Inspection on 14/03/07 for Sunningdale Nursing Home

This inspection was carried out on 14th March 2007.

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

The inspector 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 Nursing Home 26/02/09

Sunningdale Nursing Home 30/11/05

Sunningdale Nursing Home 08/09/05

Sunningdale Nursing Home 02/12/04

Sunningdale Nursing Home 25/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Sunningdale Nursing Home Town Street Nr Henley Mount Rawdon Yorkshire LS19 6PU Lead Inspector Sean Cassidy Key Unannounced Inspection 14th March 2007 10:00 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 Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunningdale Nursing Home Address Town Street Nr Henley Mount Rawdon Yorkshire LS19 6PU 0113 2505003 0113 2505003 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) Foxcliff Limited Vacant post Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2005 Brief Description of the Service: Sunningdale Nursing Home is situated in the village of Rawdon and has been established since 1990. It is accessed off the A65 between Leeds and Yeadon. The home is close to the amenities of the village and include a selection of shops, a post office and a public house. There are also a number of churches within easy reach. The home is built on a hillside and access, although level, is sloping. There is a patio area where service users can sit out however the grounds are generally not accessible to service users. However, the hillside site does offer extensive views across the valley from many of the bedrooms and from the lounges. The home provides personal care with nursing for service users over 65. Accommodation is mostly in single rooms although there are some double rooms available. None of the rooms have en-suite facilities. The weekly fees charged by the home range from £525- £561. Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence in this report has included: • • • A review of the information held on the home’s file since the last inspection. Information submitted by the registered provider in the pre inspection questionnaire. Information received from service users, relatives, staff and other professionals. An Unannounced visit to the home was conducted by one inspector and lasted one day. The majority of this time was spent speaking to residents, management, staff and relatives. The visit included a tour of the premises. A number of documents were examined which included care files, training files, recruitment files and health and safety details. What the service does well: The home provides a clean and comfortable environment. Residents are encouraged to bring in their own personal belongings. Residents said staff are friendly and helpful. They also said that they respect their privacy and dignity as much as they can. Residents and their representatives are provided with a good standard of information both before and after moving into the home. The home tries hard to ensure the health care needs of the residents are reviewed regularly and involve members of the multidisciplinary team when needed. The residents are confident that the complaints procedure is accessible and there to protect them. Residents are happy with the overall standard of the internal environment of the home. Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to moving in. They are provided with a good standard of information to assist them. EVIDENCE: Residents spoken to said they were invited to look around the home before choosing to move in. Only one took up that offer and felt it assisted their decision. They all said they were provided with information before they moved in and that they have access to a Service User Guide. All rooms have a Service User Guide displayed on the walls. There are a large number of residents who are wheelchair users and it was recommended that the Service User Guides would be more accessible if they were displayed at a height that was suitable Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 9 for wheelchair users. The manager acknowledged this. The Service User Guide does not contain the necessary information in relation to fees. All care plans inspected showed that the home had assessed the resident prior to moving in. This was confirmed through conversations held with some of the residents over the course of the inspection. Each resident was pre assessed by a member of staff qualified to do so. Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home actively promotes the health, social and personal care needs of the resident group. EVIDENCE: Three care files were inspected and the overall evidence showed that care files are maintained to a good standard. The residents or their representatives were involved with the care planning process. Information was obtained from residents’ relatives to say they had been consulted regarding the care plans and their reviews. With the exception of one care plan, all were reviewed on a monthly basis. One resident requiring a wound dressing did have a care plan in place that provided the staff with appropriate information as to how it should be dressed. The records kept providing evidence to show it was dressed at the times it should Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 11 have been were inconsistent. The manager agreed that this would be reviewed and examined during her monthly audits of the care planning documentation. Residents are appropriately risk assessed in areas such as falls, moving and handling, continence and pressure area care. When a risk was identified there was a plan of care developed to assist carers with reducing the risk to the resident. Care files showed staff had access to other health professionals such as general practitioners, chiropodists, tissue viability nurses and opticians. Residents spoken to said they were happy with the way the home responded to their health needs. The medication charts were randomly reviewed and were found to be correct. A record is kept of controlled drugs stored in the home and they are recorded correctly. There were controlled drugs that belonged to a resident that had not been living in