Inspection on 11/10/07 for Sunnyhill Residential Care Home

This inspection was carried out on 11th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Sunnyhill Residential Care Home 08/08/06

Sunnyhill Residential Care Home 04/10/05

Sunnyhill Residential Care Home 26/05/05

Sunnyhill Residential Care Home 21/09/04

Sunnyhill Residential Care Home 13/05/04

Sunnyhill Residential Care Home 01/07/03

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOMES FOR OLDER PEOPLE Sunnyhill Residential Care Home 14 Selwyn Road Eastbourne East Sussex BN21 2LJ Lead Inspector Debbie Calveley Key Unannounced Inspection 11th October 2007 10:30 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 Sunnyhill Residential Care Home DS0000021233.V348591.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. Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunnyhill Residential Care Home Address 14 Selwyn Road Eastbourne East Sussex BN21 2LJ 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) 01323 430386 01323 721191 karensunnyhill@hotmail.co.uk Sunnyhill Residential Care Home Ltd Miss Karen Amanda Noyce Care Home 20 Category(ies) of Dementia (20), Mental disorder, excluding registration, with number learning disability or dementia (20) of places Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of people to be accommodated must not exceed twenty (20) mentally disordered elderly service users. 8th August 2006 Date of last inspection Brief Description of the Service: Sunnyhill Residential Care Home provides specialist, residential and social care for up to twenty older people with a mental disorder, including dementia type illness. This large, detached house is situated in a quiet, residential area of Eastbourne, within easy walking distance of town centre shops and the mainline railway. It has parking to the front and private gardens on three sides, which are accessible to wheelchair users. Accommodation is on three floors, with a passenger lift providing level access. Residents private rooms are all equipped with an alarm call system and en suite toilet facilities. Some are also fitted with a shower. Bathrooms on all floors are equipped with assisted baths. On the ground floor there is a choice of two communal lounges and a dining area. Information about the service, including the Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective residents or their relatives, on request, as part of the admission process. The range of weekly fees, as of 8 August 2006, is £426 - £467. Additional charges, not included in the fees, include hairdressing, chiropody, newspapers and transport. Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Sunnyhill will be referred to as ‘residents’. The information contained in this report has been compiled from an unannounced site visit undertaken over 6 hours on the 11 October 2007 plus information gathered about the home since the previous inspection. This includes discussion with stakeholders involved in resident’s care, records submitted to CSCI, which have included an Annual Quality Assurance Assessment (AQAA) and the notification of accidents and incidents. There were 19 residents living in the home, of which five were case tracked and met with. One admission to the home took place on the day of the inspection. During the tour of the premises a further six residents of both sexes were also spoken with and two relatives. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including care plans, medication records, training records and recruitment files. 12 surveys from residents and relatives were received and their valued comments have been included in the report. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection reports. The Inspectors would like to thank the residents, staff and management for their assistance and hospitality during the visit. What the service does well: There is a Statement of Purpose and Service Users Guide that give prospective residents the information required to enable them to make an informed choice about where they live. Residents confirmed that they were visited by the Manager prior to admission to the home and two stated they had been invited to visit the home to see if they liked it enough to live there. Sunnyhill provides good quality individual care and support for residents, and this is proven by a robust pre-admission procedure and from a thorough care planning and review process. Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 6 ‘They look after my father very well with the up most care’ ‘Best care when he was ill’ ‘We think they cover the care of the elderly very well’, ‘Good individual care’, ‘ They certainly meet different needs with regard to age, disability and gender’. The atmosphere of the home is pleasant and inclusive with good interaction seen between residents, relatives and staff. The Comments received from residents and families regarding the care received included: ‘ The staff treat all residents as if they were their own family’. ‘A home from home’ ‘Communication is very good from all staff’. There is an open-house policy, which welcomes visitors at all reasonable times. ‘Will always ring and inform of us any changes, ‘ Always warmly welcomed’, ‘Visitors are made to feel welcome’. Staff receive an effective induction and foundation training and the training required to meet the residents needs and are clearly valued and supported by the management team. The management and staff create a warm and caring environment for the residents living there. ‘We would like to say thank you for my fathers care, it takes a great load of our minds knowing he is safe and well’ ‘I feel my mother is very fortunate to be cared for a Sunny hill. It provides a caring and comfortable environment’. What has improved since the last inspection? What they could do better: Residents’ care plans need to be developed to detail the action and interventions to guide care staff in ensuring that all individual health, personal and social care needs are met in a structured and consistent manner. Risk assessments for individual residents in respect of their mental health needs and personal safety need to be developed. Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 7 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. Sunnyhill Residential Care Home DS0000021233.V348591.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 Sunnyhill Residential Care Home DS0000021233.V348591.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives with a good level of information about the home, its facilities, services and the costs involved. The admission procedures allow for the needs of prospective residents to be assessed by a competent person before admission, and ensure that the home has the necessary facilities and skills to meet the resident’s needs. EVIDENCE: There is a Statement of Purpose and Service Users Guide, both of which contain clear information about the home and the services it provides. Copies of these are available on request. It was discussed that it would benefit the Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 10 residents if it could be written in a more user friendly format with colour and pictures and each resident be given their own copy to refer to. It was confirmed whilst talking to residents and two relatives that the contract arrangements were clear and understood. The registration certificate is clearly displayed and was found to be accurate. Five admissions to the home were viewed and the records relating to the admission procedures followed were reviewed. This confirmed that pre admission assessments are completed and provide a clear assessment of prospective residents care needs. These are completed by the Manager and discussion with the Manager confirmed that these are used to ensure new admissions to the home are appropriate and that the home have the staff, equipment and environment to meet their care needs. Residents are invited to the home to meet the other residents and staff and have a look around the home. Prospective residents’ are seen either in their home or hospital before admission and the input from relatives and other professionals is used whenever possible. This approach should be more clearly recorded on the assessment documentation to demonstrate the procedure followed. It was however noted that the home does not confirm with regard to the assessment that the home can meet the assessed needs of the prospective resident. This was discussed with the Manager who was advised that this should be completed in writing in accordance with the required documentation. Sunnyhill Residential Care Home DS0000021233.V348591.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although care documentation provides a framework for the delivery of care, it needs to be developed to provide clear guidance for care staff on meeting the care needs of residents in a consistent manner, along with robust systems for risk assessment to ensure individual person centred care is delivered. The homes practice ensure resident’s medicines are stored and administered safely and residents are treated with respect and have their privacy and dignity maintained. EVIDENCE: The care documentation pertaining to five residents was reviewed as part of the inspection process. These were found to include plans of care, social histories, personal histories and risk assessments. On the whole the care documentation demonstrated that the care was reviewed and evaluated, however it was noted that not all the plans of care contained the action and interventions required by the staff to ensure continuity of care. Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 12 For example one resident who has communication problems did not have any guidance in the documentation to facilitate this vital need, the staff though were observed communicating very well with the resident. Another did not provide guidance for staff to deal with her depression and behavioural problems; again the staff were knowledgeable and discussed this in detail during the inspection. These shortfalls however do not impact on the positive outcomes of the residents due to the stable care team and the knowledge they have on individual residents. Six monthly monitoring reviews are held and involve the resident, their relative or representative, (if the resident wishes) a community psychiatric nurse, a social worker and the Manager and key-worker from the home. The home are pro-active about ensuring that they access specialist input when required, and the care plans evidence referral to doctors, chiropodists, community psychiatric nurse and dieticians. Staff were observed when administering medicines and they were seen to be working safely. The records seen were found to be accurate and the storage areas were found to be appropriate and well managed. Recommendations of good practice include: for medication administration purposes a staff signature and initials comparison list to be introduced to provide an audit trail and staff must not use tippex on the medication administration charts. A key-worker system is in place and the Manager and staff confirmed that it worked well. The induction programme includes the principles of dignity and respect. The interaction with staff was seen to be positive and residents were seen to be treated with dignity and respect throughout the inspection. Feedback from residents was positive in the main and comments included. ‘Best care when he was ill’ ‘We think they cover the care of the elderly very well’ ‘Communication is very good from all staff’ ‘ They look after my father very well, up most care’. Sunnyhill Residential Care Home DS0000021233.V348591.