Inspection on 17/10/06 for Sundridge Court Nursing Home

This inspection was carried out on 17th October 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sundridge Court Nursing Home 09/09/08

Sundridge Court Nursing Home 13/09/07

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 Key Unannounced Inspection 17th October 2006 09:30 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.V307425.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.V307425.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 Caring Homes Limited 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.V307425.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Notice issued 18 December 1998 Date of last inspection 12th January 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. Sundridge Court Nursing Home DS0000010144.V307425.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 a visit to the care home. The company’s clinical nurse specialist and regional manager assisted throughout the visit. The inspector met with service users and staff, toured the premises and examined various pieces of documentation. As part of the inspection, a sample of the home’s service users were invited to complete a questionnaire for the commission, giving their views about the services they receive. Similarly, visiting professionals were also invited to give their views about the home. What the service does well: What has improved since the last inspection? What they could do better: Recruit and retain a permanent home manager, whose fitness has been assessed by the commission. Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 6 Improve record keeping, to ensure it is always evident that care has been given. Ensure all aspects of medicine administration are always carried out according to the company’s policy and procedures. 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. Sundridge Court Nursing Home DS0000010144.V307425.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.V307425.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users and their representatives have access to the information they need to make a choice about whether to move into the home. Service users are assessed to ensure the home can meet their needs and are provided with a contract. The home does not offer intermediate care, thus standard 6 does not apply in this instance. EVIDENCE: The commission received written comments from service users or their representatives. They confirmed service users had been given enough information about the home before they moved in so they could decide if it was the right place for them. Service users had been invited to visit the home before moving in. The home had met a previous requirement to provide all service users with information about the terms and conditions of their residency. The regional manager confirmed it was company policy to always issue a contract Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 9 regardless of the service user’s funding source. Service users providing comments to the commission and service users spoken with during the visit confirmed they had received contracts. The sample of care documentation seen during the visit confirmed that assessments of service users’ needs had been carried out. The company’s clinical nurse specialist had begun working with staff to meet a previous requirement under these standards to complete care plans and risk assessments for risks identified and care needs of the individual, such as falls, moving and handling, and pressure care. Named nurse and key-worker arrangements were being strengthened in this regard. At the time of the inspection visit, this work was continuing and the requirement had not yet been met in full. The inspector was shown evidence that newly referred service users are given written confirmation that the care home is suitable to meet their needs. This met a requirement from the previous inspection. Sundridge Court Nursing Home DS0000010144.V307425.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 at least once during a 12 month period. 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. All service users have a care plan, based on assessment of their needs. Physical needs are subject to more detailed assessment than other needs, such as, social or psychological ones. Service users health care needs are met, though it is not always evident that particular aspects of care have been delivered. Service users are treated with respect and their privacy upheld. Medicine administration is generally satisfactory, though some improvements are needed. EVIDENCE: Examination of a sample of care documentation showed that care plans are based on assessment of the individual service user’s needs. The care plans seen gave guidance to staff about meeting service users’ needs but it was not always evident that plans had been reviewed regularly or that service users (or their representatives) had been consulted about their care. The assessment and guidance were focused mainly on physical needs and were less comprehensive in relation to service users’ other needs. For example, a service user recently admitted to the home had care plans based on assessment of her needs but the ‘biography’ section of the assessment remained blank. Thus, an Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 11 opportunity had not been taken at an early stage to gain information about the person’s life and help determine whether she had psychological or social needs that the home could meet. Evidencing the care given to service users needed to be strengthened. For example, the food and fluid chart and turn chart for a service user who was ‘case-tracked’ were not up to date or accurate. There were long gaps in recordings of this service user’s weight, which her care plan stated should be measured every two weeks. This need to strengthen evidencing of care was discussed with the regional manager and it was reassuring that the company’s clinical nurse specialist (CNS) had already begun working with staff to bring about improvement in this respect. The CNS said she was working one-to-one with nursing staff and was aiming to complete these improvements by the end of November 2006. A local GP practice provides medical support