Inspection on 26/07/05 for Sunningdale Lodge

This inspection was carried out on 26th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Sunningdale Lodge 29/10/09

Sunningdale Lodge 11/11/08

Sunningdale Lodge 07/11/07

Sunningdale Lodge 11/10/06

Sunningdale Lodge 23/01/06

Sunningdale Lodge 08/03/05

Sunningdale Lodge 30/07/04

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

CARE HOMES FOR OLDER PEOPLE Sunningdale Lodge Dene Road Hexham Northumberland NE46 1HW Lead Inspector Aileen Beatty Unannounced 26 July 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sunningdale Lodge Address Dene Road Hexham Northumberland NE46 1HW 01434 603357 01434 608865 sunningdalelodge@highfield-care.com Highfield Home Properties Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Michelle Kinmont CRH 50 Category(ies) of DE (E) Dementia - over 65 (50) registration, with number of places Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 08/03/05 Brief Description of the Service: Sunningdale Lodge is a 50-bedded care home, which provides care including nursing for elderly people with dementia.The home is located on the outskirts of Hexham, adjacent to another residential care home, both of which are owned by the Highfield Group.The home is purpose-built with accommodation on three floors accessed by a lift shaft. The lower ground level provides catering and laundry facilities.There is a large attractively landscaped rear garden, with seating. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days as the acting manager was absent on the first day. The inspection involved a review of care records, discussion with residents visitors and staff. The overall standard of care is satisfactory. What the service does well: What has improved since the last inspection? 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. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2. Prospective service users are given the information they need before coming into the home. Each service user has a contract and statement of terms and conditions. EVIDENCE: A service user guide and statement of purpose are provided to prospective residents. These are available to their representatives if they are unable to read these themselves. Details of services available are included in these guides and this includes services for which there will be an additional charge. Standard 4 was not fully assessed but it is recommended that staff receive training in person centred care, which encourages staff to see all residents as individuals and to tailor the care to suit their needs. See standard 14. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 11. Service users needs are set out in plans that are generally good. Health care needs are met. Medication procedures are not always satisfactory. Procedures relating to the care of dying are satisfactory. EVIDENCE: A number of care plans were examined. In most cases they are well written and reviewed regularly. Sometimes where an assessment shows there is a risk of a problem developing (e.g. pressure sore) a preventative care plan is not always written. Some residents were found not to have access to the correct incontinence product due to a mistake with the order. This was discussed with the acting manager who felt it was a “one off” mistake. Residents must have access to the equipment they have been assessed as needing. The wording in some records is inappropriate and must be challenged and training provided. Health care needs are met. On the day of the inspection, one resident had an unexplained injury and this was dealt with effectively by staff. She received prompt hospital attention. Care plans for residents who are very frail or receiving bed rest were examined. They contain sufficient detail and are reviewed regularly. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 9 Medication records were examined and it was noted that there are a number of gaps in records which must be explained by inserting the correct code. The fridge temperature in the treatment room must be recorded. The suction machine must be stored so that it is accessible in an emergency. It was on top of a cupboard. A number of items were stored in the trolley instead of the fridge. Some items in the fridge were nearly two years out of date. Eye drops must have date of opening written on. Satisfactory policies are in place relating to death and dying. Very frail residents visited upstairs were found to be very comfortable in tranquil surroundings. Soft music was playing and efforts had been made to provide visual stimulation such as adding streamers to a fan. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. The home tries to meet the social and recreational needs of residents. Relatives are encouraged to visit at any reasonable time. A balanced diet is provided. EVIDENCE: A number of activities are available but this could be improved. There are however, two main sessions a week, including Bingo on Fridays. A hairdresser visits each Tuesday. Records show that some residents have been out for bar meals and there has been a pie and pea supper. There was also a trip to South Shields on the ferry, with fish and chips! Some entertainers are booked. While this has been an improvement, further improvements are necessary. Visitors are encouraged at any reasonable time. Some visitors spoken to said that they feel welcome. It was noted that the request from one service user to have their own key was automatically declined. A subsequent risk assessment found that this was acceptable. Individual risk assessments must be carried out to ensure residents are afforded maximum independence. Staff must receive training to explore their own attitudes and ideas around rights and choices. A balanced diet is provided. On the day of the inspection there was Pork sausage casserole and Fruit Crumble on the menu. This is what was served. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 11 The kitchen was inspected and found to be clean and well organised. Cleaning schedules were inspected. A record of food delivered to the home is maintained. The chef is aware of how to fortify diets for those residents who are nutritionally compromised. A four week menu cycle is in place. Residents spoken to said that they enjoy the food. Cold tea choices must be specified on the menu. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. Relatives are confident that their complaints are taken seriously. There are satisfactory sustems in place to protect residents from abuse. EVIDENCE: There is a satisfactory complaints procedure in place. It is publicly displayed in the home. Recruitment procedures include criminal records checks on all applicants to make sure that they are safe to work with vulnerable people. Staff records examined contained all of the required information. