduce regular staff supervision. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 6 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. Bernard Sunley Nursing Home DS0000017593.V307842.R01.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 Bernard Sunley Nursing Home DS0000017593.V307842.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user is only admitted to the home following a comprehensive needs assessment to ensure that the home can meet the service user’s identified needs. The home does not offer intermediate care. EVIDENCE: Following the previous inspection the home have updated their Statement of Purpose and Service Users’ Guide. At the time of this visit the home were in the process of amending these documents in line with new legislation that comes into effect on the 1st September 2006. Three care plans were sampled for the most recent admissions to the home. In each case full and comprehensive pre-admission assessments had been carried out prior to admission to ensure that the home could meet the service users’ identified needs. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 9 Sixty per cent of service users surveyed confirmed they had received enough information prior to deciding to move into the home. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to ensure that all service users have an up to date, individual care plan that details the care required to fully meet all aspects of their health, personal and social care needs. Policies, procedures and practices are now in place to ensure the safe administration of medication. Service users feel they are treated with respect and that their right to privacy is upheld. EVIDENCE: The care plans sampled during this visit were all based on comprehensive preadmission assessments. The care plans sampled were all drawn up shortly after the service users’ admission to the home and the company has a comprehensive system of preprinted care plans and risk assessments for the staff to use. However, the care plans sampled did not include all areas of need identified in the pre-admission assessments and the pre-printed care plans had not been fully personalised with the service users’ preferences or individualised needs. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 11 E.g. One service user was identified in the pre-admission assessment as having a pressure sore. The risk assessment on admission showed that the service user was at high risk of developing pressure sores but there was no documentation to show what preventative action had been taken by the home to prevent skin breakdown and no mention of his skin integrity having been assessed either on admission or at any other time. In another file the GP had identified new problems on the GP notes that had not been added to the service users’ care plan. All files had risk assessments for the service users’ rooms but other risk assessments were not present (i.e. risk assessments regarding falls.) No care plans included social care needs and none sampled had been signed by service users or their representatives to signify their agreement with the contents. The care plans were reviewed on a monthly basis, however, some of those sampled, whilst signed as reviewed, had not been updated to reflect the current situation. Daily notes are made but do not provide evidence that specific needs are being met or that staff are carrying out the actions identified in the care plans. In discussion with the manager and on inspecting the available care planning system, it was clear that the home have developed a comprehensive system for planning, developing and evidencing the care provided. However, this system is not being fully implemented by the staff and the quality of the care plans is inconsistent and depends on the member of staff writing up the care plans. Two of the previous requirements regarding care plans have not been fully met and have been carried forward and incorporated into one requirement. Of the ten service users surveyed, four said they always receive the care and support they need, four answered ‘usually’ and another answered ‘always during the day’ and ‘usually during the night’. One service user commented ‘this is a very caring institution’. The medication administration records, medication storage, policies and procedures were all sampled and found to be in order. The lunchtime medication round was observed and seen to be in line with the home’s policies and procedures. During the tour of the home staff were observed to always knock before entering the service users’ bedrooms and all service users surveyed and spoken with stated that they felt their privacy was respected. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. 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. The activities provided by the home are varied, well planned, and include contact with the local community both within and outside the home, but attention must be paid to individualising activity plans and providing opportunities for all service users to partake in meaningful activities. Contacts with family and friends are encouraged. The meals in this home are good, offering both choice and variety and catering for special dietary needs. EVIDENCE: The home employs two activity co-ordinators. One works Monday-Wednesday and the other works Wednesday-Friday. The inspector was advised that activities provided include: arts and crafts; poetry readings; book reading; discussion groups; games; reminiscence sessions; musical entertainers; exercise sessions and outings (e.g. recently to Kew and Wisley gardens). During this visit the inspector saw that the activity co-ordinators have taken a detailed social history with each service user and document daily which activities service users attend. This information is kept in the activity room and is not available to staff at times when the activity co-ordinators are not Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 13 working (i.e. each weekend). It has already been noted in the previous section that service users do not have individualised care plans for social care and this has been included in the requirement already made regarding care plans. Of the ten service users surveyed, two said there were always activities they could take part in, two answered ‘usually’ and two answered ‘sometimes’. Comments made included: ‘if I can hear’ and another that poor hearing makes taking part in activities difficult. The comments made indicate that the home need to review their activity provision for all service users, paying particular attention to people with dementia and sensory impairments and incorporating individual service users’ previous hobbies, pass times and interests into individual plans. The survey results and comments made were discussed with the manager. Some information leaflets were left at the home for ideas and the manager stated she would explore external links for advice, ideas and possible specialised training. There are no restrictions to visiting times and staff support and encourage service users to maintain family links and friendships inside and outside the home. Menus were sampled and seen to be varied and well-balanced. The lunchtime meal was taking place during the visit and the food was presented in an appetising manner. Ample staff were present and offered help or assistance where needed in a discreet and sensitive way. The atmosphere in the dining rooms on the day of this visit was convivial and unhurried. