Inspection on 08/05/06 for Sunnymead Manor

This inspection was carried out on 8th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Sunnymead Manor 01/12/08

Sunnymead Manor 20/11/08

Sunnymead Manor 17/04/08

Sunnymead Manor 04/06/07

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Sunnymead Manor 575-579 Southmead Road Southmead Bristol BS10 5NL Lead Inspector Vanessa Carter Key Unannounced Inspection 08:30 8 and 9th May 2006 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 Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 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. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sunnymead Manor Address 575-579 Southmead Road Southmead Bristol BS10 5NL 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) 0117 979 1212 0117 979 2680 None Mimosa Healthcare (No4) Limited To be Appointed Care Home 76 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (42), Old age, not falling within any other of places category (34) Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate 34 persons in the OP category on the ground floor only - The Hollies Unit May accommodate up to 42 DE (E) persons on the Dementia Care Unit, of whom 5 may be aged between 55-65 years (DE) - The Poplars Unit The Registered Manager must be a RN1 or RNA on the NMC register A named person, who is either an RN1 or RNA with additional Dementia Care training, or a Level 1 Registered Nurse Mental Health (RN3 or RNMH) must be responsible for the running of the first floor (the Poplars Unit) First Inspection Date of last inspection Brief Description of the Service: Sunnymead Manor is a 76-bedded care home, situated in the Southmead area of Bristol, close to the South Gloucestershire borders. It is a purpose built care home and is operated by Mimosa Healthcare Limited. Mimosa have three other care homes in the Bristol area – Bedminster (Honeymead Care Home), Bishopsworth (Bishopsmead Manor) and Shirehampton (Kingsmead Lodge). Mimosa also own homes in the Midlands and the North of England. The home is located near to Southmead Hospital and only a short distance from the centre of Bristol. There is a regular bus service into the centre of town that passes the front of the home. Sunnymead is a purpose built care home with accommodation provided over two floors. The home is run as two units. The first floor, Poplars unit, accommodates 42 persons requiring specialist dementia care nursing. The ground floor, the Hollies unit, offers 34 beds for general nursing placements. Both floors have communal and bathing facilities, and there is lift access, making the home fully accessible. The majority of the bedrooms are for single occupancy and have ensuite toilet facilities. The cost of placement is between £456 – 508, the price dependent upon assessed need. Additional charges are made for a number of services – these are listed in the homes brochure. Prospective residents can be provided with information about the home and this will detail the services and facilities available at the home. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days, starting at 8.30am on both days. A total of 16½ hours were spent in the home. Evidence was gathered from • Observations of staff practices and interaction with the residents • A tour of the home • Case Tracking the care of a number of residents • Talking with a number of the residents • Talking with a number of visitors to the home • Talking with the home’s manager, and some of the care staff and ancillary staff • Looking at the homes records What the service does well: What has improved since the last inspection? The home has made improvements with their medication management systems, and five requirement notices, issued to the previous provider at the last inspection have been complied with. The numbers of ancillary staff have been increased and this has improved the quality of the catering and housekeeping services. Staff, visitors and residents remarked on the improvements. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 6 The majority of the communal areas in the home have been redecorated, with the stronger colours being toned down. This has enhanced the “feel” of the home and makes it look nicer and a much easier place in which to live. 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. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 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 Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 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): 1, 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families are given information about the home and are assessed prior to being offered placement, thereby ensuring that placement is only offered to those whose needs the home can meet. EVIDENCE: The homes Statement of Purpose and Service User Guide (Welcome Pack) follows the Mimosa Healthcare Ltd corporate design, but the manager plans to further personalise the document to reflect the staffing arrangements, facilities and services available at the home. Each resident is provided with a welcome pack, but those spoken to said they had not referred to it “I leave that sort of thing to my daughter”. One visitor confirmed there was a copy in their relative’s room. Included in the pack is a Residency agreement and the resident or their representative, and the manager will sign this, following a discussion. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 9 Newly printed brochures about the home were delivered to the home during the inspection – these will be given to any person who enquires about the home and prospective residents. The home offers placement to people aged 65 years and over who require general, or specialist dementia nursing care. They are able to offer up to five places to people between the ages of 55-65 years in the dementia care unit. CSCI may agree to a person being accommodated on the general nursing floor, who is younger than 65 years, if they can demonstrate they can meet the persons needs and make application to CSCI for a variation to the conditions of their registration. The home has had a number of new admissions to the home, and the preadmission assessment documentation was examined in respect of two people. These forms must be signed to evidence that they were completed prior to admission. Both residents had been admitted from the local hospital, but family members had previously visited the home to have a look around. All new admissions will be reviewed after a ‘trial period’ usually of about four weeks. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents care needs may not be fully met as the care planning processes are inadequate. This has the potential for putting the residents at risk of receiving inadequate care. Improvements have been made to the medication management systems, meaning that residents can be assured they will receive the medicines they are prescribed. EVIDENCE: Five care plans were looked at, three from the general nursing unit, and two from the dementia care unit. The manager explained that they were waiting for Mimosa corporate documentation to be received. This delay however, does not negate the homes responsibility in ensuring that resident’s needs are properly assessed and a comprehensive plan of care is written. These plans must detail those needs, and states what action the staff must take to meet them. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 11 Of the five plans all had serious omissions and this has the potential to mean that residents care needs may not be fully met. One persons plan gave a very confusing picture of their nutritional needs and how much support they need. The plan referred to monitoring of food and fluid intake, but staff stated this was no longer necessary. Observations of this person at lunchtime evidenced that their dietary intake should be monitored. One resident in the dementia care unit had a very poor plan in respects of the mental health needs that did not give any clear guidance for the staff. One person had very clear wound care planning documentation, and it was easy to see how the home was monitoring the wound and managing the dressings. Monitoring was supported by photography and ‘mapping’ - however the manager does need to ensure that mapping is carried out correctly. There was no evidence that the care plans had been reviewed with the resident or their representative, and records of reviews were generally brief. The record of one such review evidenced changes in the residents needs however the plan had not been updated to reflect the change in needs. One visitor said they had never been involved in a review of their relatives needs. The home no longer has the services of a retained GP and therefore if new residents are unable to keep their own longstanding GP, they are allocated a local GP by the health authority. There was evidence in the one persons file that a specialist tissue viability nurse had been consulted for advice, whilst a speech and language therapist visits another. A chiropodist visits the home on a regular basis and maintains a record of the care provided. A number of residents are nursed in specialist profiling beds or with alternating air mattresses, in order to aid their comfort. It is concerning to see that one resident developed a serious pressure sore 11 days after admission, despite their risk of developing pressure sores being classed as “very high risk” upon admission. Nursing staff had described the wound as being severe, but the daily notes for the previous 11 days had made no reference to any concerns. This evidences a serious failure in the homes ability to promote and make proper provision for the health and welfare of service users. The home do not deal appropriately with residents who have ‘end of life’ needs, and the recordings made in the person’s care file are not adequate. The home must ensure that appropriate advanced care plans are discussed with a resident and their relatives, and relevant healthcare professional, to ensure that their wishes are known, and therefore met. Improvements have been made in the homes management of medications and there was evidence of safe procedures in respects of the ordering, receipt, storage, administration and disposal of medicines. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 12 Residents and relatives spoken with during the inspection had a mixed response regarding how they were treated. “Top class” and “ the girls are kind and caring” were two positive comments, whereas other residents said “there are good and bad ones” and “ they don’t have much time”. The staff were seen going about their duties in a friendly and professional manner and responding to visitors in a familiar style. In general there was good interaction between the staff and residents however at times staff appeared to be slow to respond to residents requests for assistance. One person became quite disruptive before getting the help she needed. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to participate in a range of activities and can have visitors at any reasonable time. They are offered a choice in what to eat and are provided with a varied and well balanced diet. EVIDENCE: The home have recently employed an Activities Organiser who works for 25 hours per week and covers the weekdays. Due to the numbers of residents and the specific needs of most of the people, it is planned to increase these resources so that there is a worker for each unit. The new worker has already identified her own need for specific dementia care training, but not had the opportunity to discuss with a manager. The development of this facility will remain a focus of future inspections. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 14 The organiser has put together a basic activities programme and has some good ideas for future events. On the first day of the inspection a music man visited and sang for the residents. Bingo sessions were also arranged but one resident commented, “it was all over after just one game and only one person could win a prize”. One resident with dementia was taken out for a wheelchair ride and appeared to be more settled during this time of attention. Some residents chose to remain in their own rooms and not to participate in any of the homes activities. Two inspectors from CSCI recently visited the home and undertook a two-hour period of observation, in one area of the home. The results of this study were disappointing in that there was very little interaction noted between the residents, staff and any visitors who arrived. The manager did not feel the study recognised activity elsewhere in the home. Observations made during the inspection was that there was a lot of interaction between some residents by some staff, whilst other residents were left to repeatedly call out and at times appeared to be distressed. Visitors are encouraged and can visit at any reasonable time. Four visitors stated they visit on a daily basis, are welcomed by the staff, and offered refreshments. Two visitors like to help out with their care of their relative. There is some evidence that residents can make decisions about how they are cared for. They can choose where they want to spend their time and what time they want to get up and retire to bed. Residents have a choice of breakfast and were heard being offered a choice of what they wanted to eat. One resident took their breakfast later than the others, as was his choice. There is a choice of two main meals at lunchtime, and on the first day of inspection, beef stew or sausages were the option. The meal was tasty and well presented. A number of residents were served with second helpings and enjoyed their food. The majority of residents take their meals in the dining room, but can choose to be served in their rooms. Cold drinks were provided with the meal and residents were asked what they wanted to drink. One resident struggled to feed themselves with a knife and fork and was observed “chasing pea’s around the plate”. When a plate guard and spoon were provided, they ate easily and with greater dignity. Staff must ensure that residents are provided with appropriate aids to enable them to retain their skills and their independence. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be assured their concerns will be listened to and acted upon. Staff are knowledgeable about adult protection issues and will ensure that residents do not come to any harm. EVIDENCE: An examination of the complaints log evidences that the home has a system in place to log complaints and a protocol for recording the outcome. A discussion with the manager evidenced that there is a problem getting complaints “signed off” when the investigation has been completed and the outcome has been reported. The homes complaints procedure is displayed in the main reception area and is included in the service users guide. The home has received 3 complaints since Mimosa have been the owners. The complaints were in respect of a particular meal that was served, concerns regarding care of a resident who was admitted into hospital with dehydration and of a relative who was not dressed warmly enough. The manager had responded to each complainant and detailed the outline of the finding. The complainants were advised of the outcome of their complaint. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 16 One relative said “the girls are always more than helpful and will always sort things out for me”, whilst another said they would ask to see the manager with any concerns. The home has a policy on the Protection of Vulnerable Adults (POVA) and clear guidance is available for the staff to follow if abuse is suspected, alleged or witnessed. A large percentage of the staff have attended a POVA training session but Mimosa will be arranging further updates. Discussions with staff evidenced that they are aware of their responsibilities to safeguard the residents from harm and are aware of any actions they should take. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 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 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is safe, comfortable and maintained well. Some minor improvements would further improve this area. EVIDENCE: The home is a purpose built care home with accommodation arranged over two floors. There is lift in situ, meaning that the home is fully accessible to disabled persons. Visitors to the dementia care unit on the upper floor can use the lift or the key padded staircase. Communal spaces are available on each floor, consisting of two lounges and a dining room per floor. The corridors are wide with grab rails either side. The home is now well decorated throughout – the strong colours on the walls have been toned down, giving the home a much calmer feel. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 18 The bathrooms are equipped with bath seats or hoists. There are sufficient toilets located throughout the home. The majority of bedrooms are single and all but two rooms have ensuite facilities of a toilet and wash hand basin. Shared rooms have appropriate screening in place to ensure residents privacy. Most rooms are furnished with ordinary beds but a number of specialist profiling beds have been purchased and there will be a rolling programme of replacement. The home has a plentiful supply of manual handling equipment; this has all been recently serviced and repaired where necessary. The standard of cleanliness in the home was good and all areas were clean tidy and free from any offensive odours. The allocation of housekeeping staff has been increased and this has obviously had a positive effect. One relative made reference to the improvement. There are now appropriate numbers of staff working each day in the laundry room however still, several comments were received from residents about missing items of clothing. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 19 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a lot of movement in the staff team and the induction of new staff is poor. This shortfall does have the potential to mean residents will be cared for by staff who may not have the necessary skills and be competent to care for them. EVIDENCE: The staff rotas showed that a mix of registered nurses and senior care assistants are allocated for each shift - there appears to be sufficient levels of staff. There is lead nurse covering the general nursing wing and the home has just recruited a lead nurse for the dementia care wing. This person has qualifications and experience in the care of dementia care residents and is expected to join the team at the end of May 2006. This unit has been without a lead nurse for a long time and will benefit from someone who provides strong leadership and direction for the staff team. A number of the staff team are about to leave the home, and the recruitment for replacements is ongoing. The manager explained that three new registered nurse are due to commence within the next few weeks. Residents would benefit from an established staff team, to ensure the continuity of the people who look after them. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 20 In addition to the care staff there are catering, housekeeping and laundry personnel. An increase in the numbers of these ancillary staff has had a positive effect in the home. The manager plans to look at the skill mix within the kitchen staff to ensure that the team have the necessary skills and qualifications to provide a good catering service. Staff spoken to during the course of the inspection, were helpful and friendly, and the care staff were knowledgeable about the residents needs. One relative said they have difficultly understanding the speech of some overseas staff, and in making themselves understood – they expressed concern that their deaf relative must find this even more of a problem. This was not evident during the inspection, however the home must ensure that effective communication is maintained between staff and residents to ensure that care needs are met and residents feel able to express their concerns. The staff team includes only a small percentage of care staff who are qualified to NVQ Level 2. Some of the staff from abroad have higher qualifications in care (nursing) and are employed as senior care assistants. The training manager is due to visit the home to “sign up” more staff on NVQ training. This will improve the quality and competency of the staff and ensure that residents are cared for by a staff who are able to meet their needs. A sample of staff recruitment records was examined. There was evidence of good recruitment practices meaning that the right staff are employed at the home and residents are safeguarded. An induction training programme for new staff members is not provided for all new employees. Two staff said they had not been provided with any sort of programme to follow, whilst for a third person, very little attention had been paid to their induction records, as the information recorded was incorrect and had not been amended. The home must ensure that staff are properly inducted into their role to ensure they have the necessary skills to care for the residents. This major shortfall has the potential to place residents at risk from being for by staff who are not aware of their role or the policies of the home. The manager had been led to believe that the staff training files had been removed by the previous owners, however some had been retained in the home. The sample looked at evidenced a range of differing training. The manager has completed a profile of the mandatory training requirements for each member of staff and these will be addressed in the near future. Two staff said they were attending training in wound care management soon. A training and development review is recommended for all staff to ensure there is an appropriate skill mix and that staff are suitably qualified. The home has yet to produce an annual training plan, and will need to do once this review has been completed. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 21 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, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made in the management of the home and this will lead to the home being run in the best interests of the residents. EVIDENCE: The home manager has been in post since February 2006 but has yet to make her application to the CSCI to be the registered manager. She is a registered nurse, has experience in dementia care and was previously employed in a management role within another care home setting. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 22 The home has a deputy manager, who is also the lead nurse for the general nursing unit. The dementia care unit has been without a lead nurse for a long time however Mimosa have just been successful in recruiting an appropriately qualified nurse – this will ensure that the home meets a condition of their registration. The unit has been without clear leadership and direction for some time. Improvement must be made to ensure that the residents receive a consistent service, and that the unit is developed in line with current good practice. During the course of the inspection, a staff meeting was held on the dementia care unit. A good exchange of instruction and ideas was generated between the manager and the staff team. The home has a number of quality assurance and monitoring procedures in place. Mimosa are planning to do their first full quality assurance exercise, to encapsulate all stakeholder views and opinions. This information will then be correlated into an action plan of improvement for the home. This will be followed up at the next inspection. Staff confirmed they are regularly supervised, and that written notes are kept of the meeting. Work performance, welfare issues and training issues are discussed. The manager was observed to have a visible presence in the home – both staff and relatives commented upon this improvement. Day-to-day supervision of the care staff by the registered nurses has been increased, however on the dementia care unit it appeared that the senior care staff controlled the work schedule. In general the homes records are satisfactory and are kept secure. Comments regarding the care planning documentation have already been referred to in the second outcome group. The home has a maintenance person who undertakes all environmental checks and organises or completes any repairs. Maintenance also complete regular audits of the fire alarm system, fire fighting equipment, emergency lighting and the water temperatures. An examination of the homes records evidenced that all necessary service contracts were up to date. Manual Handling Assessments are not completed for each resident. This has the potential to place both residents and staff at risk from injury as they may not be following safe working practices. These assessments must then be kept under regular review to ensure the ‘safe system of work’ remains appropriate. Staff must also ensure that they manage soiled linen appropriately and do not put themselves, their colleagues and the residents at risks from crossinfection. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 23 Since new staff have not received an induction training programme, the home have failed to provide health and safety training, and again may be placing staff and residents in unsafe situations. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 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 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 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 1 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 1 Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 Requirement Pre-admission assessments must evidence they have been completed prior to placement at the home. Care plans for each resident must be comprehensive, clear and person centred. They must be drawn up and reviewed in collaboration with the resident/representative. (Requirements have previously been issued to the home. Further non-compliance may result in enforcement action being taken) Timescale for action 08/06/06 2. OP7 15(2)c 08/06/06 3. OP7 15(2)c Where end of life care needs are identified, there must be appropriate consultation and documentation maintained Appropriate and effective measures must be taken to prevent pressure sore formation. Staff must ensure that they communicate effectively and can be understood, by residents and their relatives, at all times. 08/06/06 4. OP8 12(1)a 08/06/06 5. OP27 19(5)b 08/06/06 Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 26 6. OP29 18(1)c Induction training for new staff must meet current guidelines and be available for all new staff (Requirements have previously been issued to the home. Further non-compliance may result in enforcement action being taken) 08/06/06 7. OP30 19 Schedule2 9 Schedule2 13(5) Staff training records must be kept for each staff member, and be available at future inspections The manager must make application to CSCI for registration 08/06/06 8. OP31 08/06/06 9. OP38 Staff must assess and follow safe 08/06/06 systems of work when moving and transferring residents Staff must take measures to prevent the spread of infection. 13(3) 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. 5. Refer to Standard Good Practice Recommendations Staff should ensure residents have appropriate mealtime aids to enable them to retain their skills and independence. That a stable work force be established so that consistency of care is maintained for the residents. An over view of the skills and qualifications of the catering staff, would identify any skill gaps. The homes commitment to NVQ training should be increased to ensure that care staff are suitably trained. An over view of all care staff skills and qualities, will identify and skill gaps and training needs. A training plan should be formulated for the home. Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Sunnymead Manor DS0000066340.V290324.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!