Inspection on 07/08/07 for Bernard Sunley Nursing Home

This inspection was carried out on 7th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 14/08/06

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 Lesley Garrett Unannounced Inspection 7th August 2007 09:30 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.V339188.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.V339188.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 www.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.V339188.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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 14th August 2006 Date of last inspection 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 £795 - £1,075 per week. This fee does not include newspapers, hairdressing, chiropody, transport or arranged outings. Bernard Sunley Nursing Home DS0000017593.V339188.R01.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 09.30 and was in the service for five hours. The inspection 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 the CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at the home’s records and completed a tour of the building. The inspector also 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. No people who use the service, their relatives/representatives or other visiting health care professionals had returned surveys to us therefore these comments cannot be included in this report. What the service does well: All people who use the service are assessed prior to admission to the home to ensure that their needs can be met and individual care plans are in place. There are good relationships with the healthcare professionals to ensure that their health needs are met. Policies and procedures are in place that helps to protect service users from harm and these include the safeguarding adult’s procedure and the home’s recruitment practices. 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 backgrounds. People who use the service told us ‘this is a lovely home I have been her quite a long time. My husband used to live here as well’. ‘I like the food I am always given a choice’. ‘My bell is usually answered quickly, I like the girls who work here’ Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 6 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. Bernard Sunley Nursing Home DS0000017593.V339188.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.V339188.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. 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 individuals have a pre-admission assessment and are confident that their needs will be met. The home does not provide intermediate care beds. EVIDENCE: All individuals have a pre-admission assessment prior to admission to the home. The manager stated that either herself, the deputy or the team leaders carry out these assessments. The manger showed us the assessment forms, which were detailed and enabled the home to have all the necessary information to enable them to care for the service user on admission. The manager stated that she does all the assessments for the dementia unit. Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 9 The manager also told us that she also carries out assessments on individuals that return to the home following admission to hospital. She stated this was to ensure that they could still meet their needs or change existing care plans. The pre-admission assessments are kept in the individual care plan folders and care plans are generated from this assessment. Bernard Sunley Nursing Home DS0000017593.V339188.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals who live at the home have 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 the individuals. The privacy and dignity of the service users is respected. EVIDENCE: We sampled six folders containing the plans of care for those individuals. At the last inspection in August 2006 a requirement was made that these plans contain risk assessments and they were to be individualised and reviewed regularly. All plans sampled contained individualised care plans with evidence of monthly reviews by the nurses and service user and relative or representative involvement. Risk assessments were also in place, which was relevant to that individual, but they also contained environmental risk assessments. The plans also contained a good social history, an activities care plan and a catering slip which highlighted likes and dislikes for their diet. Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 11 The manager told us that they have god support from their local general practitioners (G.P.) who visit the hoe every week. One of the G.P.’s in the practice visits the dementia unit and the other covers the elderly frail unit. Individuals who are admitted to the home can retain their own G.P. if they wish and their practice is local to the home. The manager told us that the home employs two physiotherapists to work one on each unit to aid individuals with their mobility and rehabilitation. 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. Individuals can lock their bedrooms doors if they wish and there is a master key held by the staff team. Bernard Sunley Nursing Home DS0000017593.V339188.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to exercise choice and control in all that they do and the food is of a good quality. EVIDENCE: The manager told us that the home has two part time activity organisers and they are trying to recruit another person to support the individuals with activities at the weekend. A variety of activities are available to the individuals who live at the home and these include exercise to music, quiz’s and art classes. Organised outings are also arranged and these trips have included a visit to a local garden, meals at a local restaurant and a boat trip. The manager stated that they can organise a local bus to pick them up and it is also able to take wheelchairs. We also observed that the home has its own chapel and services take place here twice a week. Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 13 The manager stated there are no restrictions on visiting and that they are welcome at any time. When the reception area is not staffed there is a video entry system so that all visitors to the home can be monitored. The manager explained that all the individuals at the home are given choices about their daily lives. On the day of the visit we observed one individual enjoying her morning coffee with a member of staff. They were both sitting in the office and we were told this happens frequently as that is where that individual prefers to be. All individuals are given choice about when to get up in the morning and go to bed. The manager stated that unless they have to take a particular medicine at a stated time all individuals are left to wake naturally. The manager also told us, and this was also documented, that individuals have choices about hospital admissions and end of life issues. The home has a full time chef and a catering company supplies him. He had a good knowledge of special diets and showed an example of a pureed diet, which he places in moulds to improve the presentation of these dishes. The chef has also got a comments book which is in the dining rooms and we saw these and comments made about the food by both individuals who live at the home and their relatives were favourable. The chef reads these books every day and also attends all resident meetings. The only negative comment being that the beef was tough one particular day. Fresh fruit and vegetables are always available. Bernard Sunley Nursing Home DS0000017593.V339188.