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All required policies and procedures are in place to ensure that service users and their relatives feel their views will be listened to. Policies are in place to protect service users from abuse but staff recruitment procedures are placing them at possible risk of harm or abuse. EVIDENCE: The home has a complaint’s procedure in place that is available to all service users and their relatives and is also included in the service users’ guide. Following the last inspection the home have reviewed their documentation and made sure that the same complaint’s procedure is in all documents. At present the complaint’s procedure states that a complainant can contact CSCI if they are not happy with the outcome of any complaint to the home. A recommendation has been made that this be amended to advise people that they can contact CSCI at any stage of the procedure. Of the ten service users surveyed, six knew how to make a complaint, one answered ‘usually’ and one answered that they did not know how to make a complaint. Seven answered that they always knew who to speak to if they were not happy, one answered ‘usually’ and one answered ‘sometimes’. The home has a ‘Whistle Blowing’ policy in place and basic awareness of the protection of vulnerable adults is included in the home’s induction training. A copy of the latest ‘Surrey Multi-agency Procedure for the Protection of Vulnerable Adults’ is available in the manager’s office for staff to refer to. The Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 15 home’s own policy has been amended and now indicates that staff will follow the local Surrey procedure. The manager demonstrated a sound knowledge of the local procedure. Service users spoken with told the inspector that they felt safe at the home. Staff recruitment is addressed in the ‘Staffing’ section of this report. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home and gardens are suitable for their stated purpose. An ongoing maintenance and redecoration programme provides the service users with clean, pleasant and homely surroundings in which to live. EVIDENCE: Service users spoken with expressed their satisfaction with the accommodation provided at the home. Six of the ten service users surveyed stated that the home was always fresh and clean, with four answering ‘usually’. The home is divided into two units, one for service users with dementia and one for service users requiring nursing care. Each unit consists of two floors and has been built around it’s own central, secure courtyard. There is a key pad entry system for all doors into/out of the dementia unit. The inspector was impressed to see the freedom that this design offers service users with Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 17 dementia to access all areas of their unit, including access to the internal courtyard/garden area. Laundry facilities are sited on the ground floor with washing machines appropriate for the needs of the service users at the home. On the day of this visit the home was found to be warm and bright with a homely atmosphere and a high standard of housekeeping apparent. The grounds and internal courtyards were well maintained with additional, shaded seating areas provided for the service users and their visitors. All personal rooms seen were individualised to the service users’ wishes and were seen to contain personal items and mementos. One of the service users commented on how much she liked her room and the view of the garden from her window. However, it was noted, and mentioned to the inspector by some service users, that recent building works have affected the views from some rooms. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing numbers meet service users’ needs. The home has a staff training programme which is designed to ensure, as far as reasonably possible, that service users are in safe hands at all times but the home needs to produce an action plan showing how the percentage of staff qualified to NVQ level 2 in care will be increased from 17 to 50 . Action must be taken to improve the staff recruitment procedures to ensure that the service users’ safety is protected and that all required information and checks have been obtained and verified for new employees before they commence employment. EVIDENCE: The staff rota evidenced that staff are provided in sufficient numbers to meet the needs of the service users at the home. Of the ten service users surveyed, four stated that staff are always available when needed, four answered ‘usually’, one answered ‘sometimes’ and one answered always during the day and usually during the night. The inspector was advised that the home now have two external verifiers for NVQ training. To date there are forty-two carers, seven have achieved NVQ level 2 in care, seven are in progress and carers are being enrolled on the course as others finish. The manager said that there had been a limit of seven at a time when there was just one external verifier but that they will now be Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 19 able to increase numbers with a second verifier, thereby, eventually bringing the percentage of qualified staff up to the required 50 . A requirement has been made that the home develop a clear plan, including timescales, setting out how the home will meet the minimum 50 of qualified carers. During this visit the files of three recently recruited members of staff were sampled. In these files, all had completed application forms, all contained two references and all had valid enhanced Criminal Record Bureau (CRB) certificates which included a check on the Protection of Vulnerable Adults (POVA) list. However, two files did not have recent photographs, their application forms had gaps in employment that had not been explored or explained and references had not been obtained from their last place of employment which involved working with vulnerable adults. The manager was unaware of the amendments to the regulations that came into effect in July 2004. These amendments were discussed with the manager and a copy of the new Schedule 2 was left for reference. A copy of the CSCI recent publication ‘Safe and sound?: Checking the suitability of new care staff in regulated social care services’ was also left at the home on this visit and requirements have been made. Bernard Sunley Nursing Home has an induction and ongoing training programme which covers all areas required by the Skills for Care organisation (previously TOPSS). The training logs seen at this visit evidenced that all mandatory training and updates are provided promptly and the training records were well maintained and easy to follow. The inspector was advised that individual training needs are identified at the employee’s annual appraisal and additional training is provided that is relevant to the needs of the individual service users at the home. The inspector was advised that the home have also recently developed a new training initiative, covering the provision of care to people with dementia. There is a one day course ‘stage 1 dementia training’ which all staff, including ancillary staff are required to attend. Stage 2 dementia training is a six month part time course that selected registered nurses and care assistants will be attending and Stage 3 dementia training which is a year long training which the new deputy manager will be attending. Service users spoken with were complimentary about the staff at the home. Of the ten service users surveyed, nine stated that staff always listen and act on what they say and one answered ‘usually’. One service user commented that ‘most of the staff are very polite and kind’. