Inspection on 06/10/05 for Sunbury Nursing Homes

This inspection was carried out on 6th 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.

Other inspections for this house

Sunbury Nursing Homes 24/02/09

Sunbury Nursing Homes 03/10/06

Sunbury Nursing Homes 11/10/04

Sunbury Nursing Homes 27/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sunbury Nursing Home Thames Street Sunbury on Thames TW16 6AJ Lead Inspector Denise Debieux Announced 6 October 2005 @ 10:00am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sunbury Nursing Homes Address Thames Street Sunbury On Thames TW16 6AJ 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) 01932 785414 Sunbury Nursing Homes Limited Mrs Ellen White CRH - Care Home 87 Category(ies) of DE(E) - Dementia over 65 (87) registration, with number OP - Old Age (87) of places Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 - In the case of this service, service users may be admitted from the age of 60 years. Date of last inspection 7th April 2005 Brief Description of the Service: Sunbury Nursing Home has been a family business for a number of years. The Manager and her four children are the Registered Persons who are involved in the day-to-day running of the business. The home consists of several buildings, which are set in well-maintained grounds. The main building comprises of West Lodge, a grade 2 listed building, to which further substantial wings were added in the 1960’s. Administration buildings are situated between the main building and Weir House, which provides accommodation to a further 22 service users. Some staff accommodation is also located in Weir House and West Lodge. The majority of bedrooms are single and there are a total of 11 double bedrooms. The main communal areas consist of a large conservatory at the front of West Lodge and the drawing room on the ground floor of Weir House. Several smaller communal areas are to be found elsewhere in the home. The home is located close to local amenities and an attractive stretch of the river Thames. Accommodation and services, including nursing care, are provided to a maximum of 87 older people and those with Dementia. Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 6 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service. Mrs E White (Registered Manager), Mr J White (Responsible Individual), Miss N. White, Mrs J. Hartland and Mr C. White were present as representatives for the establishment. A tour of the premises took place. Prior to the inspection, survey forms were sent to the home and distributed to service users, with eleven being returned, to their relatives, with thirty-two being returned and to health and social care professionals, with one being returned. The results of these surveys and comments made are used in this report, as are comments made by service users and their relatives to the inspector during this inspection. Five care plans were inspected in depth and menus, staff rota, staff files, maintenance records, safety check records and staff training records were all sampled. Five of the service users were spoken to at length; with a further eight service users and fourteen on-duty staff being spoken with during the tour. The inspector would like to thank the service users, managers and staff for their time, assistance and hospitality during this inspection and the service users, their relatives and health and social care professionals who participated in the surveys. What the service does well: What has improved since the last inspection? The home continues with their ongoing plans for improvements to the facilities and décor. Many rooms have now been fitted with ceiling hoists and plans are underway to continue fitting hoists in remaining rooms, where needed. Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 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. Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 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 Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 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 (standard 6 does not apply as the home do not offer intermediate care) The home is able to demonstrate their capacity to meet the assessed needs of the service users accommodated at the home. EVIDENCE: The five care plans sampled during this inspection were seen to be based on comprehensive assessments of needs and clearly set out staff actions required to be taken in order to meet those needs. All relatives surveyed stated that they were satisfied with the care provided by the home, with one health care professional adding ‘Very much so.’ Five service users were spoken with at length and all indicated that they felt that their needs were being met. Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 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) 9 Policies, procedures and practices are in place to ensure the safe handling and administration of medication. EVIDENCE: The medication administration record sheets, medication storage, controlled drug storage and controlled drug record book were all sampled during this inspection and found to be accurate and well-maintained in line with the home’s policies and procedures and current legislation. Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 Page 10 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) 13 and 15 Service users are supported and encouraged to maintain contact with family and friends. Meals are well-balanced and varied with individual choices and preferences catered for. EVIDENCE: There are no restrictions to visiting at the home and visits from family and friends are encouraged. All relatives surveyed stated that the staff welcome them in the home at any time. Menus for two weeks were inspected and seen to be varied and well-balanced. Service users are able to request different meals if there is something they do not like on the menu. The lunchtime meal was taking place during the inspection and the food was presented in an appetising manner. Ample staff were present and offered help or assistance where needed in a discreet and sensitive way. The atmosphere in the dining areas was convivial and unhurried. One service user stated ‘you get quite a variety, the food suits me’ with another saying how the staff will cook her favourite of beans on toast, if asked. Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) none EVIDENCE: Standards 16 and 18 were fully assessed and met at the last inspection and were not covered on this visit. Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 Page 12 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) none EVIDENCE: Standards 19 and 26 were fully assessed and met at the last inspection and were not covered on this visit. Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 Page 13 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, 29 and 30 The numbers and skill mix of the staff meets service users needs. The home has a comprehensive staff recruitment and training programme which is designed to ensure that suitable staff are employed and provided with the training they require to do their jobs. EVIDENCE: The staff rotas inspected demonstrated that the staffing numbers and skill mix are appropriate to meet the assessed needs of the service users living at the home. 82 of relatives surveyed stated that, in their opinion, there were always enough staff on duty. Six staff files were reviewed and were found to contain all information and pre employment checks required. The home obtains two written references and explores any gaps in applicants employment histories. In some instances staff commence employment on the basis of a POVAfirst check whilst waiting for the CRB certificate to be returned. In these instances the inspector was advised that the shift leader on each shift supervises new staff. However, new legislation requires that the new staff member be allocated to a specific, named member of experienced staff and this practise needs to be adopted by the home. A requirement has been made regarding this area of recruitment. The home has a comprehensive training programme which covers all areas required by the Skills for Care organisation (previously TOPSS). Staff training records were sampled and found to be well maintained with all staff training up to date. Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 Page 14 All interactions observed between the staff and service users during this inspection were seen to be caring and respectful. All service users who returned survey forms stated that they felt safe living at the home. One service user spoken with commented that ‘they’ve been very good to me, I am very happy here.’ Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 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 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) 33, 35 and 38 The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users. Service users’ financial interests are safeguarded by the policies and practices of the home. All other policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of service users and staff. EVIDENCE: Service users views are sought on a regular basis and monthly visits by a representative of the responsible individual now take place. The inspector was advised that the home are currently in the process of developing further and finalising their quality assurance and monitoring system. One service user commented on their comment card ‘Very good management and very good response to any concerns.’ Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 Page 16 The home do not handle financial affairs for service users. However, on occasions when service users want valuables stored securely for a short period of time, the home has a safe which can be used. Any items stored in this way are recorded in the service users’ files and signed for. All required safety monitoring checks, fire drills and safe working practice training and updates have been carried out. Staff were observed to be following appropriate health and safety practices as they went about their work. Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 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 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 3 x 3 x x 3 Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 Page 18 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. 1. Standard 29.3 Regulation 19(11) (a-c) 18(2)(a) 18(2)(b) (i-iii) Requirement Where the registered person permits a new worker to start work with a POVAfirst check but prior to receipt of a valid CRB certificate AND for the duration of a new workers induction training, the registered person must: - Appoint a member of staff (the staff member), who is appropriately qualified and experienced, to supervise the new worker. - So far as possible, ensure that the staff member is on duty at the same time as the new worker. - Ensure that the new worker does not escort service users away from the care home premises unless accompanied by the staff member. (Reference The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004. Timescale for action 06.10.05 Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 Page 19 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 Good Practice Recommendations NONE Sunbury Nursing Home H58 H09 S17645 Sunbury NH V239625 061005 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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