Inspection on 30/11/05 for Sunningdale Nursing Home

This inspection was carried out on 30th November 2005.

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

Other inspections for this house

Sunningdale Nursing Home 26/02/09

Sunningdale Nursing Home 14/03/07

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 Catherine Paling Unannounced Inspection 30th November 2005 11:10 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.V266367.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 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 Mr Keith Derek Wilson Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 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 is currently registered with 28 places for service users in needs of long term care for whom Sunningdale is home. There are also seven beds currently allocated for Intermediate Care. The provider has made the decision that this provision will no longer be available from January 2006, when the current contract runs out. The home provides personal care with nursing for service users over pensionable age Accommodation is mostly in single rooms although there are some double rooms available. None of the rooms have en-suite facilities. Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was a third inspection for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was in September 2005. This was an unannounced visit carried out by one inspector over two days who was at the home for a total of five hours. The main purpose of this inspection was to make sure that the home provides a good standard of care for the service users and to assess progress on meeting any requirements and recommendations made at the last visit. The methods used at this inspection included looking at records; observing working practices, including the lunchtime meal; talking to staff, service users; and discussion with the registered manager. The inspector also spoke with a visiting general practitioner. The current provision for intermediate care will no longer be available from January 2006. What the service does well: What has improved since the last inspection? The home continues to operate at a good level. There has been a further improvement in the detail of care needs recorded in care plans. The manager has developed the TOPSS based induction and foundation training. There is external verification of this training. Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 6 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 Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 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.V266367.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were assessed at this visit. Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 9 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 and 9. The healthcare needs of residents are met and overall plans provide detailed instructions for staff to follow. Medication practices are safe. EVIDENCE: The care records were reviewed and overall the detail recorded within care plans was good. The commitment to choice was evidenced for example it was recorded that one resident ‘will ring when she wants to get up’. Although care plans were being signed as having been evaluated there was no detailed comment about the effectiveness or otherwise of the plan over the previous month. The manager said that he was working towards the involvement of residents and/or their representatives in the development of care plans. This will be via a relatives/residents forum which is to be set up and will meet every 2-3 months. A visiting GP said that he felt staff followed any instructions about the care of his patients. Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 10 There are detailed policies and procedures regarding the administration of medication. The medicine room is an internal room and ventilation is a problem. The temperature of the room is monitored regularly and various options are being considered to make sure that medicines are stored within the temperature range detailed in the manufacturers instructions. There are wellestablished systems in place for recording medicines in and out of the home. Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 11 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): 14. Residents are helped and encouraged to make choices in their daily lives. EVIDENCE: Observations and discussions with residents and staff provided evidence that choice and control is encouraged. Residents go out of the home with friends and family if they wish to. One set of care documents stated that one resident would ring for the staff when she was ready to get up in the morning. Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were assessed at this visit. Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The home offers a safe and well maintained environment for residents. There are systems in place for the control of cross infection. EVIDENCE: There are arrangements in place for the faulty carpet to be replaced early in the new year. All areas inspected were clean and fresh smelling. The laundry area was well equipped and looked well organised. The correct procedures were in place for the handling of foul linen. The control of infection procedures were being reviewed. There are systems in place to make sure that the environment provided to residents is safe and well maintained. Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 14 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 and 30. Overall the numbers and skill mix were sufficient to meet the needs of the residents. Staff receive training to enable them to carry out their jobs competently. EVIDENCE: The duty rotas indicated that overall there are sufficient staff provided to meet the needs of the residents. There were some shortfalls noted on the late shift. The nurse in charge said that she would speak to the manager and agency cover would be arranged. The care staff were supported in their role by catering, domestic and laundry staff. A maintenance man also provided support at the home. National vocational qualifications (NVQ) were being undertaken by care staff and the manager said that good progress was being made towards achieving the target of 50 of trained care staff. Three care staff had achieved NVQ level 3 in care. The home has four NVQ assessors one of whom works on night shift. The manager has developed a matrix to assist in identifying the shortfalls in training which he now has to address. Detailed induction and foundation training is provided to care staff. Workbooks are provided and a sample of these is sent for external verification to make sure that a consistent standard of training is provided. Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 15 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, 33, 35 and 38. The home is well managed. The interests of the residents are important to the manager and staff and are safeguarded at all times. EVIDENCE: The registered manager is an experienced nurse who provides staff with clear leadership and works hard to promote the interests of the residents. He holds a diploma in advanced health care management from Bradford University. The manager has a good level of support from the company and the director of nursing with the company provides regular formal supervision. There are a whole range of systems in place to monitor the services and facilities at the home. There is a monthly check of the building by the manager with particular regard to health and safety. The manager conducts monthly audits of accidents to residents. He has also used the information to look back at accidents over the last 12-18 months in order to identify any trends. This information is shared with staff. Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 16 There are a number of surveys conducted involving residents; friends and family; visiting professionals; and suppliers to the home. A stress at work survey has also been carried out for staff. The manager also produces a regular newsletter which is sent out with invoices so that all the families are kept up to date about changes and events at the home. The manager carries out night visits to the home and produces a written report for senior management in the company in addition to a monthly report on other issues such as staff sickness. The most recent staff meeting was 10 November when the proposed changes with regard to the provision of intermediate care were discussed with staff. It is the homes policy not to handle residents’ monies although the personal allowances of two residents are handled. Receipts are kept of any transactions and only two staff have access to the money. 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.V266367.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15 Requirement Evidence must be available of the involvement of the service user or their representative in the development and review of the care plan. NVQ training must continue for care staff to ensure that the target of 50 trained members of care staff is reached. Timescale for action 05/03/06 2 OP28 18 31/12/05 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 OP30 Good Practice Recommendations The manager should continue with the planned programme of training to address the shortfalls in mandatory training provided to staff. Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sunningdale Nursing Home DS0000001373.V266367.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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