Inspection on 13/09/07 for Sundridge Court Nursing Home

This inspection was carried out on 13th September 2007.

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 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

Sundridge Court Nursing Home 09/09/08

Sundridge Court Nursing Home 17/10/06

Sundridge Court Nursing Home 12/01/06

Sundridge Court Nursing Home 17/08/05

Sundridge Court Nursing Home 04/03/05

Sundridge Court Nursing Home 05/10/04

Sundridge Court Nursing Home 04/11/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Sundridge Court Nursing Home 19 Edward Road Bromley Kent BR1 3NG Lead Inspector David Lacey Unannounced Inspection 10:30 13 September 2007 th 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 Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sundridge Court Nursing Home Address 19 Edward Road Bromley Kent BR1 3NG 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 8466 6553 020 8466 5180 office@sundridgecourt.fslife.co.uk Harley Healthcare Nursing Homes Limited ** Post Vacant *** Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (29), Physical disability (1) of places Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Notice issued 18 December 1998 Date of last inspection 17th October 2006 Brief Description of the Service: Sundridge Court is situated in a quiet residential area of Bromley. It is a purpose-built home providing nursing care for up to thirty older people. The home has twenty-four single bedrooms and three shared bedrooms. All bedrooms have en-suite facilities. A passenger lift provides access to all floors. Communal space includes a lounge, large conservatory and a dining room. There is a laundry on-site. The home has a large back garden with patio seating and there is some off-street parking at the front of the building. A bus route and Sundridge Park rail station are within reasonable walking distance for those with full mobility. The fees for this home are £750 - £1100 per week (this information given to CSCI September 2007). Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced visit to Sundridge Court. My visit lasted eight hours, during which time I spoke with residents, staff members and the manager. I observed some care practices, toured the premises and sampled documentation such as care plans, staff recruitment files and medication charts. The commission also sent out questionnaires to gain people’s views about the home and its service provision, and their responses have been incorporated into this report. What the service does well: What has improved since the last inspection? Sundridge Court has recruited a permanent, experienced manager. There is more consultation with residents or their representatives about their care. The activities provision has been developed to improve the range available for residents. There have been improvements to the home’s environment. An internal security door has been installed in the reception area and exterior fire doors Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 6 have been fitted with alarms. The outdoor facilities for residents have been improved. There are now enough hoists to meet residents’ needs. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed to ensure the home can meet their needs. They can visit the home with their families before making a decision whether to move in. EVIDENCE: The manager said she carries out pre-admission assessments before residents move into the home. I saw examples of these assessments, where the care needs of the person had been identified. A relative stated the family had visited the home twice before asking for a place for their mother. On each visit they had been seen by the manager and shown around the home. They had been given information about the services and facilities, and been invited to speak with residents and relatives who were Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 9 in the home at the time. A resident told me her family had visited the home on her behalf to see whether it was suitable before she had moved in. Sundridge Court does not offer intermediate care, thus standard 6 does not apply in this instance. Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have good access to local health care services. Care plans are based on assessment of individuals’ needs, and residents or their representatives can be involved in decisions about care. Care plans and risk assessments must always be drawn up when a person is admitted so that staff members have full written guidance about meeting that person’s needs. Most aspects of medicine administration were satisfactory but immediate improvement was needed to the home’s management of controlled drugs. Residents are treated with respect but their privacy must always be upheld with regard to information about their personal care. EVIDENCE: Residents were clean, well groomed and dressed appropriately. As I arrived, a member of staff was carrying out manicures for residents. A resident who had not been in the home long told me she had enjoyed having her nails done and Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 11 the individual attention was helping her to feel more settled in her new surroundings. The residents who returned completed questionnaires to the commission stated they either always or usually receive the care and support they need. The residents also stated they always receive the medical support they need. The home has a visiting GP and maintains good liaison with local health services, including the community homes’ liaison team, specialist Parkinson’s nurse and a local hospice. While I was in the home, a social worker visited to carry out a review of a resident’s placement. The care plans I saw had been drawn from assessment of the residents’ needs and gave guidance to staff about meeting those needs. Following a requirement from the last inspection, there was more evidence that residents or their representatives were being consulted about their care. The assessments and guidance were focused mainly