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well supervised and supported staff team and from the clear management approach at the home. The home has an effective quality assurance and monitoring system in place that is based on seeking the views of the service users. Policies and procedures are in place to protect service users’ financial interests. All other policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of service users and staff. EVIDENCE: The registered manager is a registered nurse (RMN) and has worked at Bernard Sunley Nursing Home for the past five years. She was the deputy manager for one year and has now been the manager for the past year. Ms Rothschild has recently begun her Registered Manager Award training. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 21 An annual service user survey is carried out. When the results have been correlated a report is sent to the home and an action plan is developed to address any issues that are identified. The home had recently received the results of the last survey. This survey involved the service users and their relatives. A recommendation has been made that the home expand their quality assurance system to include seeking the views of stakeholders in the community (e.g. GPs, chiropodists, care managers and other health and social care professionals). Staff supervision has now been introduced with the care assistants and a schedule was seen showing that staff will be receiving supervision at least six times a year. Regular group supervision is taking place in the form of staff meetings. However, the manager was not aware that one-on-one formal supervision must be provided to all care staff, including the registered nurses and the system of staff supervision needs to be developed further. A requirement has been made regarding supervision to all care staff and also that staff carrying out supervision receive appropriate training. During the tour of the home it was noted that there was left over food in the refrigerator that had not been labelled. A requirement has been made that all staff must follow the correct health and safety procedures for the storage of food. Previous health and safety requirements have all been met. A random sample of maintenance certificates and safety checks were seen at this visit. All were found to be well maintained and up to date. All interactions observed between the staff and service users were inclusive, caring and respectful. Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 22 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 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP7 OP12 Regulation 14(2)(a) (b) 15(1) 15(2) (a-d) 16(m)(n) Requirement The registered person must review all care plans and ensure that each service user has an individual plan of care that includes the following: • A comprehensive assessment of needs covering all areas of health, personal and social care (activity) needs; • Risk assessments, to include prevention of falls, use of bed rails and risk of pressure sore development; • Details of all individual needs identified, including social care needs; • Goal/objective for each need; • Actions to be taken to ensure the goals are met and to include the service users’ preferences; • Daily report writing to evidence that identified needs and goals are being met; • Newly identified needs or problems must be promptly added to the care plan; • Signature of service user/representative to signify their involvement and DS0000017593.V307842.R01.S.doc Timescale for action 14/11/06 Bernard Sunley Nursing Home Version 5.2 Page 24 2 OP28.1 3 OP29 4 OP29 5 OP29 6 OP29 agreement with the plan. The registered person must develop a clear plan, including timescales, setting out how the home plans to increase the number of care assistants qualified to NVQ level 2 in care, to a minimum of 50 . 19(1)(b) The registered person must not Schedule2 employ a person to work at the care home unless he/she is fit to work at the care home and the registered person has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). 19(1)(b) The registered person must Schedule2 check all staff files and obtain the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) retrospectively for all staff employed since 26th July 2004. 18(2)(a) The registered person must 19(1)(b) ensure that any staff that do not Schedule2 have all the required checks and documentation in place, are closely supervised until all requirements of Regulation 19 and the amended Schedule 2 of the Care Homes Regulations 2001 are fully met. 18(1) The registered person must ensure that all staff responsible (c)(i) for staff recruitment are aware 19(1)(a-c) of, and understand, the requirements of The Care Homes Regulations 2001 and Schedule 2 18(1)(a) (c)(i) DS0000017593.V307842.R01.S.doc 14/10/06 14/08/06 21/08/06 14/08/06 14/08/06 Bernard Sunley Nursing Home Version 5.2 Page 25 7 OP36 18(2)(a) 8 OP36 18(1) (c)(i) 13(3)(4) 9 OP38 10 OP33.10 24A(1-3) (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). This must take place before any further recruitment of staff. The registered person must ensure that all care staff (including registered nurses and the manager) receive formal supervision at least 6 times a year. The registered person must ensure that any staff carrying out formal staff supervision have received appropriate training. The registered person must ensure that all food is stored correctly in line with current legislation. The registered person must submit, to the CSCI, Eashing office, an improvement plan, setting out exactly how requirements 1-9 will be met in full. The plan must set out the methods by which, and the timetable to which, the registered person intends to improve the services provided in the care home. 14/11/06 14/11/06 14/08/06 21/09/06 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 OP12 Good Practice Recommendations It is recommended that the home draw up individualised, weekly activity schedules for each service user, taking into account their preferences and previous interests and hobbies. DS0000017593.V307842.R01.S.doc Version 5.2 Page 26 Bernard Sunley Nursing Home 2 3 OP16.4 OP33.7 It is recommended that the complaint’s procedure be amended to state that a complainant can contact CSCI at any stage of the process. It is recommended that the quality assurance system is expanded to include seeking the views of stakeholders in the community (e.g. GPs, chiropodists, care managers and other health and social care professionals). Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bernard Sunley Nursing Home DS0000017593.V307842.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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