Inspection on 20/12/05 for Sunbury Lodge

This inspection was carried out on 20th December 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 02/08/05

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 Ms Pauline Lambe Unannounced Inspection 20th December 2005 09:45 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 Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 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. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sunbury Lodge Address 1 Sunbury Street Woolwich London SE18 5NA 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 8854 8254 020 8855 7511 Kent Community Housing Trust Ms Mary O`Connor Care Home 47 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Old age, not falling within any of places other category (47) Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 10 places for Mental Disorder can be used for the provision of people with mental disorder from the age of 60 upwards. 2nd August 2005 Date of last inspection 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 Care Provider. The home has recently had a change to registration and is now registered to provide care and accommodation for 47 older people which includes 10 people age 60 and over with a mental health disorder. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7.25 hours. The Commission last inspected the service on 2nd August 2005. At the time of this inspection the manager was in charge of the home. Fortythree residents were in the home, one resident was in hospital and the home had 3 vacancies. During the inspection time was spent talking to residents, relatives, management and members of staff. Records required by regulation were inspected and a tour of the premises undertaken. There has been an ongoing issue in the home relation to the preparation of individual care plans. This matter has been referred to the Commission’s provider relationship manager to address with the registered provider and compliance with regulation will be reviewed at the next inspection What the service does well: What has improved since the last inspection? What they could do better: Individual care plans must be prepared in consultation with residents to show how identified care needs will be met including individual social care plans. Daily evaluation and other records used to record care provided must be completed and support the implementation of the care plans. Care must be taken to ensure medicines are stored at the correct temperature. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 Page 6 Staff who administer insulin must be trained and assessed as being competent to undertake the task. The maintenance issues referred to in the body of the report must be addressed. The registered person should consideration having an annual maintenance programme in place to maintain, redecorate and replace the furniture and fabrics of the premises. 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 DS0000006861.V274555.R01.S.doc Version 5.1 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 Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 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): 2. No contracts for services were seen on resident files. EVIDENCE: None of the resident files inspected included a contract for services. The manager said that the home had a contract with local authorities that fund placements. Terms and conditions were included in the service user guide. Requirement 1. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 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 to 11. Individual assessments were completed for residents but individual care plans had not been prepared to show how identified needs would be met. Medicines were generally well managed but some issues remained around the administration of insulin. Residents were very positive about the care they received and said that staff treated them with respect. Relatives seen supported this information. EVIDENCE: The care provided to four residents was reviewed. Assessment of needs were done but individual care plans were not prepared to show how needs were being met. The daily records varied as to how they reflected the care provided. Staff provided verbal information on resident needs and how they met these and residents said they were cared for as they wished. However the individual resident’s records kept did not provide this evidence. For example residents requiring help or support with personal care, refusing to have a bath, being confused, having continence issues, being identified as at risk of falls or developing or having pressure sores did not have care plans to show how these needs were to be met. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 Page 10 The preparation of individual care plans has been an issue in the home since the provider introduced the current ‘care assessment format’. The matter has been referred again to the Commission’s provider relationship manager for them to discuss with KCHT senior management so the problem can be satisfactorily resolved and to ensure compliance with regulation. How the home meets this standard and complies with regulation will be reviewed at the next inspection following the outcome of the discussions between the provider relationship manager and the registered provider. 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 by residents included ‘staff are polite’, ‘staff look after us well’, ‘the food is very good’ and ‘its very free and easy here’. 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. The temperature of the medicine fridge had not been recorded since 13/11/05 and this must be done daily. The medical room felt very warm but there was no thermometer to check the temperature. Since the last inspection residents on insulin had been provided with pens, which the district nurse set up. Staff said that on occasions they administered the insulin to residents. There was no evidence to show that staff had been trained or assessed as competent to do this. Residents can stay in the home during their final days of life provided the staff can meet their needs or are assisted to do this with the help of other relevant professionals. Requirements 2,3,4 and 5. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 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 and 14. Social care plans had not been prepared to show how resident’s individual social needs would be met. From comments made by residents they were satisfied with their lifestyle. EVIDENCE: The four care plans viewed included a nice social history of the resident but individual care plans were not prepared to show how social needs would be met. The four residents said they did choose how to spend their time and what activities to take part in. Most residents said they enjoyed the entertainments arranged in the home. A number of residents said they were satisfied with the activities provided and said they had enjoyed the decorating and Xmas preparations. A programme of activities was prepared and available to the residents. This was delivered flexible dependant on resident preference. Residents were seen relaxing in the various lounges or their bedrooms. Residents said they were able to choose how and where to spend their day and generally presented as happy and settled in their environment. It was evident that residents could choose when to get up in the morning as a number had enjoyed breakfast in bed and got up when they were ready. Requirement 6. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 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): 16. The home had adequate procedures in place to manage complaints. EVIDENCE: The home had policies and procedures in place to manage complaints and this was included in the statement of purpose. A system was in place to record complaints made about the service. Since the last inspection no complaints had been made to the provider or the Commission about the service. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 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, 21 and 24. The premises were suited to meeting the needs of the residents. Some attention was required to detail in relation to general maintenance. EVIDENCE: 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. The manager said that new armchairs had been ordered for the main lounge. Residents said they were satisfied with the communal areas. There was water damage near the light switch in the hallway outside the main lounge. This was noted at the last inspection. The manager said estimates had been obtained and she was waiting confirmation for a date to do the work. Bathing and toilet facilities were adequate to meet the resident’s needs. The bath in bathroom 3 was out of order and waiting repair. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 Page 14 The following issues were noted in bedrooms; in bedroom 28 the hot water tap was loose and in bedroom 32 the paint was peeling of the skirting board. A number of other bedrooms viewed were found to be satisfactory with many nicely personalised. Requirement 7 and recommendation 1. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 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 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 and 30. The home maintained the same staffing levels as at the last inspection. Staff were provided with training relevant to their roles. EVIDENCE: Staffing rotas were inspected for the week of and the week prior to the inspection. These showed adequate staffing levels were maintained. During that period agency staff covered 29 shifts. Residents and relatives seen did not raise any concerns in relation to staffing levels. Staff had access to appropriate training and a monthly training programme was provided. Staff who spoke to the inspector said they were provided with the training and support needed to do their work. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 Page 16 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): 31, 33, 35 and 38. The home was well managed. Records were kept as required by regulation. Attention was given to providing a safe environment. EVIDENCE: The manager had been in post for some time and was registered with the Commission. The registered provider had a quality assurance system in place. The home was audited on a rolling programme together with its sister homes. Besides having a major audit every 2/3 years, areas of the service were audited at intervals in between that time with feedback provided to the manager. The procedures in place to manage resident’s personal finances were assessed as adequate. Receipts were kept for money received and spent. Records were kept for individual residents and those inspected were accurate and up to date. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 Page 17 A safe was provided to ensure safe storage of money and valuables. All residents had access to their personal allowance. A selection of safety records viewed showed attention was given to providing a safe environment for residents and others. Up to date insurance certificates were displayed. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 1 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X 2 X X 2 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 3 X 3 X 3 X X 3 Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP2 Regulation 5 Requirement The Registered Person must ensure residents have a contract for service to include the amount and method of payment of fees. 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. ( Timescale of 30/09/05 was 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 risk of falls or develoing pressure sores must have a care plan prepared to show how the identified need will be met. (Timesclae of 30/09/05 was not met). The Registered Person must DS0000006861.V274555.R01.S.doc Timescale for action 24/03/06 2 OP7 15 24/02/06 3 OP8 13 24/02/06 4 OP9 13 24/02/06 Page 20 Sunbury Lodge Version 5.1 5 OP9 13 6 OP12 16 7 OP24OP21 23 ensure safe storage of medicines. The temperature of the medicine fridge must be recorded daily and the temperature of the storage room monitored. The Registered Person must 24/02/06 ensure staff receive training from a suitable person and have their competency assessed as to their ability to administer insulin to residents. Records must be kept to show that this has been done. The Registered Person must 24/02/06 ensure individual care plans are prepared to reflect residents social interest and to show how these will be met. (Timescale of 30/09/05 was not met.) 24/02/06 The Registered Person must ensure the property is maintained in a reasonable state of decoration and repair. The bath in bathroom 3 must be repaired and available to residents. The repairs noted in bedrooms 28 and 32 must be addressed. The water damage to the wall in the hallway near the dining room must be repaired. 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 consideration to preparing and implementing an annual renewal and refurbishment programme for the property. Sunbury Lodge DS0000006861.V274555.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup 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 DS0000006861.V274555.R01.S.doc Version 5.1 Page 22 - 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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