to the home, with visits as needed. Service users confirmed that access to the doctor was available to them when they needed it. Newly admitted service users may retain their own GP, providing that GP agrees. The home has a visiting podiatrist, who was seen working in the home during the inspection visit. She visits monthly and service users pay additional fees for this service. The commission received some written comments from service users or their representatives. The comments confirmed that they either ‘always’ or ‘usually’ received the care and support they needed. It was evident from discussions with service users and relatives that they are treated with respect and their right to privacy maintained. Staff were seen to address service users respectfully and by their preferred names. Service users spoken with said staff respected their privacy and dignity when helping with personal care. The inspector met with a service user and her visitor. The service user was enjoying chatting with her visitor in the home’s lounge. The visitor said she calls into the home regularly and her relative always appears well looked after, clean and well groomed. She said she had noticed that the staff were kind and caring to all the people living in the home. The commission has received positive written feedback from a visiting health care professional about the standard of care provided to the home’s service users. This feedback included comment on the staff’s understanding of service users’ care needs and the home’s management of medication. Since the previous inspection, there had been an incident at the home when medication went missing. The acting manager in post at that time had taken appropriate action, including notifying the commission promptly. The manager Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 12 had subsequently provided the commission with a written summary of actions taken to prevent such an incident occurring again. Medication is given using a monitored dosage system, and is stored in a locked trolley within a locked clinical room. Medicine trolleys had just been obtained for each floor in the home and were due to become operational shortly. The intention is to save nursing time doing medicine rounds and ensure medicines can be given promptly throughout the home without reliance on the passenger lift to move the single trolley that is used at present. Internal and external medications were being stored separately. The temperature in the clinical room was satisfactory for the purposes of storing medication. The temperature of the drugs refrigerator had been recorded each day, with the recording signed by the person taking the reading. Controlled drugs were stored correctly, but the record for the controlled drug for one service user did not match the number of tablets held. This was discussed with the managers and it was found that some tablets were awaiting disposal. In this instance, service users’ safety had not been compromised but the home must ensure the accuracy of its controlled drugs register. A sample of medicine administration records (MAR) was seen and in general had been well completed. One MAR chart stated ‘none known’ in the allergy section, whereas the service user’s care plan stated an allergy to two specific medications. This omission was discussed with the managers and it was agreed this type of information must always be recorded accurately. Sundridge Court Nursing Home DS0000010144.V307425.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 at least once during a 12 month period. 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 to service users, to engage in as they choose. Service users choose how they spend their time and are supported to maintain contact with their families and friends. The content of menus inspected was balanced and nutritious. EVIDENCE: There was a calm, relaxed atmosphere in the home when the inspector arrived in the morning. Service users were either in the lounge or their rooms. Staff enable service users to make choices about their day-to-day lives, for example, helping service users to make choices about what clothing to wear and which meals to eat. The inspector saw a staff member talking with a service user after lunch to help him decide how he wished to spend the afternoon. Service users 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.V307425.R01.S.doc Version 5.2 Page 14 Service users said they were able to have visitors at any time. A relative who were visiting during the inspection said she was always made to feel welcome at the home. A service user said she enjoyed going out on trips from the home with her relatives, and that staff encouraged this. The home offers a programme of planned activities, including music afternoons, baking, art, quizzes and visits to a bowls club. There are listening books available. A service user told the inspector she liked the activities – she said, “I got up and danced the other day, I haven’t done that for a while”. Service users 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. The inspector visited the kitchen and found it to be clean, tidy and well organised, with equipment in good working order. Service users are offered a choice of menu at each meal, and can ask for an alternative if they do not want what is on the planned menu. A service user told the inspector that the food was always well cooked, and confirmed there are a variety of meals offered from which she could choose. At present, a fourweek menu rota is in operation. General discussion took place with the chef regarding the frequency of reviewing and rotating menus to include seasonal changes of fruits and vegetables. Sundridge Court Nursing Home DS0000010144.V307425.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 inspected at least once during a 12 month period. 