Inspection on 08/09/05 for Sunningdale Nursing Home

This inspection was carried out on 8th September 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 30/11/05

Sunningdale Nursing Home 02/12/04

Sunningdale Nursing Home 25/05/04

Similar services:

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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 Town street Nr Henley Mount Rawdon LS19 6PU Lead Inspector Catherine Paling Unannounced 8 September 2005 10.50hrs th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sunningdale Address Town Street Nr Henley Mount Rawdon LS19 6PU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2505003 0113 2505003 Foxcliff Ltd Mr Keith Derek Wilson Care Home with Nursing 35 Category(ies) of Old Age (35) registration, with number of places Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13th June 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 Sunningadle is home. There are seven beds allocated for Intermediate Care. This facility provides recuperation and rehabilitation for people who, for a variety of reasons, need extra help and support for a short period. These clients normally return to their own homes. The home provides personal care with nursing for service users over pensionable age There is a majority of single rooms with some shared rooms available. None of the rooms have en-suite facilities. Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 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 second 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 June 2005 and was carried out as a result of a complaint received by the CSCI. This was an unannounced visit carried out by one inspector who was at the home from 10.50 until 16.50. 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 relatives; and discussion with the registered manager and the Group Operations Manager. What the service does well: What has improved since the last inspection? What they could do better: The manager needs to make sure that the standard of recording in service users’ records is done to a consistent level. This is to make sure that the care plans contain specific details about the care needs of the service users. The manager needs to involve service users and/or their families in the development of the care plans. Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 Page 6 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 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 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 standard(s) 3 and 6. All service users have their needs fully assessed before they are admitted to the home. EVIDENCE: The manager carries out thorough, detailed pre-admission assessments before service users are admitted to live permanently at the home. These assessments include information on how the decision has been reached as well as any specialised equipment required. Service users admitted for intermediate care have their needs assessed by the intermediate care team who provide written instructions about their care. The intermediate care service is well established at the home and all the staff work well together to help service users return home. There are designated bedrooms for the service users admitted for intermediate care and they share the communal areas at the home. Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 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 standard(s) 7, 8 and 10. The health care needs of service users are met. The variable standard of recording provides the opportunity for care needs to be overlooked. Staff treat service users with dignity and maintain their privacy, showing an awareness of the service users’ needs. EVIDENCE: All the service users had individual care plans with instructions for staff on how to meet their needs. The standard of recording in these plans was variable with some very good personal detail in one case and a lack of specific detail in another. In the case of one service user there was a range of risk assessments in place that were well detailed providing detailed information for staff about how an identified risk could be managed. This was not the case for another service user where risk assessments had not been fully completed. Where risks had been identified there was a lack of information about how these risks would be managed. It was not possible to establish from the records whether bed safety rails were in use for this service user. This service user had a low weight and there were instructions for her to be weighed weekly. This was not being done and the instructions in the care Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 Page 10 plan were rather vague regarding additional snacks stating that snacks should be ‘little and often’ without specific information for staff. There was no evidence to indicate that the service users or their representative had been involved in the development of the care plans. The care plans for one service user with impaired sight were very well written detailing the effect of the visual difficulties and the support needed from staff to meet daily needs. Staff respect the privacy and dignity of the service users and approached them with respect. The records for a service users admitted for intermediate care gave reasonably clear instructions to the home’s staff about rehabilitation. The service user was clear about what was happening and had enjoyed the recent home visit which had taken place to assess his progress. Records reflected this. Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 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 standard(s) 12, 13 and 15. Residents are encouraged to participate in social and leisure activities and to maintain links with friends and family. A good varied and nutritious diet is provided for service users. EVIDENCE: Service users are encouraged to maintain their contacts with their family and friends. There were several relatives in the home during the course of the inspection with one visitor taking her relative out for the afternoon, which was a regular routine. Other visitors spoken with said that they were always welcomed to the home and were kept informed about their relatives’ changing condition. The activities organiser arranges a variety of outings and in-house activities for the service users. Over the summer there was a trip to Bridlington which service users had thoroughly enjoyed. During the visit service users were enjoying a ball game and in the afternoon one service user clearly enjoyed a manicure. There was a choice of main course at the lunchtime meal and service users said that the food was good. The meal looked appetising and was well presented. Drinks of squash and tea were served with the meal. Care staff gave support and assistance appropriately. Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Residents feel safe living in the home and staff are aware of their responsibility to protect service users. EVIDENCE: A complaints procedure is available at the home and one relative spoken with said that she felt that her concerns were listened to and dealt with appropriately. The investigation of recent complaints demonstrates that the provider takes complaints seriously and makes sure that service users are protected from abuse. The manager is cooperative and acts upon recommendations made as a result of complaints received. Care staff spoken with were able to describe appropriately the actions they would take if they suspected any adult abuse. Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The service users live in a safe and well-maintained environment. EVIDENCE: The carpets laid in the corridors and communal areas less than a year ago had been found to be faulty and looked unsightly, particularly in the entrance area. The provider was working hard to get them replaced. The provider is committed to making sure that the environment is safe and well maintained. Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29. The numbers and skill mix of staff were sufficient to meet the needs of the service users. There are good recruitment procedures in place to protect service users. EVIDENCE: There were sufficient staff on duty to meet the needs of the service users and the care staff were well supported by domestic staff, an administrator, the activities organiser and a handyman. There were some nurse vacancies and these were being advertised. Two recently employed care staff were spoken with and described the recruitment process. This had included the receipt of written references and a Criminal Records bureau check and demonstrated robust procedures. Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of these standards were assessed at this visit. Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x x Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 Page 17 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement Evidence must be available of the involvement of the service user or their representative in the development and review of the care plan. The care plans must contain specific details of all care needs. (previous timescales of 4/10/04 and 6/06/05) NVQ training must continue for care staff to ensure that the target of 50 trained members of staff is reached by 2005 The provider must ensure that the staff training and development programme meets the TOPSS training standards. (previous timescale 31/03/05) Fire training must be extended to include the night staff who must take part in at least one fire drill in a 12month period. (previous timescale 31/03/05) Timescale for action 5/12/05 2. 29 18 31/12/05 3. 30 18 5/12/05 4. 38 23(4)(d)( e) 5/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 Page 18 No. 1. Refer to Standard Good Practice Recommendations No recommendations. Sunningdale 20050908 Sunningdale UN Stage 4 S1373 V242155 J52.doc Version 1.40 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. 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