Inspection on 15/10/05 for Sunnymede Nursing Home

This inspection was carried out on 15th October 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 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

Sunnymede Nursing Home 25/07/07

Sunnymede Nursing Home 19/01/07

Sunnymede Nursing Home 08/06/06

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 Sunnymede Nursing Home 4 Vandyke Avenue Keynsham Bath & N E Somerset BS31 2UH Lead Inspector Karen Walker Unannounced 15 October 2005 09:30 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. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sunnymede Address 4 Vandyke Avenue Keynsham Bath & N E Somerset BS31 2UH 0117 9863157 0117 9862232 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) Charlton Care Homes Ltd. Bernice Currey Care Home with Nursing Category(ies) of OP Old age, for 41 registration, with number of places Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Staffing Notice dated 8th April 2002 applies. Date of last inspection 10/03/05 Brief Description of the Service: Sunnymede is registered to provide nursing care for up to 41 older people. The manager was asked to consider reviewing the registered numbers due to some of the rooms being unsuitable and currently used for storage. There are currently 32 residents at Sunnymede. There is one shared room and when this becomes vacant will revert to single occupancy. The home is a converted older property partially extended and set in well-manitained gardens with a pleasant location. The home offers accommodation over 3 floors. Level access being provided by stair and main passenger lift. The Home is situated within a ¼ mile of the centre of Keynsham and many local amenities. Local venues are best accessed by car because of the gradient of the local roads. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector met with staff and residents and discussed the support provided. Case tracking took place for four residents, which included examining records, speaking to key-workers and meeting with family members. Records relating to the home including health and safety were also examined. The manager was available throughout the inspection. A tour of the property was undertaken. What the service does well: What has improved since the last inspection? The requirements made at the last inspection have been met. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.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 Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.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 Residents are assured that their needs will be met when they move into the home. EVIDENCE: The records relating to residents were well-presented and provided detail of the pre-admission assessment of residents care needs. Care assessments had also been regularly reviewed and updated, this included detail of the residents’ risk assessments and evaluation. The home’s ability to meet the assessed needs of the residents relies on the individual and collective clinical skills of the Registered Nurses. It was evident from the well-presented training records of the RNs that they have attended clinical update training relevant to the care needs of residents in the home. It was evident that care had been taken when carrying out the pre admission assessment of residents to ensure there were adequate skills in the care team to provide care. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.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) 7-10 Residents’ health, personal and social care needs are set out in an individual plan. Residents can be assured that the home or the appropriate professional will meet their needs. The home’s medication policies are not always adhered to and gaps were found in medication administration sheets. EVIDENCE: The manager was complimented on the detail included in the care plans. The commitment to the care documentation remains high. There was a range of documentation available in the individual care files from the pre admission assessments, activities of daily living (ADL) assessments, admission / contact information, review, daily reports and personal history profile. All of the documentation viewed contained identification of a range of holistic needs, which were detailed in the plans of care. The plans of care not only evidenced how to meet identified care needs they also contained health promotion and personal wellbeing plans, the home is to be commended for this holistic approach. Residents confirmed that they had access to the appropriate professional e.g. optician, dentist, audiologist, physiotherapist etc. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 10 A range of risk assessments were available including moving and handling, pressure sore development risk, falls risk, nutritional risk, consent to restrictions as well as generic risk assessments. Where risk assessments and care plans had been reviewed it was noted that comments were made that were not informative i.e. ‘no change’. This was discussed with the manager. Three monthly weight monitoring was also being recorded. There was some evidence of family involvement, especially in the completion of the family tree and personal history profiles. The home also utilises the ‘Pool Activity Level (PAL) Personal History Profile’ which when fully completed provides tools of engagement for individual residents. The activity coordinator uses this to assist in the provision of appropriate methods of stimulation for each individual. The inspector took the opportunity to observe the lunchtime medication round. The medication and administration sheets were examined and it was noted that there were some gaps in the administration sheets. This was discussed with the manager who said this was due to staff forgetting to sign. It was also noted that creams and ointments were not signed as administered. It is a requirement that all medication is signed as administered including creams. ‘As and when’ medication was examined and found to be appropriately stored. The inspector chose medication at random and found the balances to be correct at the time of this inspection. The inspector was informed that privacy and dignity issues are discussed during induction: this was further evidenced when the inspector viewed the induction records. Staff and resident interactions were seen to be friendly and supportive. All resident comments indicated staff were courteous and respectful. It was noted that the residents preferred form of address is established prior to admission and noted in their care files. Staff were observed to be knocking and waiting before entering bedrooms and bathrooms. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.