This inspection was carried out on 25th October 2005.
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.
CARE HOMES FOR OLDER PEOPLE
Sunbridge Care Centre 108 Hickory Close London N9 7PZ Lead Inspector
Tony Brennan Unannounced Inspection 25th October 2005 11:00 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 Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 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. Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Sunbridge Care Centre Address 108 Hickory Close London N9 7PZ 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) 020 8804 3354 020 8804 2316 Ashbourne Healthcare Limited (Southern Division) Ms Diane Burgess Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Four specified service users who have dementia may remain accommodated in the home. The home must advise the regulating authority at such times as any of the specified service users vacate the home. 3rd August 2005 Date of last inspection Brief Description of the Service: Sunbridge Care Centre is a modern purpose built care home registered to care for 43 older people. The home is owned and operated by Ashbourne Healthcare, a private company. All bedrooms are single with en-suite facilities. There are lounge/dining areas on each floor, assisted bathrooms and a shaft lift. The home is in a pleasant residential area of Edmonton near a park and local shops. Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken as part of the annual inspection process. The inspector also sought to confirm that the fifteen areas for improvement found at the last inspection were addressed. The manager, Tracey Wilson, assisted the inspector. The inspection took place over one day. The inspector spoke with eight service users, three relatives and seven staff. The inspector toured the building and examined a range of records relating to the care and management of the home. What the service does well: What has improved since the last inspection?
Over the two inspections and one additional visit that have been carried out since April 2005 the home has made consistent improvement in the care and support offered. At the last inspection fifteen areas for improvement were identified. Only one of these remains to be addressed. People who live at the home said that they had been consulted about the contents of their care plans. Care plans had been updated and contain more detailed information on the needs of those living at the home. Risk assessments and care plans had been put in place for the prevention of falls and pressure sores. People who live at the home said there were varied activities on offer. Those who live at the home felt that they were supported to make positive choices and their privacy was respected. Sufficient staff are available to meet the needs of people who live at the home. Training had been provided on care planning and recording. Staff spoken to confirmed that they had supervision with the manager and that they felt supported. All records are complete and accurate. Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 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. Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 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 Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 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): 4 The home does meet all of the assessed needs of service users. EVIDENCE: Service users said that they felt well cared for and staff are ‘attentive’ and met their needs in a sensitive way. Assessments and care plans identified the needs of service users and how they should be supported. Since the last inspection there had been an improvement in the care plans. These now provide more detailed information on the needs of service users and the support they need to live comfortably in the home. A key worker system has been introduced. Service users commented that they felt this was a positive development. Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 10 Service users have sufficient information on how their needs are met. The medical needs of service users are being met. Service users dignity and privacy is always maintained. EVIDENCE: Service users said that they had been consulted about the content of their care plans. They confirmed that care plans reflected how they wished to be cared for. The inspector found that care plans were reviewed monthly and updated to reflect any changes in the needs of service users. Since the last inspection falls assessments had been completed for all service users and, where appropriate, falls prevention plans were in place. The home provides music and movement, and light exercise to ensure that service users remain mobile and prevent falls. Diary notes were found by the inspector to be more detailed and showed that appropriate follow up of any issues identified was taking place. Service users who are at risk of developing pressure sores have a tissue viability assessment and care plans were developed that outlined the treatment recommended by District Nurses. Training had also taken place on tissue viability. Service users said that staff respect their privacy and always knock on their bedroom doors. Service users also said that staff take time to ask how they
Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 10 wished to be assisted. Staff understood how to assist service users in a way that ensures that their privacy is maintained. The inspector observed staff interaction with service users and found that they were accorded respect. Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 Service users are provided with sufficient and varied activities. Service users are supported to maintain contact with relatives and other representatives of their choice. Service users are able to make choices about how they live in the home. EVIDENCE: Service users said that a range of activities in which they could choose to participate were provided. The inspector spoke with the activities organiser who explained that she was organising further activities and entertainment in the lead up to Christmas. An activities programme has been prepared. Service users said that they had been consulted about what would be provided. Service users spoken to confirmed they had a choice as to whom they wished to see. Service users also said that there were no restrictions on visiting times. Service users spoken to confirmed that they could make choices and control their lives. The inspector found that personal preferences were recorded in the service users care plans. This included choice of food. Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 12 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): None of these standards were inspected on this occasion. EVIDENCE: Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 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 the following standard(s): 19 Service users live in a safe and homely environment. EVIDENCE: Service users felt that the home provided a pleasant and comfortable environment. Redecoration had taken place. The inspector saw that regular maintenance was taking place. Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 14 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 30 Sufficient staff are available at all times to meet service users needs. Staff need to achieve NVQ in care at level 2 so that they can meet the needs of service users. Staff do have the skills to meet all the assessed needs of service users. EVIDENCE: Since the last inspection the manager has tried different ways of organising the way that staff are deployed. The manager explained that recruitment has taken place to ensure that more staff are available to meet the needs of service users when this is necessary. Training records showed that training had been provided on recording and care planning. Statutory training has been provided and records showed that it is up to date. The manager explained that she is receiving support from the company’s Regional Training Coordinator. The manager was able to confirm that all staff are now registered for the NVQ in care and that she is aiming to meet the 50 target for staff to have the qualification. Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 15 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): 33 35 36 Service users have not been consulted about the quality of the service provided and encouraged to make suggestions for improvement. Service users financial interests are protected by the home’s procedures. Staff are appropriately supervised to ensure that the needs of service users are met. Records are maintained as is required for the protection of service users. EVIDENCE: The home has a system in place to consult service users about the quality of the service provided. The inspector saw minutes of a recent meeting with relatives and service users at which they had discussed issues that concerned them. The manager said that there needs to be a survey of the views of service users as this had not been carried out recently. The home operates a system to hold small amounts of money for service users expenses. These are held in separate accounts. No large amounts of money are held. Receipts are held and two signatures certify all transactions. The manager explained that all staff had now been supervised. The inspector was able to see records of
Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 16 supervision to confirm this. Staff meetings had also taken place and relevant issues had been addressed. All records seen were up to date and accurate. Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 17 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 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X x STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X 3 3 3 x Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 18 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 OP33 Regulation 24 Requirement The registered persons must ensure that service users are consulted about their views of the quality of the service provided. Timescale for action 01/01/05 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 OP28 Good Practice Recommendations The registered persons must ensure that 50 of staff have achieved NVQ at level 2. Sunbridge Care Centre DS0000010682.V258586.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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