Inspection on 28/04/05 for Bernard Sunley Nursing Home

This inspection was carried out on 28th April 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 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

Bernard Sunley Nursing Home 07/08/07

Bernard Sunley Nursing Home 14/08/06

Bernard Sunley Nursing Home 22/08/05

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 GU22 8BT Lead Inspector Mrs Susan McBriarty Announced 28 April 2005 th 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_v21345_280405_stage4.doc Version 1.30 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 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_v21345_280405_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Dementia (35), Dementia - over 65 years of age (35), Old age, not falling within any other category (60) Date of last inspection 6th September 2004 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_v21345_280405_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, the first for 2005 – 2006. Previous inspection reports are available on request from the Commission for Social Care Inspection (CSCI). During this inspection 3 family members of different service users, 3 service users, 4 staff and 1 General Practitioner were seen and spoken to at length. 19 comment cards were received from family members and service users and have been taken into account as part of the inspection. The manager had also provided a pre-inspection report. Records and documents were sampled including; policies and procedures, staff personnel files, service user files, training plans, business plans, quality assurance audit documents and the home’s statement of purpose. A tour of the home took place and all communal areas and five bedrooms were seen. Food preparation and menus were seen but not sampled. 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_v21345_280405_stage4.doc Version 1.30 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_v21345_280405_stage4.doc Version 1.30 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) 1, 2, 3, 4, 5 Information provided by the home to the service users requires updating and review. Admissions to the home are based on assessment and wherever possible visits by prospective service users are made before moving in. EVIDENCE: The statement of purpose and service user guide need considerable updating and review. The present documents do not show the change in management structure, staffing qualifications and a number of the policies mentioned in the document require review. A requirement has been made to ensure that the statement of purpose and service user guide is updated. The current manager undertook the assessments for those people with dementia and the team leader for the nursing needs unit undertook any remaining assessments. Both are qualified nurses. The prospective service users and their families or representatives can visit the home prior to moving in. All service users have a signed contract stating the charges for services provided. Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 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, 10, 11 The home provides care plans and risk assessments that require some updating. The organisation has policies and procedures in place for supporting people at the end of their lives. EVIDENCE: Detailed care plans that include the health needs of service users are provided. Some updating is required to ensure that all the service users needs are reviewed regularly. Where standard forms are in use staff should ensure that only the support required is noted. The care plans included forms for visiting health professionals to complete and sign on the occasion of every visit. During this inspection staff were observed speaking to service users in a respectful manner. The majority of comment cards received by CSCI from family members and friends were complimentary about the staff and the service offered and felt the staff treat the service users well. Those service users spoken to during this inspection were satisfied with the service offered. The general practitioner spoken to discussed the meetings that were taking place with the primary care team regarding roles and responsibilities within nursing homes. At times, the doctor felt that nursing homes were asked to be specialists in all areas and sometimes had difficulty in getting the local advise and support the doctor felt they required. Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 9 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) 12, 13, 14, 15 Service users are able to exercise choice wherever possible and family members and friends can visit the home throughout the day. EVIDENCE: Comment cards received from service users, the pre-inspection report, records of activities attended by individuals and discussions with service users and family members during the inspection offered a variety of views about the activities on offer. Some service users and their families would like to see more choice others were very satisfied with the options available. One problem was said to be transport. The available transport is not able to take all the service users who wish on all the trips out, as there is not enough room. The staff tries to ensure a fair distribution of events for those that can go. One family seen by the inspector spoke very highly of the home including the way that service users can choose what they wish to do. One of the service users stated that the home was “very good”. Friends of the Elderly are considering offering the relatives the opportunity of regular meetings at the home and CSCI would recommend that this opportunity be offered. Friends and family were observed visiting the home throughout the day. During this inspection four weeks of menus were seen as was the preparation and serving of lunch. The menu was varied and nutritious and plenty of fresh vegetables and fruit were seen. A number of comment cards asked that more green vegetables be served in particular cabbage or greens. Requirements Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 10 have been made with regard to ensure that food stored in all the fridges is dated and that chilled food temperatures are recorded consistently. One issue was raised with the inspector and the manager, this was being dealt with and the manager will be investigating the concerns raised with her manager, CSCI will be informed of the outcome. Following the outcome of a recent quality assurance audit some changes are planned re menu planning and choice. See also the section on management and administration. Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 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) 16, 17, 18 The complaints procedure held within the statement of purpose requires some updating and the policy and procedure for the protection of adults requires review, as do some others. Staff training is adequate to safeguard service users. Advocacy services are noted within the statement of purpose and also require updating. EVIDENCE: The complaint process within the statement of purpose requires some amendment to make clear how the complaint process works. At the time of this inspection the main policy made clear who could be contacted by who and when. The policy within the statement of purpose did not match and was unclear. A number of the comments cards received stated that families and service users were unclear as to how to make a complaint. However a number of copies of the complaints procedure were seen posted throughout the home. The family meetings suggested by the organisation would be useful to ensure that information about the complaint procedure was made clear. One family member expressed some concern, that service users may be affected if a complaint were made on their behalf. The use of advocacy services were noted and advised that the doctor or a nurse could act as advocate, the policy then stated that the address and telephone number followed but no details were given. The present policy for the protection of adults is unclear and does not offer staff a procedure to follow should an adult protection referral be made. Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 12 All these areas require change and or updating. The homes policy on managing aggression and violence and the policy on rights, risks, restraints of older people also require review and updating. Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 13 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) 19, 20, 21, 22, 23, 24, 25, 26 The home provided adequate communal and individual space for the service users use. Sufficient bathing and toilet facilities were provided. EVIDENCE: The home is located near the town centre and access to local shops and facilities were good. Parking is available for visitors to the home and the grounds were kept clean and clear of obstruction. A patio area was available for use by the service users. The communal rooms were all clean, well decorated and homely. Space was available for families and service user to meet each other privately. The comment cards received confirmed this and all noted that private space could be used. The bedrooms are all single rooms and have en-suite toilets and showers, however most service user preferred to bathe and adapted baths were provided. All the bedrooms were personalised. One of the service users spoken to said that she preferred “to be in her own room and read”. The service users Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 14 family were very pleased that she was not “made to join in” as she was not someone who liked group activities. Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 15 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) 27, 28, 29, 30 Staffing levels meet the needs of the service users. Training plans are in place however further work is required to ensure qualifying training levels are met and that records are kept at the home. Progress is required with regard staff not employed by the care home but working within the home. EVIDENCE: The pre-inspection report provided evidence that adequate staffing levels had been provided to the service users. The kitchen staff are contracted from a separate company and domestic staff ensure that day to day tasks such as laundry are completed. The nursing and care staff are therefore free to meet the needs of the service users. The home provides regular basic training to all staff members including; fire safety, health and safety and manual handling. An adaptation programme is provided for overseas-qualified nurses. At the time of this inspection only two staff had the NVQ Level 2 with a further 4 taking the course. The manager has been asked to provide a plan of how the home will meet the 50 of care staff having the NVQ Level 2 by the end of this year. Since the last inspection senior staff are now undertaking management training. Induction training is provided to all staff. The recruitment process protects the service users and CRB checks are completed, as are identity checks. One of the files sampled did not have copies of the identity checks required and the remaining had photocopied CRB checks. The manager said that both the identity check and the original CRB documents Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 16 were held at the organisations head office. A requirement has been made to ensure that all original staffing records are held at the home. Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 17 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) 31, 32, 33, 34, 35, 37, 38 Further work is required in a number of areas and requirements have been made to reflect this. A recent quality assurance audit has been completed. Records for both staff and service users are held appropriately. EVIDENCE: The manager is new in post and is a qualified nurse. The manager now needs to work toward the qualification for registered managers including the registered managers award. The manager’s hours of work had been between 8am and 4pm each day and this has now been adjusted to ensure that for at least one day a week she is available in the evening. One family member had said that she found the manager difficult to see; this should help to resolve this. Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 18 Since being in post some changes have been made and this has assisted clearer record keeping and enabled the manager to maintain an overview of staffing needs. The organisation completed a quality assurance audit looking at all aspects of the service including service user and family member feedback. Each part of the audit resulted in an action plan. The responses show that as at March 2005 the service users and their families were very satisfied or quite satisfied with the service provided. One area where there were less favourable responses was with regard to menu planning. For example of 29 responses 10 were either not very satisfied or not satisfied at all. See also the section on daily lives and activities. A copy of the business plan for 2004/05 was given to CSCI and no concerns were raised. The home is part of a large organisation and is expected to provide their own business plan as part of the organisations overall planning. An administrator is in post to ensure that the service users finances are recorded regularly and accurately. However a large number of service users family members hold the Power of Attorney and are responsible for their parent’s finances. All records on staff and service users are held confidentially and in a locked area. Care plans are accessible to staff and those service users who wish to. Some requirements have been made including ensuring that sharp boxes are dated. An immediate requirement was made during this inspection. A trigger spray-cleaning chemical was found in an open cupboard and was immediately locked away by the manager. The kitchen has a separate staff toilet and some chemicals are held in the adjoining small room. It was recommended that the manager of the kitchen have a key to the room to ensure that when staff members are not present the area can be locked. The service users and their families do not have access to the kitchen and this action would be a precaution. The fridge temperatures were not kept consistently throughout the home and foods stored in the fridges were not dated. One bathroom had a leaking shower and water was pooling on the floor, the manager was aware of the leak. It was required that the room be locked immediately and a notice posted for the room not to be used until the leak had been fixed. It is the registered person’s responsibility to ensure that those people who are working within the care home but not employed by them are CRB checked and qualified to undertake the role they are employed for. Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 19 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 2 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 2 2 3 3 3 3 3 x 3 2 Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 20 No 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 Timescale for action 31st July 2005 2. 3. 7 16 4. 17 5. 18 6. 28 7. 29 The registered person must ensure that the statement of purpose and service user guide are updated and a copy forwarded to CSCI. 15(1)(2)( The registered person must a)(b)(c) ensure that the care plans are (d) updated and reviewed regularly. 22 The registered person must ensure that the complaints procedure is updated and accurate in all of the homes documentation. 13(4) The registered person must (c )(6)(7) ensure that the procedures for rights, risks and restraint and managing aggression are reviewed and updated. 13(4)(c The registered person must )(6) ensure that the policy and procedure on the protection of adults is reviewed and updated. 18(1)(a) The registered person must (c) provide the CSCI with a plan stating how they will meet the NVQ requirements. 19(1)(a)(( The registered person must b), ensure that all records regarding Schedule the employment of staff are kept 2, at the care home. The original Schedule CRB checks are required for. H58_s17593_Bernard Sunley_v21345_280405_stage4.doc 31st May 2005 31st July 2005 31st July 2005 31st July 2005 30th June 2005 30th June 2005 Bernard Sunley Nursing Home Version 1.30 Page 21 8. 38 4 (6)(a)(c)( d)(e)(f)(g ) 13(4)(a) inspection by CSCI. 9. 38 13(4)(a) 10. 38 13(3)(4) 11. 12. 38 38 13(3)(4) (c ) 19(1)(4)( a)(b) The registered person must ensure that all Control Of Substances Hazardous to Health substances are stored safely appropriately at all times. The registered person must ensure that any area causing a hazard to the health and safety of others is appropriatley safeguarded. The door to the bathroom that has a leak must be locked and a clear notice provided that the room was not in use The registered person must ensure that all food stored in a refrigerator within the home is dated The registered person must ensure that sharp boxes are dated The registered person must ensure that all persons working within the home but not employed by them are suitably qualified and have a CRB check 27th April 2005 (immediate ) 27th April 2005 (immediate ) 28th April 2005 28th April 2005 30th June 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 38 Good Practice Recommendations It is recommended that the kitchen manager holds the key to the toilet area where chemicals are stored. This should reduce the risk to any other person entering the kitchen and gaining access. Bernard Sunley Nursing Home H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 H58_s17593_Bernard Sunley_v21345_280405_stage4.doc Version 1.30 Page 23 - 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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