the home for some time. These should have been appropriately disposed of following the home’s procedure. The manager has introduced a new system for assessing whether a resident is able to self-administer their medication. This is good practice. Staff interacted well with the resident group. There was plenty of chatting between staff and residents. One gentleman had his birthday and a cake was supplied which he appeared to enjoy. Residents said that they felt the staff were polite and helpful. One resident spoken to felt that if she was given the right assistance she would be able to do a lot more for herself. She feels awkward having to ask staff to do too much for her. This person gave permission for this information to be handed to the manager. The manager said she would look into the matter. Two residents raised concerns about the responsiveness of the staff when they need assistance with personal care. They said that they could be left for long periods of time before the staff attend to them. This caused them some distress. Passers by can view many of the rooms at the front of the house. Two residents and one relative said this sometimes compromised their privacy and that they would like this to be reviewed. Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is not meeting the daily social needs of the resident group. EVIDENCE: The residents spoken to said that they would like to have more activities during the day and that they would like to have more access outside of the home. Two residents leave the home in arranged transport, which takes them to local amenities. Residents said that they looked forward to this but the time they have to wait before their next outing is too long. Some comments residents made during the inspection were, “Fresh air is missed” “More interesting activities would be appreciated” “I’ve no reason to go downstairs as there is nothing to do.” “ I did some seed planting recently but I have not been able to re pot them as no one is able to help.” The manager acknowledged these comments and said the activity coordinator for the home has recently left. It was pointed out that the provision of activities is not solely the role of Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 13 an activities person and that staff must have sufficient time over the course of the day to provide for these needs. There are a significant number of residents living in the home that have dementia. There was no clear evidence available to show their dementia needs with regards to the provision of activities were met. Residents said the home arranges for their religious and spiritual needs are provided for and that if they wanted to discuss personal issues with a religious representative then they said this would be arranged. Good feedback was given with regards to the food supplied by the home. Residents were observed during the lunchtime meal. This was seen as a social occasion and assistance was provided to those that needed it. Staff were seen to assist two residents with their meals at the same time. This was highlighted as bad practice and the manager said it would stop. Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes complaints and safeguarding adults policies and processes properly protect residents. EVIDENCE: There is a complaints procedure in place and it is highlighted within the Service User Guide. Residents that were spoken to were able to give assurances that they knew how and to whom they would make a complaint. The manager said she is committed to ensuring complaints are dealt with correctly. Staff spoken to confirmed that they receive training in the area of safeguarding adults. Those staff spoken to gave a good awareness of what constituted possible abuse and how they would deal with this issue if it presented itself. Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a safe and well-maintained environment for residents. EVIDENCE: The residents gave positive feedback about the standard of the environment of their home. Residents said their rooms were kept clean and tidy by the domestic staff. A random inspection of residents bedrooms found that several of the bedside lights and the televisions were either broken are did not work properly. Two residents said they would appreciate having televisions that had a picture they could watch. This was highlighted with the manager who said she would review Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 16 furnishings in resident rooms. The dining area on the first floor does not appear homely as it is used to store teaching materials and other items. The outside environment is very restrictive, as the residents have very little access to it. There is a very small patio at the back of the house, which the manager is hoping can be made accessible to the residents. Quotes are being obtained to gain costing for this work. The front access to the home is also very narrow and steep. It poses a possible risk to users and the manager was asked to carry out a risk assessment to minimise the risk of harm to users. All areas inspected were clean smelt fresh. The laundry area was well equipped and looked well organised. The correct procedures were in place for the handling of foul linen. There are systems in place to make sure that the environment provided to residents is safe and well maintained. Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all the residents are assured that the home is suitably staffed. Residents would benefit from receiving care from a staff group that have received training in the areas of care need that are relevant to them. EVIDENCE: The manager has developed a four-week rota system that identifies which staff are on duty over the course of each shift. Three residents said that they thought there could be more staff on duty over the course of the day. As earlier stated, residents said they are being left for long periods of time before staff can attend to their needs as they are busy with other residents. Feedback returned from residents’ relatives also highlighted concerns with the numbers of staff on duty. During the inspection staff were seen to be very task orientated. They were very involved with assisting those residents who had poor mobility. There was little time for staff to sit and involve themselves with the residents or have one to one time, as they were busy doing other things. Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 18 The care staff took their breaks together as a group and this left the floor short during this time. The manager agreed this was an issue and said she would review this process. Care staff employed to provide personal care are also involved with the domestic duties of the home in the afternoons. This practice means that staff are not available to provide for the personal care needs of the residents. The recruitment files of two new employees were seen and these included all the necessary information needed prior to commencing work. Evidence was seen to show each new employee is suitably inducted when the commence work. Staff spoken to provided good evidence to show they have received a good standard of mandatory training. The manager agreed that carers should receive training in the areas of care need relevant to the resident group. These included areas such as nutrition, continence care, pressure area care and diabetes. The manager felt that this programme of training would be developed in the near future. Particular attention should also be paid to specialist dementia training. This will assist staff to have a better understanding of the disease and therefore enable them to meet those specialist care needs of the residents. The manager has now ensured that at least 50 of the staff group have received training at NVQ Level 2 and above. Well done. Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a home that is managed to a good standard. EVIDENCE: The manager has experience of managing a care home in her previous role. She has made an application to become the registered manager at Sunningdale and this is ongoing. The residents, relatives and staff speak highly of the manager and feel that she is approachable and gets things done. Her work is open and transparent and she welcomes good practice where it can be introduced. She is beginning to develop her own systems for managing the Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 20 care home and expects to improve the standard of care continually. There have been difficulties with obtaining the registered manager certificate. These are being looked into at present. Staff meetings and resident meetings are held. The home has a policy for looking after resident monies. They assist two residents in the home with their pocket monies. The evidence provided showed these monies are managed correctly. The manager does have some systems in place for assuring the quality of care provided to residents. Regular monthly audits are carried out on falls and accidents that occur at the home. Questionnaires are provided to relatives and residents. The manager was encouraged to correlate all the information and present it in a form of a quality report. This will be good practice when it has been developed. In addition to the regular health and safety checks of the building there is a detailed fire risk assessment in place, together with clear and detailed instructions for staff of what to do in the event of a major incident. Staff have received fire instruction. Fire drills have been held regularly and have included all the night staff. Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 21 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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 2 x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 3 Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5(1) Requirement The registered person must ensure that the Service User Guide contains the required information. This will keep the resident group fully informed. The registered person must review the viewing access into residents’ rooms. This will promote resident privacy and dignity. Timescale for action 30/06/07 2 OP10 12(4)(1) 30/06/07 3 OP12 12(2)(m) 4 OP24 16(2)(c) The registered person must review the privacy promoted in residents’ rooms at the front of the home. This will help reinforce the privacy of residents. The registered person should 31/07/07 ensure the provision of activities within the home meets the assessed needs of the resident group. Particular attention must be paid to those residents with dementia. The registered person must 30/06/07 provide residents with working bedside lights. If residents are provided with a television then they should ensure they work properly. DS0000001373.V321824.R01.S.doc Version 5.2 Page 23 Sunningdale Nursing Home 5 OP27 18(1)(a) 6 OP30 18(1)(c)(i ) 7 OP33 24(2) The registered person must 30/06/07 review the numbers of care staff on duty during each shift. This will assist the home with ensuring the correct numbers of staff are on duty to meet the residents’ care needs. The registered person must 31/07/07 ensure carers receive training in the areas of care need that are relevant to the resident group. This will enable them to provide a better standard of care. The registered person must 30/06/07 develop a system for evaluating the quality of the services provided by the care home. This will help to maintain and improve the quality of care provided. 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 Refer to Standard OP20 OP1 Good Practice Recommendations The registered person should provide access to the environment outside of the home. It is recommended that the registered person ensures that all available information is suitably accessible to wheelchair users and others with differing forms of disability. The registered person should return dispose of any controlled drugs that are not being used. The practice of one carer feeding two residents at once is poor and should stop. The manager should possess a recognised management qualification to assist her with the running of the home. 3 4 5 OP9 OP15 OP31 Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sunningdale Nursing Home DS0000001373.V321824.R01.S.doc Version 5.2 Page 25 - 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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