Inspection on 02/08/05 for Sunbury Lodge

This inspection was carried out on 2nd 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.

Other inspections for this house

Sunbury Lodge 29/12/06

Sunbury Lodge 20/12/05

Sunbury Lodge 03/02/05

Sunbury Lodge 12/08/04

Sunbury Lodge 03/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Tudor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sunbury Lodge 1 Sunbury Street Woolwich London SE18 5NA Lead Inspector Pauline Lambe Unannounced 2 August 2005 09:50 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. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sunbury Lodge Address 1 Sunbury Street Woolwich London SE18 5NA 020 8854 8254 020 8855 7511 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) KCHT Mary OConnor CRH 47 Category(ies) of OP 47 registration, with number DE(E) 1 of places MD (E) 1 Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The registered person has a variation to registration to enable them to provide care and accommodation to two named residents with mental health problems and one resident with dementia. Date of last inspection 3/2/05 Brief Description of the Service: Sunbury Lodge is a former purpose built local authority home. Accommodation is provided on two floors and built around an enclosed garden. The home is located in a quiet residential road opposite a park. It is within walking distance of Woolwich town centre and bus routes. Kent Community Housing Trust is the Registered Provider for the home. The home has recently had a change to registration and is now registered to provide care and accommodation for 47 older people. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours. The service was last inspected by the Commission on 3rd February 2005. The manager was in charge of the home. Forty five residents were in the home and one resident was in hospital. During the inspection time was spent talking to residents, relatives, management and members of staff. It included a tour of the premises, inspection of care plans, safety systems and records kept as required by regulation. What the service does well: What has improved since the last inspection? What they could do better: The preparation of detailed individual care plans must improve to reflect the needs of the residents and to show how these will be met. Daily evaluation or other records used to record care provided must be completed and support the implementation of the care plans. Individual social care plans must be improved and must be prepared with the involvement of individual residents or their relatives. The home should have an annual maintenance programme to maintain, redecorate and to replace furniture and fabrics of the premises routinely. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 6 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. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 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 standard(s) 3 and 5. standard 6 does not apply service. The home used a general risk assessment format to assess needs prior to admission. Residents said they or their relative had the opportunity to visit the home prior to admission. EVIDENCE: The home used a general format for pre-admission and risk assessment. The same format was used to reassess residents at six monthly intervals. The original assessments were not seen in the three resident’s records viewed as they had been filed separately. Based on the outcome of the assessment further risk assessments were completed and care plans prepared. The home had a system to write to residents to confirm whether the home could meet their assessed care needs. Copies of these were not seen on the resident’s records viewed as the paperwork had been filed separately. Some of the residents said they visited the home prior to admission or their relatives had done this on their behalf. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10. Individual care plans were prepared but did not show how all needs identified were to be met. From the records kept it was not possible to assess how well the home met residents health care needs. Medicines were generally well managed but some issues were brought to the attention of the Commission pharmacist for clarification. Residents said that staff treated them with respect and were complimentary about the way staff interacted with them. EVIDENCE: The care provided to three residents was reviewed. Care plans were scanty and did not provide details as to how care needs identified would to be met. The daily records did not reflect the care provided and a tick list record for such things as when a resident had a bath, had chiropody care or had their weight monitored and had not been kept up to date. Although staff provided verbal information on resident needs and how they met these, the individual care plans seen did not support this. For example residents requiring help or support with personal care, refusing to have a bath, being confused, having Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 10 continence issues, being identified as at risk of falls or developing pressure sores did not have care plans to show how these needs were to be met. Without reading all the daily evaluation records for the three residents care plans viewed, where staff said they recorded care given and social activities, there was no way to assess how these residents needs were actually being met. This matter has remained an issue since the provider introduced the current care planning format and has been raised at previous inspections. The manager said that some care such as bathing, washing and dressing and continence management were done ‘routinely’ in the home. The issue with this and the