Inspection on 20/10/06 for Sunningdale Nursing Home

This inspection was carried out on 20th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 15/11/05

Sunningdale Nursing Home 04/05/05

Sunningdale Nursing Home 02/11/04

Sunningdale Nursing Home 06/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Sunningdale 7 - 9 Albany Road Southport Merseyside PR9 0JE Lead Inspector Mrs Claire Lee Key Unannounced Inspection 9am 20 October 2006 and 6th November th 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 DS0000017257.V298393.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 DS0000017257.V298393.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunningdale Address 7 - 9 Albany Road Southport Merseyside PR9 0JE 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) 01704 538568 Mrs Patricia Jane Bennett Mrs Amanda Jane Williams Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users to include up to 32 OP This service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. May from time to time admit persons between the ages of 60 and 65 years of age. Service to include 1 named SU within the PD category Date of last inspection 15th November 2005 Brief Description of the Service: Sunningdale is a large detached building that provides nursing care for 32 older people. The home is situated within a short walk to Southport town centre and local amenities are close by. The home has 30 single rooms and 1 double room and some have ensuite facilities. The accommodation is situated over 4 floors and a passenger lift is used to access all areas. The conservatory on the ground floor us used as lounge and dining area. There is also a separate dining room. The home has wheelchair access via a ramp to the side of the building and residents benefit from an attractive landscaped garden. The home has suitably adapted baths and a walk in shower to assist those who are less able. A call system is available throughout the home. Mrs Patricia Jane Bennett privately owns Sunningdale and it is managed by Mrs Amanda Williams. Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days for a duration of nine hours and twenty nine residents were accommodated at this time. A site visit took place as part of the unannounced inspection and a partial tour was conducted of the premises. A number of the home’s care, staff and health and safety records were viewed. Discussions took place with eight residents, five staff, the home’s administrator (deputy manager) and registered manager. During the inspection three residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. Discussion also took place with three relatives. All the key standards were inspected and also previous recommendations from the last inspection in November 2005 were discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents prior to the inspection. Comments included in the report are taken from the survey forms and also during the site visit. What the service does well: On entering the home there was a very pleasant welcoming atmosphere. Areas seen were very clean and tidy and several residents commented on this always being the case. A resident said, “A cleaner comes in my room every day”. The home was attractively decorated; furnishings were of a very good standard and each room individually decorated. A resident commented on the very good upkeep of the building. In the hall there is a welcome desk with a variety of information regarding the home including the Service User Guide and the latest Commission for Social Care Inspection report. There were also brochures on community services, which can be accessed by the residents. The notice board has staff photographs to help the residents to get to know the staff. The exterior of the building was well maintained with attractive flower arrangements. Prior to admission the manager and/or a qualified member of staff assess residents’ health and social care needs. The assessment information is then used to form the basis for a plan of care. Care files seen were organised, easy to read and provided good detail with regard to individual care needs. Care Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 6 plans were seen to be person centred. A member of the care staff said, “The care files are really helpful and they record a lot of detail regarding each resident”. An interview with a relative confirmed that they were aware of the care plans and were happy for staff to provide this support. Through discussion and observation it was evident that residents were treated respectfully and the home ensured good standards of privacy and dignity. Doors to residents’ rooms were closed when staff were assisting them with personal care. A resident said, “The staff are always kind and polite”. The home’s routine was relaxed and staff interviewed discussed how residents could choose what they wanted to eat, get up in the morning or retire at night. Those residents seen were appropriately dressed and staff were spending time with them chatting in the lounge or in their private rooms. A resident stated the home is, “Peaceful and quiet and I can eat and drink to my heart’s content”. The home employs an activities organiser (member of the care staff) and residents interviewed were pleased with the range of events and social pursuits on offer. Social input is arranged each morning and the activities organiser was described as ‘very good and full of fun’. Residents and relatives were complimentary regarding the standard and choice of the meals. The menu was varied and offered an excellent choice of hot and cold home baked foods. Comments included, “Really good”, “Tasty”, “Served hot”, “Lovely Cook”, “Good choice of cereals” and “Meals are served nicely”. Staff are recruited through robust recruitment procedures. CRB (Criminal Record Bureau) disclosures and POVA (Protection of Vulnerable Adult) checks are obtained for staff and two references sought. The staff have access to numerous courses including moving and handling, infection control, first aid, food hygiene and NVQ in care, domestic services and food preparation. Other courses regarding care of the elderly are arranged and the management team work hard to provide new learning material. A resident said, “The staff are the best”. The home is very organised and well managed. Residents’ opinions are sought regarding the service and staff have advised the manager they feel “Valued” in their work. What has improved since the last inspection? There were no requirements from the last inspection. Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 7 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 DS0000017257.V298393.R01.S.doc Version 5.2 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 DS0000017257.V298393.R01.S.doc Version 5.2 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 and 6 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents were provided with information to enable them to make a choice about whether the home is suitable for their needs. Pre admission assessments were undertaken to ensure staff could meet their needs in full. EVIDENCE: In the main hall there was a welcome desk with a variety of information regarding the home including the Service User Guide and the latest inspection report from the Commission for Social Care Inspection. The home are currently revising the Service User Guide and the proposed changes were discussed in relation to equality and diversity. Residents are also given a pocket size leaflet regarding the home and its philosophy of care. A relative confirmed that the information he received was beneficial. There were also brochures on community services available to the residents and the notice board has staff photographs to help the residents to get to know the staff. Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 10 Contracts stating terms and conditions of residency had been given to the residents who were case tracked. Residents have an assessment of need which is carried out by the manager and/or qualified member of staff. Three assessments were viewed and this included residents who had recently been admittred to the home. Inspection of admission documents confirmed the good standard of information recorded regarding general health, mobility, risk of falls, nutrition, dependency assessment for psychological care and details of social contact. There was evidence of assessment information from social services and also transfer letters from hospital to assist the home with collating the assessment information. A resident said, “I am very pleased with everything and staff have explained all about the home to me”. Standard 6 is a key standard to be assessed however the home provides long term care only and does not provide intermediate care. Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 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 and 10 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents’ health, personal and social care needs were addressed in detailed care plans and staff were observed delivering this care in a respectful manner. EVIDENCE: Residents had an individual care file and three files were viewed as part of the case tracking process. The care files were accessible for staff; the information recorded was organised and easy to read. A plan of care had been written for key areas, for example, skin, nutrition, continence, personal hygiene, pressure area care, mobility and social background. A plan of care had also been recorded for specific medical conditions and wound care. There was evidence of the resident and/or their advocate being informed of the plan of care and giving their consent. Care documentation seen had also been reviewed regularly to ensure it was accurate and reflected current care needs. This was discussed in relation to concerns regarding a resident’s nutritional intake. There was evidence of the home contacting a GP for advice for this resident and extra monitoring provided by staff. A GP was also contacted for a resident Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 12 who required pain relief. The home are quick to seek advice when needed. Care plans included good instructions to staff on how to deliver the care. Staff spoken with were able to describe how they use the care plans and described the care they provide residents with each day. This knowledge means that residents can be confident that they will get support from people who understand their care needs. Staff currently do not record the care they give, this is something that should be encouraged and ways of recording this were discussed. Comments regarding the care included: “The care is always good, it never matters who is on duty”. “The help the staff give is very good” “Care is available all the time” “The staff help me get up in the morning and never rush me” General risk assessments including moving and handling instruction were in place for residents who were at risk of falling. This included a moving and handling assessment for mobility. Risk assessments for, nutrition and care of resident’s skin for pressure relief had also completed. GP records were evidenced in care files viewed and also a number of appointments to external professionals where a need had been identified. The home has a policy and procedure for the safe handling, storage, administration and disposal of medications. Medicines were administered from a medicine trolley, which