Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 22/08/05 for Bernard Sunley Nursing Home

Also see our care home review for Bernard Sunley Nursing Home for more information

This inspection was carried out on 22nd August 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service is covering the absence of the manager well although this has had an impact with regard of the completion of the requirements. The home was clean and without any smells. A continence advisor was working within the home at the time of the inspection and was working closely with staff to meet the needs of the residents.

What has improved since the last inspection?

The home has worked toward meeting the requirements made at the announced inspection on the 28th April 2005 and has made reasonable progress taking into account the difficulties of an absent manager and a delayed report.

What the care home could do better:

Requirements were made at the inspection on the 22nd August; these include reviewing the procedures for the storage and administration records of medication and reviewing the contract for services supplied to the residents.

CARE HOMES FOR OLDER PEOPLE Bernard Sunley Nursing Home College Road Maybury Hill Woking GU22 8BT Lead Inspector Mrs Susan McBriarty Unannounced 22 August 2005 nd 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 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 H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Friends of the Elderly Mrs Cheryl Rothschild (acting manager) Care Home 60 Category(ies) of DE - Dementia (35) registration, with number of places DE(E) - Dementia - over 65 (35) OP - Old Age (60) Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 2. 25 beds providing nursing care to elderly people over the age of 60 years. 4. Of the 60 residents accomodated, up to 35 may be within the category DE(E) or DE, over the age of 60 years. 5. In respect of this service, residents may be admitted from the age of 60 YEARS AND OVER. 6. Level 4 NVQ Management to be obtained by 2005 7. Manager to attend training in protection of Vunerable Adults by 1st July 2004. Date of last inspection 28th April 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 aranged 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. Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second inspection for 2005-2006. For a fuller picture of the home please see previous inspections reports. The inspection focuses on the standards not assessed at the last inspection and progress of the requirements made on the 28th April 2005. There has been a delay in the completion of the requirements, in part due to the delay in the previous report being sent out and in part due to the ill health of management within the home. This has been recognised within the report and the dates for outstanding requirements extended. The Inspector was able to speak to only one resident as others were found by the Inspector to be engaged in other activities including seeing their visitors. A continence advisor was present and discussed their ole within the home with the Inspector. The continence advisor is in the early stages of reviewing, with the staff, the needs of the residents. What the service does well: 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. Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 7 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 standard(s) Standards 1,2,3,4, and 5 were assessed at the announced inspection on the 28th April 2005. EVIDENCE: Standard six (6) does not apply. A requirement was made at the announced inspection on the 28th April 2005, that the statement of purpose is updated. The report from that inspection was delayed and the requirement completion date has therefore been extended and is noted again in the requirement section of this report. Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 8 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 standard(s) 7,8,9 Standards 7,8,10 and 11 were assessed at the announced inspection of the 28th April 2005. Further work is required to ensure the home meets Standard 9 of the Minimum Standards Older People. Some further aspects of Standards 7 and 8 were assessed and requirements have been made to ensure that residents needs are met. EVIDENCE: A requirement was made at the announced inspection on the 28th April 2005, that the care plans are reviewed and updated. The report from that inspection was delayed and the requirement completion date has therefore been extended and is noted again in the requirement section of this report. The inspector sampled the records for the administration of medication and medication in use. Some gaps were found in the medication administration records, medication that required disposal prior to the inspection was noted and the recording of allergies was unclear. A requirement is made that the home reviews the procedures for the storage and administration of medication. The home has provided the CSCI with a number of Regulation 37 notifications since the last inspection regarding residents falling within the home, the Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 9 majority of falls note that no injury to the resident was found. It is required that the home reviews the number of falls and involve an appropriate specialist assist the review process. The home provides bed rails to a number of residents that have not been risk assessed. In order to ensure that the correct rails have been fitted for each resident it is required that the home risk assess each resident where bed rails have been provided. Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 10 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 standard(s) Standards 12,13,14 and 15 were assessed at the announced inspection on the 28th April 2005. EVIDENCE: A requirement was made that all food stored in the fridge is dated. The requirement has been met. The issues raised with the inspector at the announced inspection on the 28th April had been resolved. Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 11 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 standard(s) Standards 16,17 and 18 were assessed at the announced inspection on the 28th April 2005. EVIDENCE: A requirement was made at the announced inspection that the policy for the protection of vulnerable adults be reviewed to include a procedure for staff to follow. At the unannounced inspection on the 22nd August 2005 the CSCI were given a copy of the draft update. The requirement has not been met and the registered person is referred to the local guidelines for the protection of vulnerable adults. A requirement was also made regarding the home’s complaint procedure. The requirement has not been met and a further date has been given. As stated previously the last inspection report was delayed and this has impacted on the organisations ability to meet the timescales given. At the inspection on the 22nd August the Inspector sampled contracts provided to residents by the organisation. The complaint section of the contract stated that the resident may only complain to the home manager. It was unclear whether this was with regard to any complaints regarding the contract of any complaint a resident may wish to make. The organisation must include the contract as part of the reviewing process to ensure that information given to residents and or their representatives is correct and clear. The homes policy on managing aggression and violence and the policy on rights, risks, restraints of older people also required review and updating. The organisation had not met this requirement and is reviewing their services taking this issue into account. Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 12 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 standard(s) Standards 19,20,21,22,23,24,25 and 26 were assessed at the announced inspection on the 28th April 2005. EVIDENCE: Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 27,28,29 and 30 were assessed at the unannounced inspection on the 28th April 2005. EVIDENCE: A requirement was made at the announced inspection on the 28th April that all employment records are held at the home in line with The Care Homes Regulations 2001 (as amended). This was nearing completion at the time of the unannounced inspection on the 22nd August 2005. A requirement that the home provide the CSCI with a plan to show how they will meet the National Vocational Qualifications by 2005 was made at the unannounced inspection on 28th April 2005. The home has been in discussion with their Human Resources Department and are able to support a further five people on the course before the end of this year. This action does not fully meet the 50 of staff being qualified as required however it was recognised by the CSCI that the home could not effectively support more than five on the course at one time. It is required that the home provides the CSCI with a plan to complete the required training within a reasonable timescale and to inform the CSCI of the details of that plan. Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35,36 Standards 31,32,33,34,35,37,and 38 were assessed at the announced inspection on the 28th April 2005. Further work is required to ensure that Standard 36 of the National Minimum Standards Older People is met. EVIDENCE: The requirements made at the announced inspection on the 28th April 2005 have been met. However during the unannounced inspection on the 22nd August 2005 a cupboard containing chemicals and electrical wiring was found by the inspector to be unlocked. A requirement is made for the home to ensure that chemicals hazardous to health are stored appropriately. The home has reviewed those staff working at the home whether employed by them or otherwise and was in the process of ensuring that all had a current Criminal Record Bureau check (CRB). Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 15 The Inspector sampled a number of resident finances and found very minor shortfalls in the recording process. Recent financial transactions had not been recorded in full in some of the finances sampled. It is required that the home review the procedure for recording financial transactions. Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x 2 2 x x Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 17 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4(1)(a)(b) (c)(2), 5(1) (af)(2) Requirement The registered person must ensure that the statement of purpose and service user guide are updated and a copy forwarded to CSCI. Timescale of 31st July 2005 not met. The registered person must ensure that the care plans are updated and reviewed regularly. Timescale of 31st May not met. The registered person must ensure that a review of falls involving service users within the home are reviewed and involve an appropriate specialist. The registered person must ensure that where bed rails are in use a risk assessment has been completed and a copy is on file and open to inspection. The registered person must ensure that the procedure for the recording, handling, safekeeping, safe administration and disposal of medication is reviewed. The registered person must ensure that the complaints procedure is updated and accurate in all of the homes Timescale for action 30th September 2005 2. 7 15(1)(2)( a)(b)(c) (d) 13(4)(c ) 30th September 2005 15th October 2005 9th September 2005 9th September 2005 3. 7 4. 7 13(4)(c ) 5. 9 13(2) 6. 16 22 30th Septmebr 2005 Page 18 Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 7. 17 13(4) (c )(6)(7) 8. 18 13(4)(c )(6) 9. 28 18(1)(a) (c) 10. 35 17(1)(2) (3) 18(1)(a) 11. 36 documentation. Timescale of 31st July not met. The registered person must ensure that the procedures for rights, risks and restraint and managing aggression are reviewed and updated. Timescale of 31st July not met. The registered person must ensure that the policy and procedure on the protection of adults is reviewed and updated. Timescale of 31st July not met. The registered person must provide the CSCI with a plan stating how they will meet the NVQ requirements within a reasonable timescale. The registered person must ensure that the procedure for recording residents financial transactions is reviewed. The registered person must ensure that staff supervision is provided at least six times a year and is recorded and the documents open to inspection. 30th September 2005 9th September 2005 9th September 2005 9th September 2005 30th September 2005 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 Good Practice Recommendations Bernard Sunley Nursing Home H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 1RT 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 H58 s17593 Bernard Sunley v236968 220805 stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!