current care planning was to provide evidence as to how residents’ individual needs were being met. The inspector agreed to discuss the concerns regarding care plans with the Commission provider relationship manager for the organisation. The residents and relatives who spoke to the inspector did not express any dissatisfaction with the care provided. Both residents and relatives said staff treated them with respect. Comments made included ‘staff are polite’, ‘staff are very nice’ and ‘I can do what I want and I do not like to join in activities’. Medications were generally well managed with records kept for receipt, administration and disposal of medicines. Administration charts were well maintained and reflected compliance with prescriptions. No hand written entries or as directed medicines were seen on the charts. Issues identified included soluble aspirin was not always being dissolved at the time of administration, the balance of medicines not in the cassettes was not accurately recorded on the new weekly administration chart for one resident and one resident who managed their inhaler did not have a record made to show compliance with prescription. The number of doses in stock for one homely remedy was inaccurate. The district nurses drew up doses of Insulin in advance and left these in marked containers in the fridge. If they could not get back to the home to administer the dose they asked staff to give the syringe to the resident for self-administration. There were no risk assessments in place to show that residents could manager this. This issue was discussed with the Commission pharmacist who advised the inspector discuss it with Greenwich PCT who employed the district nurses who visited the home. Requirement 1,2,3,4 and 5. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 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 standard(s) 12, 13 and 15. Residents said they were satisfied with their lifestyles, the quality of meals provided and that they enjoyed contact with family and friends. Social care plans must be prepared to show how residents individual social needs will be met. EVIDENCE: The three care plans viewed did not reflect the resident’s social interests and individual care plans were not prepared to show how social needs were to be met. Two of the three residents said they did not like to join in activities but did enjoy the entertainments arranged in the home. The third resident was unable to give information as to what social activities they enjoyed. Other residents said they were satisfied with the activities provided and a number of residents had been to Camber Sands for a holiday earlier in the year. From comments made it was obvious they enjoyed the holiday. Residents and staff had worked hard on the garden and had won the garden competition held within the organisation. A number of residents were enjoying knitting and sewing session during the inspection. A programme of activities was prepared and available to the residents. The home had an open visiting policy. Residents said visitors were made welcome and that they enjoyed family contact. Some residents said they went out regularly with their relatives. The majority of residents had their meals in the dining room. Residents who did not want to participate in activities said they liked to have their meal with Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 12 others. Lunch was served in a calm and organised manner. Staff were attentive to the residents, a choice of meal was available and tables were properly laid. Residents said they enjoyed the meal and were generally satisfied with the food provided. Requirement 6. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 13 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) 18 The home had adequate procedures in place to ensure residents were kept safe. EVIDENCE: The home had policies and procedures in place relevant to adult protection and the management of complaints. Allegations or suspicions of abuse were referred to Greenwich Social Services for investigation. Staff who spoke with the inspector displayed a good understanding of adult protection and how they would manage such a situation. Residents who spoke to the inspector said if they had concerns they would talk to one of the staff or the home manager. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 14 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 - 26 The premises were suited to meeting the needs of the residents. Some attention was required to detail in relation to general maintenance. EVIDENCE: Staff and residents were very proud of the garden with its vegetables and flowers. The home did not have a planned maintenance programme and undertook repairs and redecoration as needed. Some areas of the premises required repairs and redecoration but overall it was reasonably well maintained. Residents said they were satisfied with the communal areas. The flooring had been replaced in the smoking lounge since the last inspection. The hairdressing room was quite dreary and would benefit from repainting and made a more pleasant and relaxing area for residents to enjoy having their hair done. There was water damage near the light switch in the hallway outside the main lounge. The manager said this was being addressed. Bathing and toilet facilities were adequate to meet the resident’s needs. In bathroom 4 the seal round the bath must be replaced. In bathroom 3 the assisted seat must be kept clean. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 15 The home provided equipment needed to meet the needs of the residents. Assisted baths and moving & handling equipment was regularly serviced. Three bedrooms were assessed against the standards and found to be satisfactory. Residents who spoke to the inspector said they were satisfied with their bedrooms and had been invited to personalise these. During a tour of the home other bedrooms were viewed and many had been nicely personalised. Some of the bedrooms viewed needed attention to maintenance. Bedrooms 29 and 38 were malodorous. In bedroom 19 the paint was peeling of the windowsill. In bedroom 30 the carpet was stained and must be cleaned. The carpet in bedroom 35 had several cigarette burns and should be replaced. In bedroom 36 the light over the bed was not working. A number of fire doors were held open with wooden wedges and this practice was not considered safe. All the maintenance issues were brought to the attention of the manager. Staff had access to protective clothing and hand washing facilities were provided where waste was handled to prevent the spread of infection. Requirement 7 and recommendation 1. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 16 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 and 29 The home maintained the same staffing levels as at the last inspection. Adequate procedures were in place to recruit new staff as required by regulation. EVIDENCE: Staffing rotas were not inspected on this occasion and the manager said the home maintained staffing levels as at the last inspection. Residents and relatives seen did not raise any concerns in relation to staffing levels. Residents and relatives paid compliment to the staff. Comments made included ‘I’ve got no complaints’, ‘They are very good and look after me’, Staff are polite’ and ‘I can do what I like and I do not like joining in activities’. Since the last inspection one new member of staff had been recruited. The information obtained for the employee complied with regulation. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.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, 37 and 38. The home was generally well managed. The home kept records as required by regulation. EVIDENCE: The manager had been in post for some time and was registered with the Commission. Records viewed were well maintained and kept up to date. A selection of safety records viewed showed attention was given to providing a safe environment for residents and others. Certificates not available at the inspection in relation to the hoist service were sent to the Commission prior to writing this report. Safety and maintenance issues identified during the inspection were brought verbally to the attention of the manager at the end of the inspection. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 18 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 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 2 3 3 2 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 x x x x x 3 3 Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 19 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 7 Regulation 15 Requirement The Registered Person must ensure that a written care plan is prepared for service users showing how their needs are being met in respect of health and welfare. Where a need has been identified through assessment a care plan must be prepared showing how the need will be met. ( Timescales of 15/10/04 and 17/3/05 were not met) The Registered Person must ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The assessment used to identify service users at risk of developing pressure sores must be reviewed to ensure prevention of pressure sores is appropriately managed. (Timescale of 15/10/04 and 17/3/05 were not met). The Registered Person must ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Residents assessed as being at G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Timescale for action 30th September 2005 2. 8 13 30th September 2005 3. 8 13 30th September 2005 Sunbury Lodge Page 20 4. 9 13 5. 9 13 6. 12 16 7. 19,21,24 23 risk of falls must have a care plan prepared to show how the risk will be managerd. Residents identified as requiring assistance with personal hygiene must have a care plan prepared to show how this need will be met. The Registered Person must ensure records are kept for administration of all medicines brought into the home. This includes homely remedies. Records mst be kept to show compliance with prescription when a resident self-administers medication. A risk assessment must be completed for residents who self administer any of their prescribed medicines. The Registered Person must ensure medicines such as Insulin are not prepared in advance by external professionals and left for administration at a later time by them, other professionals or the residents. The Registered Person must ensure individual care plans are prepared to reflect residents social interest and to show how these will be met. The Registered Person must ensure the property is maintained in a reasonalbe state of decoration, repair and kept free of offensie odours. The maintenance and hygiene issues included under these standards must be addressed. 30th September 2005 1st September 2005 30th September 2005 30th September 2005 Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 21 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 19 Good Practice Recommendations The Registered Person should give serious consideration to preparing and implementing an annual renewal and refurbishment programme for the property. Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.doc Version 1.30 Page 22 Commission for Social Care Inspection Riverhouse 1 Maidstone Road Sidcup Kent DA14 5RH 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 Sunbury Lodge G51G01s6861SunburyLodgev229568.14.7.05stage4.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. 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