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24 and 25. The home is generally clean and well maintained. Rooms are cpmfortably furnished with residents own belongings. The home is generally clean pleasant and hygienic. EVIDENCE: Communal areas and bedrooms were inspected. They were found to be generally clean and hygienic. There are odour problems in a small number of bedrooms, these were pointed out to the acting manager. A number of areas have been redecorated since the last inspection. The home is generally “homely”. At the last inspection it was noted that the Tannoy system calling for staff to pick up telephone calls, is quite intrusive, and not homely. A written protocol to minimise its use must be devised. There was quite loud “pop” music playing at one point in communal areas. There were some residents pacing the corridor in an apparently agitated state. It is recommended that the use of music in communal areas be monitored to ensure it is not adding to any existing restlessness or agitation. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 14 Additional storage is required in some en suite bathrooms. The domestic spoken to on the day of the inspection was aware of COSHH guidance and has been trained by the domestic supervisor. Induction training has been carried out. Some safety concerns were identified see standard 38. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, and 29. Service users are in safe hands. Recruitment procedures protect service users. EVIDENCE: There are suitably trained staff on duty at all times. The recruitment procedure in place is satisfactory and is designed to protect residents from people who may not be suitable to work with them. At the last inspection, these procedures had not been followed. At this inspection, records for the most recently employed staff were examined. They were found to contain all of the required information. Standard 27 was not fully assessed but was met at the last inspection. On the day of this inspection, there were sufficient staff on duty. Some visitors expressed concerns that there does not always appear to be enough staff on duty. During the inspection, one resident was taken to Accident and emergency. One member of staff had to accompany them, which did appear to make the remaining staff very busy, and not very visible. It was also noticed that staff do not always check who is left supervising residents before spontaneously deciding to go upstairs/downstairs for example. They must be reminded to check with the person in charge before leaving the “floor”. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, and 38. It is the aim of the home to meet service users best interests. Financial procedures do not fully meet regulations. EVIDENCE: The acting manager and staff strive to run the home in the best interests of service users. Some training around rights and choices (see standard 14), will improve some aspects of care provided. It is also recommended that health and safety awareness training is provided to staff, as a number of safety concerns were identified. These include: 1. The bubbled linoleum in the ground floor bathroom must be replaced. 2. Fire doors are wedged open. Bedrooms must have door holders that release in the event of a fire. Residents must be able to sit with their door open if they wish to. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 17 3. A resident was observed being manually lifted from the floor. This is contrary to manual handling regulations. 4. Toilet cleaner was found in the en suite of a resident. 5. Cans of beer were found in a resident’s bedroom which were accessible to other residents. 6. Toiletries are left in bathrooms. 7. The sluice was left unlocked. Towels are stored in the bathroom (advised not to due to damp – infection control guidance). 8. Wet clothes were carried, not in a bag, along the corridor. 9. Emergency pull cords are tied up and must be lengthened to skirting board height. 10. It must be confirmed that the assisted bath is back in use. 11. Items must not be stored on top of wardrobes. Financial records are rigorously maintained by the administrator. There have been no concerns relating to access to residents money. It was noted, however, that money is all pooled which is contrary to standard 35.3 which states “Where money of the individual service user is handled, the manager ensures that the personal allowances of these service user’s are not pooled and appropriate records and receipts are kept”. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 2 COMPLAINTS AND PROTECTION 2 x x x x 3 x 2 STAFFING Standard No Score 27 x 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 2 x x 2 Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 19 yes Are there any outstanding requirements from the last inspection? 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 7 Regulation 15 (1) Requirement Training in writing care plans must be provided to staff. Preventative vare plans must be written where assessments show high risk.e.g.pressure sores. Residents must have access to continenc aids appropriate for them. Medication records must be accurately maintained. Medication must be stored correctly and discarded after use by date. Eye drops must be dated when opened. The suction machine must be easily accessible in an emergency. Training must be provided relating to residents choices and rights. The odour problems in identified rooms must be addressed. The following safety requirements must be addressed. Those asterixed require immediate attention. 1. The bubbled linoleum in the ground floor bathroom must be replaced. 2. Fire doors are wedged open. Bedrooms must have door Timescale for action 01/10/05 2. 3. 8 9 12 (1) (a) 13 (2) Immediate Immediate 4. 5. 6. 14 19 38 12 (3) 16 (2) (k) 13 (4) 01/11/05 01/11/05 01/10/05 Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 20 7. 8. 35 19 16 (2) (l) 23 (1) (a) holders that release in the event of a fire. Residents must be able to sit with their door open if they wish to. * 3. A resident was observed being manually lifted from the floor. This is contrary to manual handling regulations. * 4. Toilet cleaner was found in the en suite of a resident. * 5. Cans of beer were found in a resident’s bedroom which were accessible to other residents.* 6. Toiletries are left in bathrooms.* 7. The sluice was left unlocked.* Towels are stored in the bathroom ( advised not to due to damp – infection control guidance).* 8. Wet clothes were carried, not in a bag, along the corridor.* 9. Emergency pull cords are tied up and must be lengthened to skirting board height.* 10. It must be confirmed that the assisted bath is back in use.* 11. Items must not be stored on top of wardrobes.* Residents personal allowances Immediate. must be held seperately. A written protocol must be 01/09/05 devised relating to minimusing use of the tannoy system. Additional storage must be provided in some en suite bedrooms. 9. 10. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 21 No. 1. 2. 3. Refer to Standard 19 12 15 Good Practice Recommendations It is recommended that the use of popular music in communal areas be monitored in relation to preferences of service users and potential to cause agitation. The programme of activities must be further developed particularly with individuals. Items available for cold tea must be specified on menus. alternative choices must also be specified. Sunningdale Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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 Lodge B53-B03 S40471 Sunningdale Lodge V228881 260705 Stage 4.doc Version 1.30 Page 23 - 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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