CARE HOMES FOR OLDER PEOPLE
Sunningdale 5 North Park Road Manningham Bradford West Yorkshire BD9 4NB Lead Inspector
Sue Dunn Announced Inspection 6th December 2005 12:30 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 Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 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. Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Sunningdale Address 5 North Park Road Manningham Bradford West Yorkshire BD9 4NB 01274 510800 01274 543265 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) Crabtree Care Homes Mrs Georgina Melvin Care Home 32 Category(ies) of Dementia (32), Dementia - over 65 years of age registration, with number (32) of places Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th May 2005 Brief Description of the Service: This is a 32 bedded home for people with dementia, some of whom may be under 65, in the Manningham area of Bradford overlooking the park. The home, which has recently had a change of name, is owned and operated by Crabtree Care Homes, a family run business. The building, a large Victorian house has been extended to provide additional single en suite bedrooms. Accommodation is on two floors with passenger lift access. Some of the very large rooms in the older part of the house are shared between two people. The walled garden surrounding the property has a parking area and has been pleasantly landscaped to provide secure outdoor walking and sitting areas. This allows residents the freedom to wander in and out of the house without restriction. Access to the property is through electric gates controlled with the help of CCTV cameras by staff from inside the house. Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two inspectors undertook the inspection, which was announced. The inspection started at 12.30pm and finished at 9.00pm. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents. A pre inspection questionnaire and comment cards were sent to the home before the inspection. The questionnaire completed by the manager was available on the day of the inspection but none of the comment cards had been returned. There have been 5 additional visits to the home since the last inspection to investigate two anonymous complaints and discuss the findings with the proprietor and manager. Some aspects of the complaints were not upheld, others partially upheld. The proprietor and manager welcomed the findings and have taken action to deal with the requirements and recommendations, which are included in bold print at the end of this report. This was a positive inspection. Some standards had minor shortfalls but overall there were marked improvements throughout and a willingness to work cooperatively with the inspectors for the benefit of the residents. What the service does well:
Staff respect the residents right to privacy and individuality. The manager and staff were familiar with the routines and preferences of each resident and adapted their approach accordingly. Residents get good support from local health professionals. The food is nutritious and offers choice, including fresh fruit, and efforts are made to celebrate special occasions. Individual skills are supported and encouraged and restriction of movement is kept to a minimum. The proprietor and manager have invested time and effort in trying to ensure residents have clothing suited to their age and situation in order to maintain peoples’ dignity. The proprietor and manager are committed to improving the quality of life for people living in the home and have demonstrated an open attitude to dealing with complaints which help them to achieve their aims. The home does an excellent job of being receptive to different levels of ability and needs and supported residents and their families in equipping their
Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 6 bedrooms according to their own tastes. The level of odour control in the home was good. The majority of staff felt the manager was supportive and sympathetic to their personal circumstances, as long as this did not affect the care of residents and the smooth running of the home. What has improved since the last inspection? What they could do better:
The pre admission process should be followed at all times to protect against inappropriate admissions to the home. The frequency and standard of personal and hair care could be improved as there were still long periods noted between baths and some peoples’ hair
Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 7 looked dull and poorly cut. The appearance of some items of clothing would be improved by ironing. The care plans should include more details which show the rewards and incentives used to encourage people to eat and maintain a satisfactory standard of personal hygiene. There could be a more imaginative approach towards day to day social and recreational activities by building activities and events around information found in the care files. Every member of staff must take responsibility to support the manager in maintaining the standard of the environment, keeping it comfortable and warm and being alert to situations which may create a risk for residents. There were indications on the day of the inspection that this was not happening. As this is a ‘specialist’ home where residents need prompting and support, more could be done to provide distinct ‘signposting’ around the home in the form of pictures and signs which direct people to their own rooms, toilets, bathrooms and dining room. Though some training has taken place there were shortfalls in staff training in several areas. The present system of recording training does not allow gaps in individual training to be picked up easily. There was a degree of complacency amongst some staff who did not feel they had anything more to learn, yet there were some areas of poor practice noted as identified in the body of the report. Information recorded in the staff communication book must comply with data protection and appropriate wording be used when recording messages. The records of income and expenditure on behalf of residents must be available in the home and be in sufficient detail to show how money has been spent. The reports on the monthly regulation 26 visits should include an action plan to deal with any matters arising from such visits. 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. Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 8 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 Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 9 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): 1,2,3,4,5 The Statement of Purpose provides information about the services and facilities to enable service users or their relatives to make an informed choice about the home. The home’s pre admission assessment process makes up for the poor quality of information received from other agencies outside the home. However the procedures must be followed to avoid unsuitable admissions, which potentially affect the lives of all residents in the home EVIDENCE: The home has reviewed the Statement of Purpose in discussion with the manager. This contains all the required information in a format which is more to the point and makes for easy reading. A service user guide has been developed in draft form. This needs some editing and amendments if it is to benefit the service user group it is meant to inform. Each resident or their representative had received a copy of the terms and conditions of occupancy. One had not been returned but others were in the care files.
Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 10 Pre admission arrangements were mixed. The quality of information in one assessment from a hospital unit was poor. This was little more than a statement saying that 24 hour secure care was required. The home’s assessment gathered enough information to provide a summary of how the person’s physical care needs would be met and showed a preadmission visit by a representative. Families are encouraged to provide some background information about people before the onset of their illness to help staff to develop a care plan to support emotional, social, recreational and spiritual needs. Another person who moved into the home did not have an opportunity to look around the home before moving in. An assessment had not been carried by anyone from the home and the information provided by a social worker did not contain very much detail. The admission process took place over a very short space of time and was described as an emergency admission, however, there was no clear reason why the admission was treated as an emergency. The manager should provide clear guidance for staff on the admission process to avoid people being admitted to the home whose needs cannot be met. Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 11 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 The health care needs of residents were met and care plans provided clear and detailed instructions for staff to follow. However there was still room for improvement in the frequency of bathing and the quality of hair care and care of clothing. Residents privacy was respected and staff had a good understanding of each persons’ preferences. Medication practices had improved since the last additional visit to the home. This needs still needs regular monitoring to ensure standards are maintained EVIDENCE: A selection of care files was inspected. These showed a marked improvement in layout and the content of the information. Care plans gave a description of how physical care was to be given and how staff should behave to avoid the risk of challenging behaviour. There were risk assessments for moving and handling and nutrition with scores which generated an action plan if required. The manager and staff were able to describe routines of daily living and it was apparent that there was a different approach for each person. More of this fine
Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 12 detail could be included in the care plans so that anyone coming to work in the home for the first time would have a good idea of how to support each person. There was a good record in each file of GP and other professionals’ visits which could be cross referenced to the daily records. Residents are registered with a local dental practice and have had recent check ups. Several follow up appointments had been arranged and the home supports residents to attend. A chiropodist and optician visit residents at the home. Most of the staff had training on managing medication after the last additional visit and the system for disposal of unused medication has been reviewed Staff first ask residents if they will have their medication before removing it from the sealed packs. This is to reduce the amount of unused medication due to people refusing tablets. However it was noted by the manager that some staff were still failing to follow the procedure. The GP has discontinued medication for those people who regularly refused to take it. Overall there was an improvement in the residents’ personal appearance with people dressed in suitable clothes for their size. However some clothing looked as though it needed ironing and the standard of hairdressing was poor. The information in the bathing record had improved but there still appeared to be long gaps between baths and nothing in the care plans to show if people preferred a bath or shower. Some people have a key for their bedroom door and were seen to use it. The statement of purpose stresses the right to privacy and dignity. Staff were observed to request permission to enter bedrooms. Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 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 The staff provide prompting and encouragement to help people to retain choice and control over their lives. A more imaginative approach is needed to improve social and recreational opportunities for residents in the home and within the wider community. A good, varied and nutritious diet is provided at the home and efforts are made to celebrate special occasions. EVIDENCE: The home does try to accommodate the needs of the more able and articulate residents. The care plans show how much support and prompting is needed but could provide more guidance on suitable activities which help people to retain their skills and identity. For example one person would like to go out more, one likes folk music and another needs more tactile sensory stimulation. There was no evidence of any such activities on the day of the inspection. A cupboard for activity materials contained a few musical items, a couple of board games and two childrens’ colouring books without any pencils. The limited concentration and skills of some people is recognised, but more could be done to use information about peoples past lives to have a more imaginative approach to activities. One person in the home is able to play the piano, which gives pleasure to the rest of the group.
Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 14 Families and friends help to ensure that those people who are members of religious groups continue to attend services. On the day of the inspection the home had organised a ‘birthday tea’ for a resident, which everyone thoroughly enjoyed. One person said there was often the noise of crashing crockery and staff speaking in loud voices in the dining room but the atmosphere at teatime was relaxed and interaction between staff and residents was good. Residents said the food was good. The menus are varied and offer choice. Each mealtime a non-meat dish is available. The cook said sometimes alternative meals are provided to meet the cultural dietary needs of one resident, although these meals are not recorded. Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 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 Complaints are dealt with appropriately, though not all complainants had followed the complaints procedure. The proprietors and manager have cooperated with the CSCI during investigations into anonymous complaints about the home and have, or were already, taking action to deal with the matters raised. Overall, service users are protected from abuse with the majority of staff having had some adult protection training. It is recommended that further in house training be given to help staff understand the balance between residents rights and the home’s ‘duty of care’ EVIDENCE: There have been two anonymous complaints to the CSCI since the last inspection, which led to additional visits, and one complaint from a GP, which was not upheld as district nurses had not completed training staff to a standard to carry out the task expected. The first anonymous complaint covered the following areas:Staff communication- Not upheld -recommendation made re Data protection Managers attitude- Not upheld -recommendation made re supervision Smoking policy- Not upheld as manager entitled to breaks Personal hygiene practices- Partially upheld - was already being dealt with No activities- Partially upheld – recommendation made Quality of laundering- Partially upheld - recommendation made - was already being dealt with
Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 16 Odour- Partially upheld - was being dealt with Privacy in shared rooms - Not upheld Food- Not upheld The second anonymous complaint involved three visits to the home to interview staff and inspect records. The following areas were investigated:1) Management style – Partially upheld- Requirements made re supervision, review of policies and procedures 2) Shortfalls in staff training, moving and handling, medication, personal- care – Partially upheld – Requirements made regarding staff training, medication practices, and care plans and recording information. 3) Restriction of residents – Not Upheld The manager and proprietor responded to the findings which arose during the investigation and acknowledged that the change of ownership and management in the home has caused some problems as people have been adjusting to changes. Action has or had already been taken to deal with some elements of the complaints. Some parts of the anonymous complaints were management and teamwork issues which should have first been brought to the attention of the proprietor through the home’s staff communication systems or complaints procedures. Some staff have had adult protection training though there seems to be a lack of understanding about rights versus ‘duty of care’. All staff must have training to recognise abuse and understand the homes complaints and whistle blowing procedures. Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 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): 19,20,21,22,23,24,25,26 The appearance and cleanliness of the home has been vastly improved through investment in furnishings and décor. Systems are in place for the upkeep and maintenance of the building. Further work will provide more satisfactory laundry facilities. Staff must be alert to the small details which make a home comfortable and warm and be observant to areas of risk for residents around the home. Some attempts have been made to help residents’ orientation within the building but more could be done to ensure the environment is sympathetic to the needs of the resident group and helps people to retain some independence. EVIDENCE: There was a marked improvement in the appearance of the home with good quality furnishings, fittings and décor in most parts of the home, evidence of the rolling programme of financial investment. Since the last inspection, a lot of equipment in the kitchen has been replaced, this includes the water boiler, cooker, dishwasher, fish fryer, fridges and work surface.
Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 18 Some people had brought items of furniture and belongings into the home, making their rooms distinctive and easily recognisable. Some bedrooms had the name of the occupant on the door but these were identical labels and in quite small print. It was noted that residents were opening doors to other peoples’ bedrooms and having to ask staff the way to the toilet where areas were not clearly marked. As this is a ‘specialist’ home where residents need prompting and support, more could be done to provide distinct ‘signposting’ around the home in the form of pictures and names to direct people to their own rooms, toilets, bathrooms and dining room. It was clear that efforts were being made to furnish communal areas to create a ‘homely’ atmosphere. However, staff could do more to check that curtains were drawn after dark, bedrooms were warm enough for people who were sitting (the large rooms in the older part of the house were cold and lighting was not bright enough for reading) and suitable background music was used. There were indications that staff were not paying attention to detail to minimise the risk of accidents. An unlocked cupboard in the hallway contained an untidy heap of towels and a variety of cleaning materials and toiletries. A resident had opened the cupboard at a time when no staff were available. Another resident was walking around with a disposable razor and a pile of empty packages from continence pads were scattered around the floor in a cupboard on the half landing. During one of the additional visits an unlocked medication cabinet containing creams and lotions had been left in the corridor and residents were given tablets which the member of staff did not watch being taken. An unidentified tablet was later found on the floor. (these matters had been rectified) The communal toilets are close to the lounges but rather ‘institutional’ in appearance. The manager and proprietor have toured the whole home making a list of work that needs to be carried out when the new maintenance person starts. A loose hand washbasin in one of the toilet cubicles was included in this work. Overall the home was clean and free from unpleasant odours though there was an unpleasant odour of stale urine in some of the toilets. The manager is in the process of looking for more effective cleaning products to deal with this problem. The home has several bathrooms but no walk in shower reducing the opportunity for choice. The proprietors are aware that the laundry, which is small and cramped, is not satisfactory for the home and plan an extension to improve the facilities. The garden creates a secure area but some of the shrubs which are dense need pruning as they create areas where residents cannot easily be observed. The manager confirmed that most of the work that had been recommended at recent environmental health and fire officer visits had been completed. The only remaining work from the environmental health visit was a small area that needs painting, and from the fire officer’s visit, all schedule one work was finished but some work still needed to be done from schedule two. Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 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 Staff were kind and demonstrated skills and experience to respond to residents in a non confrontational way and keep the level of restriction to a minimum. However shortfalls in staff training and observation of some practices indicates further training is needed to improve the quality of care in the home There has been an improvement in the process of recruiting and selecting staff to ensure residents are protected EVIDENCE: Two overseas staff had left the home at short notice. The other staff were trying to maintain a satisfactory level of staff cover. The home has tightened up the procedures for sickness and staff wishing to change shifts. All staff have been made aware of and signed copies of the procedures. Staff appraisal questionnaires raised requests for NVQ training, however it was of some concern that several staff felt they had nothing more to learn. The training records were neatly filed and the manager had identified which staff needed training or refresher courses. This included fire safety, infection control, food hygiene, first aid, moving and handling and challenging behaviour. Training records showed that some staff had not completed any training for over twelve months. The information had been sent to the person responsible for organising the training programme. Some people felt the staff did not work as a team and that some people did not ‘pull their weight’. There was some evidence of this as identified in the
Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 20 section of the report on the environment. This is a matter which needs to be discussed by the manager in supervision and team meetings. One person had started working at the home since recruitment records were last inspected. These recruitment and induction records were looked at. Application details and relevant information were available but the manager had not recorded details of the interview or follow up discussions which had taken place. An induction and foundation booklet had been completed Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 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): 31,32,33,34,35,36,38 The proprietors and manager see the interests of the residents as very important and strive towards making improvements in the home which benefit the residents. The manager is working towards the NVQ4 management award. Some staff have had difficulty accepting changes which have come about as the result of a more ‘hands on’ style of management but the majority have adapted to the changes and support the manager. Overall there was a great improvement in the management and upkeep of records. The exception was the records of residents’ monies, which are not safeguarded, as financial records do not provide an accurate account of all transactions. EVIDENCE: The manager and proprietors are trying to ensure the home operates in the best interests of the residents. Staff, described as ‘kind and patient’ do not always appear to see life in the home from the point of view of the people living there.
Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 22 The inspector attended a shift handover meeting. The handover was well organised and the senior on duty provided detailed information for staff who were starting their shift. The manager confirmed that the responsible individual is agent/appointee for the finances of ten residents. However the income and expenditure records for these residents were not available in the home. The responsible individual has given the home some money to hold on behalf of these residents and these transactions are recorded, but not in sufficient detail to show how the monies have been spent. A selection of health and safety records were looked at and were satisfactory. The pre-inspection questionnaire, completed by the manager, confirmed that health and safety records were maintained. A gas safety check carried out in July identified that work was required. Most of this had been completed but grills in the kitchen still need attention. Accident records were generally well recorded. The home has a communication book for staff. The book did not maintain confidentiality as it contained some personal information about service users which should have been recorded in individual care files. Some wording and messages were also inappropriate and unprofessional. Monthly Regulation 26 visits to make sure the home is running properly should be carried out. There was evidence that visits were completed in October and November after a gap of several months. Reports confirmed that the person carrying out the visits had spoken to residents and had a look around the home. Some areas of improvement were highlighted but there was no plan of action for the manager to work to. Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 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 3 3 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 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 3 3 3 3 4 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 2 3 2 2 Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes, still within timescale for action. 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 31,32,36 Regulation 13,18 Requirement Timescale for action 31/12/05 2 9,30 13,18 3 32,37,38 13,18 4 7,27,30,3 7,38, 12,13,15 ,17,18 The manager must make sure that all staff receive formal supervision at least 6 times a year and provide ad hoc supervision in privacy as required. Started 31/12/05 All staff responsible for the management and administration of medication must have received an accredited training in line with the guidelines of the Royal Pharmaceutical Society. All staff should have an understanding of the effects of the medication prescribed to residents. Timescale met The home must develop clear 31/03/06 policies and procedures and provide evidence that all staff have been made aware of and understood their responsibilities to comply with the procedures. Started All staff must have regularly 31/03/06 updated training on moving
DS0000060012.V260015.R01.S.doc Version 5.0 Sunningdale Page 25 5 7,8,37 12,13,14 ,15,17,1 8,24 and handling which is relevant to the needs of the residents and their own protection as employees. Care plans must provide guidance on the special requirements of any residents who require assistance or display challenging behaviour. The manager must introduce systems to ensure residents health and personal care needs monitored and fully met. All staff must be responsible for reporting and recording any changes and any action taken. Recording improved
Monthly Regulation 26 visits shall be undertaken by someone who is independent of the line management structure within the home and who shall provide a written report on the conduct of the home. 30/11/05 6 32,33 26 31/12/05 Started 1 OP38OP28 OP25 12,13,18
The home must take steps to train monitor and supervise staff to safeguard the health, safety and comfort of residents with respect to accessing hazardous substances, safety in the garden and adequate heating in all parts of the home. Staff must be trained to a level which ensures they alert to the needs of service users and are competent to carry out the tasks required. Records of financial transactions on behalf of residents must be in sufficient detail to show that residents interests are protected. Written communication systems must comply with the guidance on data protection. All future new service users must only be admitted to the home following a full assessment to ensure their needs can be met
DS0000060012.V260015.R01.S.doc 31/01/06 2 OP30 18 31/03/06 3 OP37OP35 17 31/03/06 4 OP3 14 31/12/05 Sunningdale Version 5.0 Page 26 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 4 5 Refer to Standard
OP1 OP22 Good Practice Recommendations
The service user guide should be in a format which is suitable for the service user group Further adaptations in the form of suitable signposting should be made around the building Regulation 26 reports should include an agreed plan for action Staff meetings should be held with regular frequency to give everyone the opportunity to contribute to the delivery of the service, raise any concerns and identify good practice. OP33
OP3232 OP12 The home should identify someone with the skills and knowledge to develop the activity programme in the home Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Sunningdale DS0000060012.V260015.R01.S.doc Version 5.0 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!