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lifestyle experience by residents at this time matches their expectations, choice or preferences. Meals remain good in respect of both quality and variety that meets the majority of residents’ tastes and choice. EVIDENCE: All residents’ social and personal histories and preferences are documented at the pre-admission stage and are taken into consideration when planning the individual care plans. There are external entertainers and musical activity coordinators who continue to visit Sunnyhill Care Home on a regular basis. There are organised group activities and supported outings, and it was confirmed that time is allocated for one to one sessions for those individuals who prefer to spend time alone or remain in their room. Church services takes Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 14 place in the home every two weeks and it was confirmed that the residents are supported to follow their particular faith. Discussions with residents confirmed that they can choose how they spend their time; some residents prefer their own company and often spent their time in their own rooms, some residents go out with friends in to town. Resident’s rooms were found to be individual and personalised and each resident has their preferred term of address recorded in their care documentation and this preference was respected. Residents were seen to have their choices respected through out the day with decisions being responded to. Visitors spoken to were all happy with the visiting arrangements and how staff who were said to be ‘very welcoming’ received them. Comments received included ‘It would be very much less monotonous if staff could play games or do cross words etc.’ ‘ A church service takes place every two weeks by a party of members from local church’ ‘ we are helped to spend time as we want’. The kitchen was completely replaced six months ago and is well designed with a walk in fridge and plenty of work surfaces. There is a need to develop cleaning rotas and ensure that the kitchen is cleaned to a good standard. A recent Environmental Health visit identified some areas, which are being actioned. The dining area is in one part of the large lounge and is comfortable and homely with natural lighting. The midday meal service was observed and was seen to be enjoyed by the residents. The menu is displayed in the dining area and demonstrated a well thought out menu, designed with the resident’s likes and dislikes taken into consideration. Alternatives are available and residents can choose what they fancy. Resident’s weights are recorded and specialist advice sought as necessary. The staff need to be keeping a record of residents dietary intake, which will enable staff to pick up residents appetite traits and identify problems early. Sunnyhill Residential Care Home DS0000021233.V348591.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a formal complaints system with evidence that residents feel that their views are listened to and acted upon. Staff receive training to protect residents from abuse. EVIDENCE: The complaint policy and procedure is clear and uncomplicated and a copy of this is readily available in the home and the Service Users Guide. A system of recording complaints was demonstrated during the inspection. The home has not received any complaints since the last inspection. Relatives and residents spoken with confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. Comments received included; ‘Not had any cause to raise any concerns’ ‘Manager is ready to listen and is sympathetic, but not always available’ ‘ if I had a problem I would make direct contact with the home manager’. The home has relevant guidelines on the protection of vulnerable adults and staff have received appropriate training. The management team has a clear Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 16 understanding of adult protection guidelines and are aware of how to initiate an investigation if required. Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 17 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, 20, 21, 22, 23, 24, 25 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Sunnyhill provides a comfortable, clean and safe environment for those living there and visiting. Residents and their families are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. EVIDENCE: Sunnyhill Residential Care Home is a large detached building situated in a residential area of Eastbourne and its accessible layout remains appropriate and suitable for its stated purpose. A tour of the home confirmed that the home is well maintained and rooms are attractive with some being very personalised. Carpets were discussed in Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 18 certain areas as they were identified as a trip hazard and it was confirmed that they are to be replaced in the near future. Residents spoken to said that they liked their rooms one saying that the home ‘felt like his home now’. There is a large attractive garden, which is divided in to areas, and can be used by families and residents. The communal areas are also attractive and allow for different uses ensuring residents have choice and how they spend their time. There are adequate communal bathrooms and shower rooms in the home, with specialist equipment to ensure all residents can have a bath or shower. The Manager confirmed that independence continues to be promoted within the home, as far as is practicable, and this is evident from the personalising of residents’ rooms, which clearly reflects individual tastes, preferences and interests. The surveys received included comments: ‘It provides a caring and comfortable environment’ ‘Sunnyhill is a home from home’ ‘Good effort is made to keep rooms fresh and clean’. The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. Water temperatures are controlled and monitored monthly and a record kept. Random temperatures were taken and were of the recommended level. There are systems in place for monitoring safety issues such as fire checks, fire drills, PAT testing, electrical tests and gas and boiler checks and all the rooms are routinely checked for safety and maintenance issues. The records in the home confirmed they were up to date. The tour of the home confirmed that staff are aware of the fire safety policies, no doors were found inappropriately wedged open. