Inspection on 29/10/09 for Sunningdale Lodge

This inspection was carried out on 29th October 2009.

CQC found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sunningdale Lodge 11/11/08

Sunningdale Lodge 07/11/07

Sunningdale Lodge 11/10/06

Sunningdale Lodge 23/01/06

Sunningdale Lodge 26/07/05

Sunningdale Lodge 08/03/05

Sunningdale Lodge 30/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Sunningdale Lodge Dene Road Hexham Northumberland NE46 1HW Lead Inspector Mary Blake Key Unannounced Inspection 09:00 29 and 30th October 2009 th DS0000040471.V375971.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunningdale Lodge Address Dene Road Hexham Northumberland NE46 1HW 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) 01434 603357 01434 608865 sunningdalelodge@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Home Properties Limited Manager post vacant Care Home 50 Category(ies) of Dementia - over 65 years of age (50) registration, with number of places Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named resident is known to be under pensionable age. No further under pensionable age admissions are to take place without the prior agreement of the CSCI. 11th November 2008 Date of last inspection 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, next to another residential care home, also owned by the Southern Cross Group. The home is purpose-built with accommodation on three floors. Rooms are single, some with en -suite. The lower ground level provides catering and laundry facilities. There is a large attractively landscaped rear garden, with seating. Fees range from £383 to £478. Information about the home is available including inspection reports. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations. This will only happen when it is considered that people who use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. An unannounced visit was made on the 29th October 2009 with a further announced visit on the 30th October 2009. The acting manager was present for the inspection. Before the visit: We looked at: • Information we have received since the last key inspection in November 2008. • How the service dealt with any complaints and concerns. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff and other professionals, including surveys. • The Annual Quality Assurance Assessment (AQAA), which is a selfassessment document, was sent to the home for their completion and was returned to CQC. “Have your say” questionnaires were sent out to people who have used or had interest in the home, 3 of which were returned to us. During the visits we: • Talked with people who use the service, relatives, staff, acting manager and provider representatives. • Looked at information about the people who use the service and how well their needs are met. • Looked at other records which must be kept. • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. • Looked around parts of the building to make sure it was clean, safe and comfortable. • Checked what improvements had been made since the last visit. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 6 We told the acting manager and provider representative what we found. What the service does well: People who use the service and relatives explained the admission process; this usually includes a visit from the manager. This helps new residents identify their own needs and enables staff to meet their needs during their stay. Residents said, and it was seen, that staff were kind, considerate and supportive. The food provided is of a good standard, with good choice and variety. The dining rooms are well laid out with good staff attendance enabling people to have a pleasant and social mealtime. There is a good complaints policy and procedures in place to make sure that any concerns or complaints are fully investigated with a full response of the findings given to the complainant. The home was clean with no offensive odours in the home on the day of inspection and bedrooms and communal areas appeared comfortable and pleasant. During the visit the relatives visiting were chatting in a very positive way with the staff and made positive comments about the management improvements. More than fifty percent of staff have undertaken National Vocational Training in Care at level two or above and exceed the minimum standard; ensuring people who use the service receive care from a skilled and knowledgeable staff team. What has improved since the last inspection? Work to enrich the environment of the home has taken place to give a more stimulating and appropriate living space for the residents taking into account their dementia care needs. The meal times have been reviewed to make sure that they are supportive to residents having a pleasant and positive experience when having their meals. The home has undergone a refurbishment and redecoration programme providing comfortable and pleasant surroundings. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 7 Staff were friendly toward the people who use the service and were attempting to engage them in conversation. They have a good knowledge of the needs of the people living in the home and the nursing staff are giving good direction and leadership to help them in the day-to-day delivery of care although this is not always reflected in the care plan. The residents, relatives and staff made positive comment about the acting manager and staff team. The manager had made steps to address the majority of the previous requirements and recommendations from the last inspection. What they could do better: Ensure that all residents have a person centred plan of care and that this is regularly reviewed. Ensure that nutritional risk assessments are undertaken and that fluid and nutritional records are kept for those assessed as being at nutritional risk. All of this will help reduce the risk of weight loss, illness and infection. The care plans must be more person centred and improved further to fully show the complex mental health care needs of the residents and must include more detail as to the way they will be met. Ensure residents have their pressure risk assessments undertaken; changes identified and timely actions taken this will help prevent pressure damage. Ensure residents have their transfer/moving needs risk assessed, actions identified and recorded within their care plans. Ensure that all residents are given the opportunity for meaningful social activities and choice in their daily routines and are treated with respect and dignity. This will improve their health and wellbeing. To further develop the environment to help support people with dementias. Ensure that all staff have completed the recruitment process this will help protect residents. Ensure that all staff have completed the mandatory and additional training identified to meet the needs of residents and this is recorded, this will help ensure a skilled and trained staff team support residents. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 8 To submit an application to CQC for the registration of the manager this will help provide consistent leadership for residents and staff. Ensure that all records and documentation is kept up to date to ensure that the management have an overview of health and safety issues and can verify that satisfactory staff training, notifying of incidents, maintenance and fire safety are in place. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 9 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 Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Admissions to the home are appropriately managed and people who use the service know how their needs will be met. EVIDENCE: Pre-admission assessments are undertaken and reflect the needs of the residents. The acting manager is involved in the decisions and in the majority of instances visits the residents herself prior to their admission. Residents have their needs assessed by care staff and have opportunities to visit before admission to the home and this information is developed into the care plan. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 11 Residents and relatives spoke of visiting the home prior to admission and that this was useful to reduce anxiety and make the settling in process easier. A number of the residents relied upon their relatives to go to the home and advise them if it was suitable for them. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive care and support that promotes their privacy and dignity. The residents’ health, personal and social care needs are not consistently set out in their individual plan of care and some individuals health needs are not fully met. EVIDENCE: All people who use the service have a care plan which includes an assessment of their needs and a plan of how these should be met. Southern Cross documentation includes risk assessments for prevention of falls, wound care, and moving and assisting as well as assessment tools for clinical areas such as continence promotion. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 13 Four care plans were examined and three were case tracked. This means that we spoke to the individual residents or observed their care and then matched our observations to what was written in the care plan. The standard of care planning was still inadequate and we found evidence of failure to review, maintain, update and revise individual people’s care plans in order to accurately reflect their health and welfare needs. There were a number of assessment tools in place such as nutrition, pressure sore risk, moving and handling and dependency. However these had not been consistently completed, reviewed or updated. Risk assessments had been completed but actions had not been recorded to help reduce risk such as weight loss. Nutritional assessments were undertaken for some residents and risks identified but action has been inconsistent, for example one resident identified as at risk did not have her weight loss evaluated for two months and it was unclear if any weights had been recorded during this time, this also shows a weight loss but no evidence of timely actions. Staff could not find fluid or food recording charts and when found these had not been consistently completed. We found examples where the quality of recording was inadequate and information was out of date. The recorded information was inconsistent and important details found within the daily reports had been omitted from some plans. There was inadequate emphasis on people’s strengths and abilities and what staff should do to maintain these. Risk assessments had been completed but actions had not been recorded to help minimise risks such as pressure damage. The individual health needs of people who use the service are identified and people are supported to access community health services such as doctor, district nurse, dentist, and optician. Staff had completed medication training. A full assessment of medication systems was not undertaken as a community pharmacist was undertaking an inspection that day. Residents and relatives told us they were well looked after and staff gave the support to bath or shower people on a regular basis. Residents appeared clean and well dressed. Staff were kind and caring and were giving the residents the support and care they needed. People who use the service feel their privacy and dignity is respected and that they are listened to and what they say is acted upon. Staff help people make their own decisions and provided information and assistance when it is needed. Staff were friendly toward the people who use the service and were attempting Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 14 to engage them in conversation. They have a good knowledge of the needs of the people living in the home and the nursing staff are giving good direction and leadership to help them in the day-to-day delivery of care although this is not always reflected in the care plan. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a developing range of activities to meet people’s social needs and residents can maintain contact with family, friends and the local community. Residents are supported to receive wholesome diet and sufficient fluids but this is not always recorded. EVIDENCE: Residents’ social needs are not always assessed or recorded within the care plan but some progress is being made. There is a limited range of activities on offer for residents. Arrangements for residents to maintain contact with their family and friends are supported and family are encouraged to take residents out and about. Residents and relatives told us that they could have visit at any reasonable time. We noticed visitors in the home coming and going freely. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 16 Residents and relatives commented “I get a bit bored” “not much happening” “the days are very long” “wish we had more to do”. People who use the service take control of their daily routines in simple but important ways including the time they get up, what and when they eat and how they spend their time. Those able said they are able to make choices about how they spend their day. The individuals’ bedrooms were personalised, well decorated and furnished. Staff seek permission prior to entering individual rooms and were communicating well with people. People who use the service were observed to move freely around their part of the home. The lunchtime was observed. Staff managed the dining rooms and serving of food well, offering choices and with good staff support evident. We observed that residents appeared to enjoy the food and the atmosphere in the dining rooms was pleasant and relaxed. Residents were offered hot or cold drinks with the meal and throughout the day. The menu has been reviewed and the Nutmeg system for nutritional balance implemented. Residents were positive about the choice and range of food available. Residents and relatives commented “the food is lovely” “get plenty” “always get a cup of tea” “staff try to give him choice” “good range” “always looks nice”. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are procedures in place to make sure that complaints are dealt with satisfactorily and that residents are safeguarded from harm. EVIDENCE: The home ensures that people who use the service and their relatives are aware of the complaints policy by making it available in a variety of places. Complaints are managed satisfactorily and the necessary action taken and recorded. The complaints procedure is displayed in the home and available to individuals and their families. The complaints record was examined and was satisfactory. Residents and their relatives spoken to know how and who to complain to and were confident that their concerns would be dealt with commenting, “there have been a lot of managers but I still know things will get sorted” “staff listen and try to sort things out”. Three complaints had been investigated by the provider and appropriately managed and documented. Staff have undertaken training on the Protection of Vulnerable Adults and there is further training planned. Staff were aware of the whistle blowing policy and felt able to raise concerns if necessary. The manager was aware of the need to Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 18 protect all people who use the service. Safeguarding issues had been appropriately managed. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The facilities are designed to meet the needs of people who use the service. It is homely, clean, well decorated and maintained. EVIDENCE: This purpose built home has undergone a refurbishment and redecoration programme providing comfortable and pleasant surroundings. Residents has access to the enclosed garden area which are pleasant and residents said they enjoyed being able to use this area. The acting manager reported that the majority of bedrooms have been refurbished and redecorated and offer people living in the home pleasant, comfortable personnel space. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 20 The home was clean with no offensive odours in the home on the day of inspection and bedrooms and communal areas appeared satisfactory. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager ensures there are adequate numbers of staff on duty to care for the residents. Staff training is provided but the recruitment processes in place does not always protect residents. EVIDENCE: The home operates with the following staffing levels one qualified nurse and four carers on the nursing floor and one senior care and two carers on the residential floor during the day and one qualified nurse and two carers on the nursing floor and one senior care and one care on the residential floor during the night. The numbers of staff on duty on the day of inspection were satisfactory. There is good ancillary staff support. Staff said that they are undertaking or had completed National Vocational Qualifications in Care (NVQ) level 2 or over, and from the AQAA the number with an actual qualification exceeds the fifty percent target. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 22 A staff training programme is available and includes the dates of completion for mandatory, safeguarding, NVQ and other training but this needs updating to confirm that the staff team are developing the skills and training which is required to meet the needs of residents. Whilst staff confirmed a range of training they had attended we were unable to verify this as only limited information was on individual files. The home has an induction and training programme for all staff working in the home. Staff spoke knowledgably about the individual needs of residents. Four staff recruitment files were examined and were generally satisfactory. However, a recent staff member who was working unsupervised did not have two references on their file. The manager was unclear if the references had been taken up and/or not been filed. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37 and 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is not consistent to offer leadership to the staff; There are systems in place to organise the home taking into account the needs and wishes of the residents. Quality systems have been established and are being developed but the health, safety and welfare of residents and staff are not fully protected. EVIDENCE: Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 24 The home was without a registered manager for a period and a new manager is about to take up her post. Any new manager must apply to the Care Quality Commission to become the registered manager. The home is currently operating with a peripatetic regional manager who is at the home on a daily basis. The acting manager takes the necessary action to ensure the general health and safety of the service users. This is supported by the policies and procedures and by discussion with the staff. The manager had made steps to address the majority of the previous requirements and recommendations from the last inspection. During the visit the relatives visiting were chatting in a very positive way with the staff and made positive comments about the improvements. An internal audit of monies held for residents had been undertaken in June 2009 and there had been no issues, we were unable to assess this standard further. Quality assurance systems are in place with audits for a range of areas and remedial actions plans in place. Regulation visits by the provider representative had been undertaken. CQC have not been informed of any event effecting the welfare or health of residents (regulation 37) since March 2009. On discussion with the manager it was evident that incidents had happened that had not been appropriately recorded or reported. The home has been without an administrator and throughout the homes systems there was evidence of poor record keeping and documentation. For example it was unclear what training staff had undertaken as very few certificates were on individual files, if or when annual services and maintenance checks had been completed, when fire drills and testing had been undertaken. The manager felt that there was an extensive backlog of documentation to be filed. The fire log book was not available prior to October 2009. We were unable to confirm that the fire drills had been carried out at the timescales of six per year for night staff and two per year for day staff. Fire prevention/detection equipment testing had not been undertaken on the required timescales. Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X 1 2 Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP8 Regulation 15 12 (1) Requirement Ensure that all residents have a person centred plan of care and that this is regularly reviewed. Ensure residents are weighed, nutritional risk assessments are undertaken, changes identified and actions taken. Fluid and nutritional records are kept for those at risk Ensure residents have their pressure risk assessments undertaken, changes identified and timely actions taken. Ensure residents have their transfer/moving risk assessments undertaken and recorded within their care plan Ensure that all residents are given the opportunity for meaningful social activities. Ensure that all staff have undergone the recruitment process with two written references obtained. To forward staff training matrix detailing individual completion of mandatory and other training. To notify management arrangements and submit an DS0000040471.V375971.R01.S.doc Timescale for action 01/03/10 01/01/10 3 OP8 13 (4) 01/01/10 4 OP7 13 (4) 21/12/09 5 6 OP12 OP29 16 (2)(m)(n) 19 01/03/10 01/01/10 7 8 OP30 OP31 19 39 21/12/09 14/12/09 Sunningdale Lodge Version 5.2 Page 27 9 OP37 10 OP38 17 (2) schedule 4 17 (3) 37 application to CQC for the registration of the manager. Ensure that all records are kept up to date and maintained and available for inspection. 01/01/10 11 OP38 23 (2) 12 OP38 13 (4) (c) Ensure that CQC are notified and 14/12/09 a record kept of any event that occurs in the home that is detrimental to the health and welfare of residents. Provide evidence of annual 14/12/09 services and maintenance checks being undertaken and forward to CQC. Ensure that all staff undertakes 14/12/09 fire drills at the intervals of three monthly for night staff and six monthly for day staff. Ensure that testing of the fire prevention equipment is carried out at the given timescales. 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 OP19 Good Practice Recommendations To continue to develop the environment to assist and support people with dementias Sunningdale Lodge DS0000040471.V375971.R01.S.doc Version 5.2 Page 28 Care Quality Commission National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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