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. Service users are given the information they need to be able to make a complaint if they are unhappy with the care or service they receive. Service users are protected from abuse. Staff receive appropriate training about protecting vulnerable adults. EVIDENCE: A copy of the homes complaints procedure is displayed in the home and a copy is also provided in the guide given to each service user. The timescales for response to complainants were appropriate and the procedure includes the CSCI’s contact details. Service users and their relatives knew to speak with the person in charge if there was something they were not happy about. There is also a suggestion box in the hallway of the home for service users or relatives to communicate their concerns or offer their compliments. The home’s complaints file was seen and records had been kept of any complaints received, and the action taken in respect of complaints. Monthly analysis sheets are compiled and forwarded to the regional manager to facilitate monitoring. The inspector saw examples throughout the day of positive, relaxed interactions between service users and staff. A new adult protection policy and procedure is in place, which made reference to local authority adult protection guidelines and there is a whistle blowing policy available to staff. Staff receive relevant training in the protection of vulnerable adults. Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 16 Since the previous inspection, the commission has been informed of an allegation of abuse towards a service user living in the home. The acting manager in post at that time had followed procedure, including liaison with the local authority (Bromley) adult protection manager. The allegations were investigated but no evidence was found to support them. Sundridge Court Nursing Home DS0000010144.V307425.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 at least once during a 12 month period. 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. Service users have a safe, clean and homely environment. Procedures are in place to prevent infection. The home is reviewing its equipment to ensure it is appropriate to meet its service users’ needs. EVIDENCE: The home appeared generally well maintained, with good quality furnishings and décor. The commission received some written comments from service users confirming that the home is always fresh and clean. Service users met during the inspection said the home was always clean and tidy, though the inspector also heard the view that refreshing some of the decoration would be ideal. This was raised with the regional manager for her consideration. The home has a passenger lift to access upper floors. Grab rails are fitted in all corridors and toilets. An emergency call system operates throughout the home and is readily accessible to service users. Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 18 The home was working towards meeting a previous requirement to ensure there are enough hoists to meet service users’ needs. The home had a hoist and two standing hoists. New hoist slings had been obtained since the previous inspection. The clinical nurse specialist was to carry out a review to determine if the equipment in the home was still appropriate to meet the needs of its service users. The regional manager said the review report with any recommendations would be forwarded to her for consideration. Previous requirements to ensure an adequate supply of hot and cold water and that taps are appropriately labelled had been met. Good infection control strategies were in place, with disposable aprons and gloves accessible to staff. The home has two sluices, which are fitted with sluicing disinfectors for cleaning commode buckets effectively. The laundry was well organised and two service users told the inspector they were very pleased with the service from the laundry. Sundridge Court Nursing Home DS0000010144.V307425.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 at least once during a 12 month period. 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. Suitably qualified staff members were working in the home in sufficient numbers to enable good care delivery to service users. Staffing levels are being kept under review. Robust recruitment procedures provide protection for service users living in the home. Staff members are provided with training that is relevant to their work in the home. EVIDENCE: Positive comments about the quality of care given by staff members were received from service users or their representatives. A representative queried whether there are always enough staff on duty and a service user said she has to wait for attention more now than used to be the case. The number of staff working in the home on the day of the inspection visit, and the skill mix of the staff members was appropriate to meet the needs of the service users in residence. Staffing rotas seen for a four-week period showed that staffing levels had been maintained, and that there was always at least one qualified nurse in charge of each shift. Information supplied by the home in September 2006 showed that 63 (n=19) of the service users had been assessed as having high dependency needs. The inspector was assured during the visit that staffing levels and skill mix would be kept under review to ensure that service users’ needs continue to be met. Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 20 The inspector selected a sample of staff recruitment files for examination. These showed that sound recruitment procedures were in operation and that all required information was obtained about applicants before they started work in the home. The authenticity of references would be enhanced by ensuring referees use either their company-headed paper or add their company stamp to the reference; this was not evident for all references in the files seen. CRB disclosures are stored separately within the home; each of the staff files had a corresponding disclosure on file. Staff are provided with a job description and contract detailing their terms and conditions of employment. The home supplied a matrix showing training completed by individual staff members. Staff confirmed they receive statutory training and carers are supported to undertake NVQ awards in care. Nurses undertake continuing professional development in line with NMC requirements for maintaining their nursing registration. Sundridge Court Nursing Home DS0000010144.V307425.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 at least once during a 12 month period. 