was locked when not in use. The medicine trolley was found to be clean and organised. A number of medicine sheets were viewed and these evidenced staff signature following administration of medicines. The home’s records evidenced the dates when medicines are received in the building and the dates of disposal. There were no residents who were currently administering their own medications however staff would support them with this practice and a disclaimer and risk assessment would be completed. The administration of controlled medication and Temazepam evidenced two staff signatures and a stock balance. Specimen signatures of qualified staff were available for administration purposes. A resident said, “I get my tablets on time”. Staff were observed as being competent and very caring in their attitude when providing personal care for residents and also chatting with them on an individual and group basis. Staff were observed knocking on private doors before entering and also ensuring that residents were appropriately dressed for the time of year. A relative said, “The staff are just great and so pleasant”. Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Residents are able to exercise choice and control over their lives and are offered a choice of attractively presented, well balanced and nutritional meals. EVIDENCE: Sunningdale has a very pleasant atmosphere and on walking in to the home visitors were observed to be greeted warmly. A relative said that the staff always offered refreshments and had time for a chat. A member of the care staff has recently taken on the role as the activities organiser and residents spoken with were really pleased with the variety of hobbies and social events on offer. The activities organiser when interviewed was knowledgeable regarding the residents’ preferred interests and was very enthusiastic regarding her role and how she wished to develop it further. A daily record had been completed for each resident regarding their involvement with the social programme and whether they enjoyed the sessions. This record was seen and was found to be up to date. Care files viewed also included a social profile for each resident. This information is collated once the resident has settled in. A number of residents stated that they prefer to stay in their rooms and the activities organiser pops in each day to see them. Activities offered by the Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 14 home included, bingo, cards, clothes parties, birthday parties, music, hand massage, foot therapy and outings. A resident said, “The foot massage is just lovely”. Events are now being organised for Christmas. Residents are encouraged to attend local clubs and community based events and this was discussed in relation to a local stroke club, which is providing a service for one resident. At the time of the site visit a resident was going out with family member and in the past a staff member has taken a resident swimming. The home has a mobile shop, which sells sweet and toiletries. Holy Communion is offered and this enables residents to continue to practice their own faith. A resident was interested in attending a church in Liverpool and this was passed to the manager for her attention. Lunch was served in the dining room and this was observed as being a sociable time for the residents. A number of residents also had their lunch on coffee tables in the conservatory or in their own rooms. The dining room tables were laid for lunch and a copy of the menu was on display.A copy of the menu was provided with the pre inspection questionnaire and this offered residents an excellent choice of three well balanced meals day with light refreshements at other times. Residents interviewed gave very good feedback on the quality and quantity of meals and the contact they have with the cooks each day. Residents said, “The cakes are excellent”, “The food is lovely”, “and we get a good breakfast and can have a cooked one if we want”. Completed survey forms also reported that the food is always good and plentiful. The cook was seen asking residents what they would like for tea and also describing the home made soup on offer. The home caters for special diets and this was discussed in relation to diabetic meals. Food preferences had been noted on a diet sheet recorded in the resident’s plan of care and the cook when interviewed was knowledgeable regarding resident’s dietary needs. The cook is currently obtaining further qualifications in food hygiene at college. The kitchen was seen to be well organised and there was evidence of a good supply of fresh, frozen and dry goods. Hazard analysis records had been completed for environmental health purposes. It was noted that the seal to one freezer appears to be damaged and this was brought to the manager’s attention Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home has policies to protect the residents and residents and relatives have confidence that their concerns will be dealt with. EVIDENCE: The home had a complaints procedure and details of this can be found in the Service User Guide. A log was also maintained of any concerns, incidents, near misses, that may occur. No complaints had been received by the home over the last twelve months. Discussion with residents and also the return of completed survey forms confirmed that residents knew who to talk to should they have a concern and that “Amanda” (manager) would sort it. A staff member described the complaint procedure and knew where a copy of this document could be located. The home has an abuse policy and procedure and they should also acquire the latest copy of Sefton’s Guide for the Protection of Vulnerable Adults. Abuse awareness is discussed during staff induction and also ongoing training is provided. A number of staff have attended De-escalation of Violence. A staff member was able to describe the various forms of abuse. Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 16 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 and 26 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents live in very pleasant, safe, comfortable and well-maintained surroundings. EVIDENCE: Sunningdale provides very comfortable accommodation. The home was decorated to a good standard and maintenance jobs are carried out quickly and efficiently. The home was very tidy and clean and residents interviewed stated that their rooms were cleaned each day. Colour schemes were pleasant throughout and new colours are being introduced with matching bed linen. A resident said that one of the reasons her family chose the home was because of the pleasant decoration, size of the rooms and the ‘homely’ feel to it. The dining room has been decorated and the lounge/conservatory had comfortable armchairs and coffee tables. The home has a passenger lift to all floors and Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 17 there is wheelchair access to all areas. There is a small kitchen on the top floor for residents to use. Residents are able to bring in their personal belongings and a resident said how pleased she was to have her own furniture with her. Bedrooms seen were nicely decorated and furnished to a good standard. They had televisions and phone points. It was noted that an ‘attic type’ window required a blind and this was confirmed as being on order. The home has special beds for residents assessed with high dependency needs and residents case tracked said their rooms were very comfortable. Bathrooms seen were clean and odour free. The bathroom floor in the top bathroom has raised edges and this should be sealed to minimise the risk of a trip hazard. Staff record the temperature of the hot water to the baths to ensure it is delivered to a safe temperature. Records seen evidenced this. The home has a walk in shower which is popular with residents and also a good standard of equipment, for example manual handling hoists and bath hoists to assist those less able. Emergency lighting is provided throughout the home and was subject to the necessary safety checks. Although the laundry room is small, laundry is well managed and personal items stored in individual baskets to prevent loss. The home are looking to introduce better measures to segregate clean and foul linen, as laundry space is limited. Infection control training is arranged for staff and there were plenty of gloves and aprons available. The exterior of the home was well maintained with ample seating for the residents to use in the warmer weather. Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 18 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 and 30 The quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. There are appropriately recruited, trained and experienced nurses and care staff employed so that residents feel supported and that their needs are understood and met. EVIDENCE: Sufficient numbers of staff were evidenced on the staffing rota to provide the necessary care and support to the residents. An extra member of staff is also brought in to assist with the work and breakfasts in the mornings. During the morning there was a registered nurse in charge with six care staff, a laundry assistant, cook, kitchen assistant, administrator/deputy manager and maintenance person. The manager was supernumerary. A registered nurse and two members of care staff are on duty for the night shift. Additional staff are employed to meet the varying needs of the residents. The permanent staff cover sickness and holidays, agency staff are seldom used. The manager stated that there have been some staff changes however the home presented with a committed stable work force. Student nurses spend a number of weeks at the home as part of their training; there were no students at this time though. Residents stated that staff were “Efficient”, “Kind”, “Pleasant”, “Polite” “Lovely people” and “Cheerful”. One comment made was with regard to the night staff and their very caring attitude when assistance is required at night. The gender mix of the staff was seen to be good with three male staff Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 19 employed. This enables resident to choose about whether they wish to be assisted by a male or female staff member. Staff are employed using robust recruitment procedures. Three staff files were viewed with regard to recruitment practices and these evidenced the necessary checks to protect the residents. Staff had completed a job application form with a medical questionnaire. A staff photograph was on file and references had been obtained from previous employers. CRB enhanced disclosures were obtained for staff. A record is made of the date the CRB is sent off and received. POVA clearance had been obtained for staff members where there was need to start their employment prior to their CRB being received. An interview record is kept and staff are asked to provide a CV where possible. The staff files were organised and contained certificates for courses attended, including NVQ. New staff receive an induction and are provided with copies of a number of policies and procedures, for example, confidentiality, abuse and whistle blowing. Job descriptions and staff contracts are also provided. This information was confirmed when talking with staff. Changes have been made to the induction material to ensure it is very detailed and provides a good knowledge base for staff. Staff interviewed commented on the excellent standard of training provided and the manager and deputy manager’s enthusiasm for accessing learning material. Staff training was recorded in individual files and also a training matrix is kept up dated. Staff receive training in safe working practices, including moving and handling, infection control, food hygiene and first aid. Other courses include dementia care, harassment and bullying, continence promotion, fire safety, managing violence, 4 day first aid at work and mentorship for the student nurses. The training is organised on a rolling programme to ensure all staff have access. Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 20 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): 31,32,33,35 and 38 The quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. There is an open atmosphere in the home and residents, relatives and staff feel valued. EVIDENCE: Mrs Amanda Williams is a registered nurse and also the registered manager for the home. It was evident through discussion with residents, relatives and staff how much Mrs Williams is respected and liked by her colleagues. Mrs Williams has completed NVQ Level 4 in Management and is currently studying this course at Level 5. Mrs Gay Clark who holds the position as administrator/deputy manager and is also undertaking the same NVQ study. Both managers have completed courses in Managing Violence and Harassment and Bullying. It was evident that Mrs Williams and Mrs Clark are keen to further their learning and to support the staff with their training. Mrs Williams and Mrs Clark work closely together regarding staff supervision, training requirements, general administration and also reviewing policies and Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 21 procedures. The management structure is organised and there are heads of department for the kitchen and housekeeping team. A senior member of the care staff assists junior staff with regard to care issues. Staff members stated the following, “Amanda (manager) is just great and really organised”. “The home is managed really well and the residents have very good care”. “Amanda is very fair and you can go to hear with anything” “Amanda and Gay (deputy manager) work really well together”. Mrs Williams stated how much she enjoys having the student nurses at the home and welcomes their views and input. Staff supervision was not assessed however it was noted that staff receive this and also an annual appraisal. Residents are encouraged to manage their own monies. The financial records for two residents were viewed and these were maintained to a satisfactory standard. Where a resident needs support with managing their money then a record of all money they give in and take out is kept and receipts are kept for purchases whenever possible. There were some good quality initiatives that ensure residents’ views are instrumental in the running of the home. Residents are regularly given questionnaires to complete and comments receive from April 2006 included: “I love living here” “Everyone is very friendly” “Food is excellent” “No complaint whatsoever” The manager holds management reviews regularly to ensure the home is running smoothly and to look at ways of improving the service. Staff meetings are held and staff are also given questionnaires to complete. The response was that staff felt valued in their work. A staff action plan follows staff meetings to discuss points raised. A quality review circle is another forum run by the home. The owner completes an inspection of the premises and meets with residents, staff and relatives to obtain their views of the service. A report is made of the findings (Regulation 26 of the Care Standards). The home has a good range of policies and procedures. An external company on a regular basis updates these. Maintenance contacts were seen for gas, electric, lift and hoist equipment. These were all in date. Fire prevention equipment is checked annually and the fire alarms checked weekly. The fire log book evidenced this informatation. There is a fire risk assesmsent of the premises and staff receive fire awareness training. Some maintenance work has been carried out to fire escape to improve the structure. Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 22 An accident record was viewed for a resident who was case tracked. The record was completed in sufficient detail and stored appropriately. The manager and deputy manager have recently attended an Equality and Diversity course. They are currently reviewing the home’s policies and procedures that protect the staff and residents to ensure they are in line with current legislation. The home offers a gender mix of staff which enables the residents to choose whether they would prefer male or female staff to assist them with personal care. Care of a resident with diverse needs was discussed in relation to how the staff were able to maximise the resident’s social care and arrange activities to suit their needs. Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 X X X X 3 Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP7 OP18 OP19 OP26 Good Practice Recommendations The home should encourage staff to become involved with the writing up of the care provision The home should obtain the latest Sefton Guide for the Protection of Vulnerable Adults The bathroom floor should be sealed to minimise the risk of a trip hazard to residents The home should ensure a better system is introduced for the segregation of foul and clean linen Sunningdale DS0000017257.V298393.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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. 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