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. Laundry areas were found clean and safe. The home provides a good laundry service. Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 19 Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 20 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. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures are in place to protect residents, and staff training ensures they are aware of their roles and are able to provide the support and care the resident’s need. EVIDENCE: There is a stable and dedicated staff team that receive training, which enables them to meet the individual and collective needs of residents living in Sunnyhill. The staffing rota was viewed and discussed with the Manager. There are plans to increase the staffing levels in the morning. From direct observation the staffing levels were seen to be sufficient to meet the needs of the residents living in Sunnyhill. During the night there is one sleep-in person, one waking night staff and a further senior member of staff on call. Ancillary staff employed include two domestic staff, two cooks and a maintenance man are also employed in the home. Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 21 A selection of staff recruitment files including new members of staff, were viewed and demonstrate that a robust recruitment process has been maintained to protect residents and contained all the relevant information required. There was evidence of health questionnaires, Criminal Record Bureau checks, two references, a resume of previous employment and work permits where necessary. All the paperwork is kept within a locked room. The Manager stated that appropriate induction, foundation and core skills training is provided, including first aid, moving and handling, food hygiene and fire safety. The training provided was confirmed by staff and supported by the training records examined. It was noted that many of the staff have also received specific training relating to dementia and dementia awareness. There are currently eight care staff that hold the National Vocational Qualification (NVQ) level 2. Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 22 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, 32, 33, 35, 36 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The overall management of this home is good with effective systems in place to protect residents. EVIDENCE: The Registered Manager is experienced and competent and has been in her current position for almost five years. She has achieved the Registered Manager’s Award (RMA) and the NVQ level 4 in Care. Relatives and visitors state that the Manager is open and transparent and feel that they can approach the management at any time. The ethos of the home is to focus on the residents and staff were observed doing this. Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 23 A comment received ‘No complaints, I am happy at Sunnyhill and quite happy with the way it is run’ ‘ all seems excellent’. The quality assurance systems in the home include questionnaires sent out to residents and relatives following admission to the home on a yearly basis. The formal quality assurance and quality monitoring systems enables the management to objectively evaluate the service and ensure it is run in the resident’s best interests. The quality assurance results are regularly audited and action taken to address any suggestions of improvement. There are safe systems in the home for managing resident’s finances through a computerised ‘Deposit Account’. Individual balances are checked on a regular basis and all financial transactions are recorded. This system was seen in use during the inspection as residents attended a clothes party. Staff supervision was discussed and staff supervision is in place, but the Manager admitted it is behind at present; there are plans for the deputy manager to take on the majority of supervision from this month. Staff spoken with confirmed that they have received supervision. Training required by legislation, including moving and handling, fire training and infection control is provided for all staff to protect the health and safety of residents. All staff training is recorded. COSHH assessments and guidelines are in place. All accidents, incidents and injuries are recorded and reported, as required and the accident book is audited weekly. Trip hazards were identified during the inspection visit, however from discussion with staff there are already plans to renew carpets in these areas, Also discussed was the use of small unfixed rugs in residents bedrooms and ensuite bathrooms, it was decided by the management team that they would be removed immediately and therefore a requirement has not been made. Advice is to be sought from the Occupational Therapist regarding the use of wheelchairs without the required footrests. Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 24 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14(1) Requirement That registered person confirms in writing that having regard to the assessment made on any prospective service user that the home can meet those needs. It is required that service users’ care plans set out in detail the action and interventions to be taken by care staff, to ensure that all individual health, personal and social care needs are met in a structured and consistent manner. (Timescale of 30/09/06 not met.) That the Registered Person ensures that risk assessment for individual residents are robust and guide staff in ensuring the service users safety. In respect of: Mental health illness and behaviour traits. Timescale for action 12/12/07 2. OP7 15 (1) 12/12/07 3. OP8 12 (1) (a) 12/12/07 Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 26 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 OP15 Good Practice Recommendations That a record of residents nutritional intake is recorded. Sunnyhill Residential Care Home DS0000021233.V348591.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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