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. There are appropriate arrangements in place to safeguard service users’ monies. Copies of the provider’s monthly audit are being sent to the CSCI. The health and safety of service users and staff is promoted. At present, the home does not have a manager whose fitness for registration has been assessed by the CSCI. EVIDENCE: Since the change in ownership, the home has had a succession of acting managers and has not had a manager whose fitness for registration has been assessed by the commission. The most recently appointed acting manager had left a few days before the inspection. The company’s regional manager had written to inform the commission but the letter was not received until after the inspection visit had taken place. The regional manager was present at the inspection visit and outlined the interim arrangements for managing the home. Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 22 The company’s clinical nurse specialist, who has previous managerial experience and has already been working with the nursing staff on competency assessments, will manage the home temporarily until a permanent manager is appointed and put forward for registration. The regional manager will give close support. She is aware the company needs to recruit and retain a permanent manager for the home to give leadership and stability. The regional manager confirmed that any newly appointed manager would apply to the commission for registration as the manager of Sundridge Court. The CSCI has been supplied with reports of the provider’s monthly visits to the home. The regional manager receives monthly reports from the home on various aspects of service provision. The company had surveyed service users, relatives and staff members to elicit their views about the change of ownership of the home. Summary sheets detailing the findings of this survey were on the home’s notice board. The home’s administrator outlined the arrangements in place to ensure that, where the money of individual service users is handled, their interests are safeguarded. Small amounts of service users’ personal allowances may be stored safely on the premises. It was understood the storage arrangements will be improved further when the administrator moves into the room that is presently used as the manager’s office. The benefit for service users is that they are able to buy items independently, without always having to rely on staff or relatives to assist them. Each service user’s money is kept in a separate wallet, with a record maintained of each transaction. Money taken out is signed for by senior staff, and by the service users themselves whenever practicable. Three staff training files were examined during the inspection visit. Each had records of statutory health and safety training, including fire training and manual handling. From discussion with staff it was apparent that they have received regular training regarding fire safety precautions in the home. A selection of health and safety documentation was examined and found to be up to date and within the appropriate timeframes. The regional manager confirmed that remedial items noted in the electrical installation test in May 2006 had been attended to. The passenger lift had been tested in June 2006 and hoists had been serviced at six-monthly intervals. The fire alarm system is tested regularly. The home’s accident records were examined. Two different forms are in use; one for ‘accidents’ and one for ‘incidents’. It was apparent that staff were not always clear which form to use. For example, an accident had been recorded on an incident form. Also, the accident form does not have a space to state if a regulation 37 notice has been sent to the CSCI, whereas the incident form does have a section to record this action. This was discussed with the regional Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 23 manager who agreed to review these formats and consider whether it was necessary to have two separate forms in use. Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 24 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 3 3 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 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 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 25 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. 3. Standard OP3 Regulation 15(1) Requirement Care plans and risk assessments need to be completed for risks identified and care needs of the individual e.g. falls moving and handling, pressure care, etc Previous requirement – being addressed but not yet fully met. Ensure that there is adequate equipment provided to assist service users, which is kept in good working order. In this instance that there is sufficient hoists to meet the needs of service users requiring assistance of the hoist to stand. Previous requirement – being addressed but not yet fully met. The registered person must ensure the home’s controlled drugs register is up to date and accurate. The registered person must ensure that information about any known allergy is always DS0000010144.V307425.R01.S.doc Timescale for action 30/11/06 8. OP22 23(2)(c) 30/11/06 1 OP9 13 31/10/06 2 OP9 13 31/10/06 Sundridge Court Nursing Home Version 5.2 Page 26 recorded accurately on the service user’s medicine administration record. 3 OP7 15 The registered person must ensure it is evident that, whenever practicable, service users or their representatives are consulted when drawing up or reviewing their care plans. 30/11/06 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 OP7 Good Practice Recommendations The registered person should ensure service user plans address all aspects of the health, personal and social care needs of the service user. The registered person should review the formats of the accident and incident forms, to ensure staff use these appropriately. The registered person should ensure referees use either their company-headed paper for references or add their company stamp to their written reference. 1 OP38 2 OP29 Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 27 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 Sundridge Court Nursing Home DS0000010144.V307425.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!