on physical needs but, as recommended at the previous inspection, staff have also begun to pay more attention to identifying and meeting residents’ social and psychological needs. I saw some ‘biographies’ that offered important information about residents’ lives before they entered the home that would enable staff to give more individualised care and attention. Generally, the standard of care documentation had been raised since the previous inspection, though there were some examples I saw that indicated the updating of care plans and risk assessments could be further improved. A newly admitted resident did not yet have a care plan or risk assessments in place. The resident’s pre-admission assessment stated there was a risk of pressure damage and queried the assistance she might need with mobility. A history of “frequent falls” had been recorded in the daily notes on her admission. However, risk assessments for tissue viability, mobility and falls had not yet been completed. Although, in my opinion, the resident could be confident this documentation would be completed, the fact that it was not made available immediately she was admitted meant that staff lacked full written guidance about the care she needed (requirement 1). Medication is given using a monitored dosage system, and is stored in a locked trolley within a locked clinical room. Internal and external medications were being stored separately. The temperature in the clinical room, which has no natural ventilation, was higher than the recommended maximum level for storing medication. Even after the door to the room had been open for about fifteen minutes, the room thermometer still showed 28 degrees centigrade (recommendation 1). The temperature of the drugs refrigerator had been recorded each day, with the recording signed by the person taking the reading. There was an up to date list of staff members’ signatures and initials, for the purposes of medication audit. The medicines policy and procedures were on file and readily available to staff. The homely remedies protocol had been signed by the GP in June 2005. More regular reviews would be good practice Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 12 (recommendation 2). The administration of homely remedies had been recorded separately. Information provided by the home before the inspection visit confirmed there is a contract in place with a specialist disposal service so that equipment is provided for disposal of drugs and sharps. As part of case tracking, I looked at an initial sample of three medicine administration records (MAR). Two of the three charts did not yet have photographs of the residents (recommendation 3). These two residents had recently been admitted to the home. It was evident that a previous recommendation to record information about known allergies had been addressed. Two of the residents’ MAR’s had allergies recorded, and the third had no known allergies. For one of the residents, a controlled drug prescribed ‘as required’ had not been coded on the MAR to record when the resident had not required it. Some other discrepancies were evident when I inspected the home’s arrangements for controlled drugs. Two of the three residents whose medication I was case tracking were on controlled drugs. As shortfalls were evident, I also inspected the arrangements for another resident who was taking controlled drugs. Shortfalls were evident in the recording, storage and disposal of some controlled drugs. The home has a system in place for monitoring this aspect of its practice, and staff had signed to confirm controlled drugs had been checked and were correct. The nurse in charge of the home accompanied me when I was inspecting medicines, so was made aware of the issues in detail and was able to discuss them with me. I also had some discussion by telephone with the company’s Responsible Individual, so that immediate action could be taken to address the shortfalls identified (requirement 2). I saw staff addressing residents respectfully and by their preferred names. The manager had prepared written guidance for staff about communicating appropriately with a resident with severe visual impairment. It was evident from discussions that staff know about respecting residents’ privacy and dignity when giving personal care. However, I saw a notice to staff giving guidance about matters such as catheter care pinned to the outside of a resident’s bedroom door. This meant the notice could be seen from the corridor outside the room, which is not good practice as it risks compromising a resident’s privacy and dignity (requirement 3). Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Planned activities are available for residents to engage in as they choose. Residents are supported to maintain contact with their families and friends. A balanced, nutritious diet is provided and residents like most of the food served. EVIDENCE: When I arrived, unannounced, for the inspection visit, the home had a welcoming atmosphere. Residents were relaxing either in the lounge, conservatory or their bedrooms as they chose. Residents told me they were able to have visitors at any time. A relative who was visiting during the inspection said she was always made to feel welcome at the home. The home tries to develop and maintain links with the local community, for example, by involvement in a project with a local primary school. Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 14 The home has developed its activities provision since the previous inspection. An activities organiser devises and delivers a programme of activities, arranges occasional trips out from the home, and organises various entertainers to visit the home. Of the residents who returned completed questionnaires to the commission, one stated the home always arranged activities that s/he could take part in, and one stated this was sometimes the case. One resident stated there were never activities s/he could take part in, commenting, “don’t like to mix with others, as I find it hard”. In discussion with the home’s activities organiser, it was evident she is aware that group activities do not suit everyone and that she was offering one-to-one work for residents who preferred this. She was also well aware that sometimes residents choose not to take part and she makes sure such choices are respected. As one resident commented, “I like to join in with many of the activities but some days I like to rest in my room”. Residents took lunch either in their rooms or in the dining room as they chose. Sensitive, unhurried assistance with feeding was provided by staff as needed. There is a choice of menu at each meal, and residents confirmed they could ask for something else if they do not want what is on the planned menu. Several residents I spoke with were enjoying their lunch and told me the food was always good. Another said the food could be “a bit boring” but that it was always well cooked and presented. It was evident residents are consulted about their food preferences, and that their views about menus are sought and taken into account. Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents or their representatives have the information they need to be able to raise concerns or complaints. The home could improve how it evidences its handling of complaints. Residents are protected from abuse. Staff receive appropriate training about safeguarding adults. EVIDENCE: The home has an appropriate complaints procedure. A copy is displayed prominently in the home and a copy is also provided in the guide given to each resident. Most residents who returned completed questionnaires to the commission stated they always knew who to speak to if they were not happy, though one stated this was only sometimes the case. All stated they knew how to make a complaint. The manager holds a weekly ‘walk-in surgery’, when residents or their relatives can drop in without an appointment to discuss any matters. This service has been publicised in the home’s newsletter. The home’s complaints file was seen. Records had been kept of complaints received, and the action taken to address them. The commission had been made aware of one complaint. The home’s complaints file recorded the receipt of this complaint but only showed the outcome as “substantiated”, without giving any details of the investigation or response to the complainant. The Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 16 manager confirmed a response had been sent but said that the relevant documentation was at the company’s head office. If this documentation or copies of it were available, the home could readily evidence that it handles complaints effectively (recommendation 4). The adult protection policy and procedure in place makes reference to local authority safeguarding guidelines and there is a whistle blowing policy available to staff. The home’s manager is an adult protection trainer, and staff members receive relevant training in the protection of vulnerable adults. Staff members I spoke with showed appropriate understanding of their responsibilities for safeguarding the residents in their care. I saw examples during my visit of positive, relaxed interactions between residents and staff. The home provides contact details of the local (Bromley) independent advocacy service. Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean and homely environment. The home has measures in place to prevent and control infection. EVIDENCE: The home appeared generally well maintained, with good quality furnishings and décor. Residents who returned completed questionnaires to the commission stated the home was always or usually fresh and clean. Bedrooms that I saw were clean, well furnished and equipped. Residents are encouraged and supported to make their bedrooms as personal as possible, by bringing their own personal items, family photographs and small pieces of furniture. Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 18 The home has a passenger lift to access upper floors. Grab rails are fitted in all corridors and toilets. An emergency call system is installed in all areas of the home that are accessible to residents. The call system was working well during my visit. The home has installed an internal security door in the reception area and has alarmed its exterior fire doors. Since the previous inspection, the outdoor facilities have been improved, with the installation of new paths and an additional patio. I joined some residents who were sitting outside under the shade of the new gazebo. They told me how much they enjoyed being able to sit out during the warm weather. The manager confirmed that a previous requirement to ensure there are enough hoists to meet residents’ needs had been addressed. She stated the home now has two standing hoists and four other hoists, including two on hire. Good infection control strategies were in place, and disposable aprons and gloves were accessible to staff. Information provided by the manager before the inspection confirmed that ten staff members had received training in infection control. Alcohol gel dispensers have been installed in corridors on each floor, and staff and visitors are encouraged to use these. I saw a cleaner using a dispenser as he went about his duties. The home has two sluices, which are fitted with sluicing disinfectors. Residents said they were satisfied with the service from the laundry. Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has already taken action to improve its staffing arrangements. Its recruitment procedures are robust. Staff members undertake training that is relevant to their work in the home. EVIDENCE: On the day of my visit, the home was full, with twenty-nine people in residence. Although Sundridge Court is registered to provide nursing care for up to thirty people, a single resident is occupying one of the home’s shared rooms. It was evident that the home had been able to increase its occupancy levels since the previous inspection, and that the home had had few vacancies in recent months. However, it was also evident from discussion and from examining staff rotas that staffing levels had fluctuated, such that agency staff had been needed to cover some shifts. There were two agency staff on duty on the day of my visit. I have not made a requirement about staffing levels on this occasion because the provider was already addressing these shortfalls. The manager confirmed that four nurses and additional care staff had been recruited. The outcomes of recruitment checks, such as CRB disclosures, were being awaited before these newly appointed staff could take up their posts. Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 20 The home is aware that the gender mix of its staff group needs as far as possible to reflect that of its residents. At the time of the inspection visit, there were two male carers on the staff team and eight male residents. All the residents who returned completed questionnaires to the commission stated that staff listened and acted on what they [the residents] said. Most residents stated that staff were usually available when they needed them, with one stating this was always the case. During my visit, I was told that staff members sometimes appear rushed and that this may be because there are not always enough of them on duty. The recruitment procedures operated by the home are robust and contribute to the protection of residents. All required information is obtained about applicants before they start work in the home. Staff undertake statutory training and carers are supported to undertake NVQ awards. Information provided by the home showed that fifty per cent of carers had either completed or were working towards NVQ level 2 in care. Nurses undertake continuing professional development in line with Nursing and Midwifery Council requirements for maintaining their nursing registration. Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home now has a permanent manager in post, who has applied to the CSCI for registration. The provider monitors the quality of the home’s services. The health and safety of residents, visitors and staff is promoted. EVIDENCE: Since the previous inspection, the company has appointed a permanent manager for the home. This has given much needed leadership and stability after a period where there was no permanent manager in post. The manager has applied to the commission for registration as the manager of Sundridge Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 22 Court, and her application is being processed. The manager is an experienced nurse and has previously been the registered manager of a care home. The manager walks around the home each day to meet with residents and makes herself available to meet with families to discuss any matters they wish to raise. Residents’ and relatives’ meetings are held to discuss issues and share information. Notes from these meetings had been retained on file. The manager also communicates with residents and relatives via the home’s newsletter. The provider last sent a report to the commission of a monthly monitoring visit in January 2007. It is understood more recent reports are available for inspection. The company carries out regular audits at the home, as part of its strategy to assure the quality of the services offered by Sundridge Court. Examples of these were seen during the visit. At an audit in March 2007, carried out by the company’s clinical director, the home achieved an overall rating of 76 . I looked at a selection of health and safety documentation and found it to be up to date and within the appropriate timeframes. However, it was not possible to locate the home’s fire risk assessment. The manager was not on the premises and the staff members on duty were not able to show me this assessment. The manager later confirmed that a fire risk assessment had been completed and could be made available for inspection as required. The manager and one of the senior carers are manual handling trainers, and provide this training to staff members as well as providing advice and guidance about manual handling issues. There was good practice from staff members while assisting residents with restricted mobility. I visited the kitchen, which was clean, tidy and well organised. The findings from the most recent environmental health inspection were good, and the outcome of a recent company audit of the catering arrangements had a positive outcome. Catering staff have completed food hygiene training. Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 23 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement The registered person must ensure that written care plans and risk assessments are drawn up for each resident as soon as they are admitted to the home. The registered person must ensure that the receipt, storage, administration and disposal of controlled drugs are always carried out in accordance with the home’s policy and procedures. The registered person must ensure that any information about a resident’s personal care that is put on display is done so discreetly, so that the resident’s privacy and dignity is not compromised. Timescale for action 30/09/07 2 OP9 13 17/09/07 3 OP10 12 30/09/07 Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP9 OP9 OP9 Good Practice Recommendations The registered person should ensure the temperature of the room where medicines are stored is kept below 25 degrees centigrade. The registered person should ensure there is regular medical review of the homely remedies protocol. The registered person should ensure there is a photograph accompanying each resident’s medicine chart. Photographs should be labelled with the resident’s name and the date the photograph was taken. The registered person should ensure the home strengthens how it evidences complaints handling. 4 OP16 Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sundridge Court Nursing Home DS0000010144.V342357.R01.S.doc Version 5.2 Page 27 - 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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