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 Quality in this outcome area is good. 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, which we observed and she said they had received three 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. The complaints procedure for the home was displayed in the home and each of the bedrooms. 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. The manager stated that all staff has safeguarding adults training when they start their employment with the home but this is not then repeated frequently. It is recommended that this training be carried out more frequently. Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 15 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 good. 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 have en-suite facilities and communal bathrooms are also available. The manager employs a full time maintenance supervisor and two more who are part time. Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 16 Service users have access to safe well-maintained patio gardens, which the manager said in good weather is well used and table, chairs and shade were available for their use. On the day of the visit we observed individuals who live at the home using the garden and staff were ensuring that sun protection cream had been applied to those that need this. We met the laundress and found the laundry neat and tidy. She had knowledge of infection control procedures and had received training. The home has three washing machines and three driers. There was adequate facilities for washing hands around the home with gel hand rub available for all staff. Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 17 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 good. 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: The manager told us that she and her deputy do all the work rotas. She stated that dependency levels for all of the individuals who live at the home are completed every month to determine the level of staffing numbers required. We observed both the rota and the assessed staffing levels for that month. At busy times all staff work in the dining rooms delaying their breaks until the individuals who live at the home have finished. Carers are always available at the table to assist with feeding whilst one staff member serves the food. At the inspection in August 2006 a requirement was made for the home to increase the numbers of staff who held the National Vocational Qualification (NVQ). This has been actioned by the manager. She told us that the home now has two assessors and eleven staff has completed this qualification and ten are currently doing the course now. Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 18 Requirements were made again in August 2006 that the establishment improve their recruitment practices. We sampled three recruitment folders and found that all the necessary documentation and checks were in place. The manager stated in her completed quality document for CSCI (AQAA) that the home has also recently changed their application form. The manager stated that the home develops a yearly training plan and all staff has a copy of this. All staff receives mandatory training when they are first recruited and fire awareness and manual handling is repeated every year. A recommendation has been made for the manager to check what training needs to be repeated every year. Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 19 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 good. 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, has effective quality assurance systems developed by a qualified competent manager. EVIDENCE: The manager has been in post for two years and is currently undertaking her registered managers award. She also stated that she attends regular training to keep herself updated in current practice. A deputy manager and team leaders support her. Both the manager and deputy are supernumerary and the team leaders also have these hours in order to complete tasks for example medication orders. Prior to the inspection the manager had completed the quality document supplied to her (AQAA). This was completed in pencil and it Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 20 has been recommended that she complete further documents on her computer. She stated this had been her intention to transfer the information but she ran out of time. Quality audits are carried out in the home and surveys were last sent to individuals who live in the home and their relatives in March 2007. These audits go to the regional manger for analysis and an action plan is drawn up. We observed these audits and any problems had been highlighted for action. During the last inspection a recommendation was made that the home includes other visiting professionals in their surveys. This has not been actioned so far but the manager stated this had been discussed with her regional manager and this will be included in the next survey therefore it remains a recommendation. The manager told us that any personal allowance money that individuals want the home to keep safe is kept in the safe and the administrator and manager have access to this. All receipts and invoices are kept and the administrator will inform relatives if the money is getting low. The individuals who live at the home can have access to this money whenever they want it. The manager told us that monthly fire drills take place and the fire procedure has been recently revised. The alarms are tested every week and documentation is kept. On the AQAA returned to us the home did not have a current electrical certificate. The manager stated there is another certificate which she had since found dated 16/07/04 and lights and sockets and emergency lighting has been tested in June 2007. Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 21 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 22 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. 2. 3. Refer to Standard OP33 OP30 OP33 Good Practice Recommendations It is recommended that the manager clarify what is expected as mandatory training and include any changes on her training plan. It is recommended that safeguarding training within the home be increased. It is recommended that the quality assurance system be expanded to include seeking the views of stakeholders in the community. It is recommended that the quality document (AQAA) that is completed and returned to CSCI is not completed in pencil. 4. OP33 Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bernard Sunley Nursing Home DS0000017593.V339188.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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