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) 12-15 Residents benefit from a varied activitities programme, which is both enjoyable, stimulating and meets individual preferences and expectations. Residents maintain family contact and staff encourage family and friends to join in with household activitities. Relatives feel they can advocate openly on behalf on their relative. Residents receive a varied and wholesome diet that they are able to influence. EVIDENCE: The inspector met with the activitities coordinator who explained her role within the home. She is a well-established member of staff who is knowledgeable of the residents’ needs and aspirations. The coordinator said, “Empowerment was of the utmost importance”. When asked about the planning of the activitities programme, residents confirmed they chose what to do and where to go and said, “We really enjoy the people that come in to entertain us”. One resident said, “We really have a laugh”. The inspector met with relatives who were joining in with a game of bingo, the atmosphere was relaxed and friendly and staff members supported some residents with the game. Relatives were very complimentary of the service provided by the home. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 12 The home has many links with the community as well as residents accessing community services such as regular visits to local shops, restaurants and pubs. Community transport and or disabled taxis are used for transportation. The manager considers that the home is well integrated into the local community and is very proud of the level of activities provided at the home. The inspector felt the range of leisure and social activity that residents are engaged with is both extensive and impressive. There are monthly meetings for the residents arranged and conducted by the activities organiser. Residents and their relatives can have access to their care records if wished and care reviews involve all the relevant people. Discussions were held with the cook who explained how the menus were put together. The menus were examined and seen to be varied using fresh ingredients. Residents were very complimentary of the meals and comments included, “the food is lovely I have no complaints”. “If we don’t want something we can have another choice”. Other comments were made suggesting that the hot drink served with dinner could be served after, as it sometimes gets cold whilst people eat. This suggestion was passed on to the manager. Residents ate together in the lounge/dining room and some were supported to eat by staff members. This was observed to be done in a respectful way and was not obtrusive to other residents. One comment the inspector made was to stop using the term ‘feeders’ for those people that require support to eat. This was discussed with the manager who agreed that this is a derogatory term and removes ‘individuality’. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 13 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) 16-18 Residents are confident that their views will be listened to and that they are safe from abuse. Residents’ legal rights are protected. EVIDENCE: The complaints book was examined and it was noted that there were no complaints or comments recorded. This was discussed with the manager who said that she had never received a formal written complaint. It is good practice to record all concerns received both in writing and verbally. It is recommended that a ‘comments’ book be made available and kept by the visitors’ book to enable visitors to make positive comments as well as record their concerns. Residents and relatives said they had no concerns, one relative said, “they are wonderful and I am always grateful for the care given to my relative”. Another said, “no I have no concerns and if I did I would tell the manager and she would deal with it”. The manager confirmed she did not act as appointee for any of the residents and a sample number of individual finances were checked on the day of the inspection and found to be correct. All residents are on the electoral roll and a number voted in the last election. The home will arrange transport / escorts for residents to attend the polling stations upon request. Post can be left at the main office, which is posted daily by a staff member into the Royal Mail delivery service. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 14 At the last inspection evidence of a “Living will“ was observed in one individual care plan. The home has written procedures for adult protection, whistle blowing, management of aggression, abuse, bullying and management of money/valuables. The ‘No Secrets’ document was also available. The inspector did not view these documents during this inspection. The inspector was informed by the manager that the organisation actively promotes staff training and education in these areas, all staff are encouraged to attend training in dealing with difficult behaviours and protection of vulnerable adults. Staff training records evidenced this commitment. The manager was aware of the interagency protection procedures and her responsibilities in the reporting of POVA incidents to the local authority. Care staff informed the inspector that they are aware of the protection policy and have received training on this subject. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 15 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) 19-25 Residents do not live in a safe and well-maintained environment and are at risk from some areas of the environment. They do have access to the appropriate equipment needed to support mobility. There are adequate bathing and toilet facilities although some need refurbishment. EVIDENCE: The inspector took a tour of the environment. There is now a separate room for residents to meet friends and family privately. Although there are a number of requirements and recommendations made regarding the environment it was noted the home had a pleasant homely and relaxed feel to it and residents said they were ‘happy here’. A number of bedrooms on all floors were seen. Most were personalised and reflected individual tastes however others were in need of redecoration. There was one double room that had recently been filled. The manager was reminded that when this room becomes available residents must be given the choice of whether they wish to share or not. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 16 The furniture in several of the bedrooms viewed had been recently replaced, in others it was noted that there was not enough drawer space and clothes were jammed into what available space there was. This needs to be rectified. Some curtains have been replaced and more are planned. Lockable drawers were provided in most bedrooms for personal possessions. The hot water outlet was checked in one bedroom and this was found to be scalding hot. This must be investigated and made safe. It was noted that some of the bedroom doors were propped open either with furniture or a wedge. This practice must stop and suitable equipment as recommended by the Fire Brigade sought. Some of the bedroom doors were also badly damaged and would benefit from ‘strips’ being placed on them to prevent damage from wheelchairs. Although some of the bathrooms have been redecorated others require attention. The downstairs toilet leading off the lounge has paper ripped from the walls and missing tiles. The floor was dusty. An upstairs bathroom is still in need of refurbishment. The radiators in the lounges and in a number of residents’ bedrooms did not have radiator covers or temperature control valves in place. The radiator in the small lounge was scalding hot and when the inspector tried to turn the radiator down the valve fell off. The manager reported this to her maintenance manager on the day of this inspection. A requirement is made to make safe the radiators in all rooms. A short timescale has been given. There is adequate equipment to support residents with mobility needs. It was noted that wheelchairs and hoists were stored in the dining room and left in the lounge areas. This was discussed with the manager who explained that storage space was in demand. It is therefore recommended that when a ground floor bedroom becomes available this be used for wheelchair and equipment storage thus eliminating the risk of trips and falls. Staff members were observed transporting residents in wheelchairs without footrests. This was discussed with the manager who said this is an ongoing problem that she will address. The carpets on the first floor were badly stained. The manager explained these had recently been cleaned, they would benefit from replacement. It was noted that continence aids were left in the hallways and the COSHH cupboard was left unlocked. The layout and access to parts of the home are not ideal but the individual needs of residents for equipment or disability aids has been addressed. It is not possible to offer admission to any independent wheelchair users who require nursing care, because the limitations of the building would be to Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 17 restrictive for mobility to an unacceptable degree. A complete environmental review is needed. It is a requirement to carry out the following maintenance and improvement work and unless specified as ‘immediate’ send an action plan to the CSCI detailing timescales and priority areas. 1. Refurbishment of the remaining bathrooms and toilets 2. Provide adequate storage space in residents’ bedrooms 3. Make safe hot water in individual bedrooms - immediate 4. Make safe radiators throughout - immediate 5. Replace the worn carpet on the first floor 6. Remove the continence aids from the hallways and store appropriately – immediate 7. Ensure the COSSH cupboard remains locked when unattended - immediate 8. Ensure footrests are in place and used at all times Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) 27-30 Residents are not protected by a robust recruitment system. Although staff training is provided to meet the needs of the residents it would be beneficial to review the duty rota to ensure staffing numbers remain adequate to meet the needs of the resident group. EVIDENCE: The inspector met with a new staff member who explained the recruitment procedure. Although it was confirmed that all the necessary personal identification documents were in place the Criminal Record Bureau (CRB) checks had not yet been undertaken. The staff member confirmed she was supporting residents with personal care unsupervised. This was discussed with the manager who said she was sending off the appropriate documentation today. It is a requirement that potential staff do not take up their position providing personal care unsupervised without the necessary CRB and POVA first checks in place. It is further required that a risk assessment be put in place until the CRB is received. Documentation examined for two other staff members was adequate. It was noted through examination of the duty rota and discussing staffing levels with staff members on duty that the manager is often the only qualified staff member on shift. The manager must therefore carry out her managerial duties as well as provide hands on care. This often proves difficult and affects the amount of care she can give. When the inspector toured the environment it was noted that some residents were still in bed at 11.30am with the curtains Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 19 closed. The manager said this was not their choice but was due to the time it took to support people to get out of bed. It is therefore a requirement that the staffing hours are reassessed. It is recommended that the manager be removed from the numbers providing care and become supernumery thus maintaining her managerial presence and being available to cover emergencies and absences. The manager uses her own staff group to cover any staff absences and makes good use of agency staff. This is good practice and provides a consistent care service to the service users. At the last inspection training records were randomly sampled for a range of staff. These evidenced a broad range of skills available amongst the staff team and an on-going commitment to staff training and development. The home was commended for its approach to staff development. Staff had completed training in diabetes management, the care and management of a person with Parkinson’s, incontinence, care of the dying, medication management, Dementia, wound care and infection control. The R/N training records viewed evidenced clinical training in line with PREP requirements. The majority of staff had received up to date training in fire safety, manual handling, first aid, food hygiene, health & safety and POVA training. There was evidence of a rolling training programme for these core skills and the manager was happy that at least 50 of the staff team would have achieved a National Vocational Qualification (NVQ) by the end of the year. The induction programme was a fairly comprehensive document based on the TOPSS standards. The document acts as a prompt for the trainer to discuss issues, systems and policies with new staff, who then signed to say the information has been given. After completion of the induction training staff go on to commence foundation training this again was a fairly comprehensive document based on the TOPSS standards, which was evidence based. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 31, 35-38 The homes record keeping policies and procedures safeguards residents and ensures their best interests are met. Residents and staff will benefit from the Responsible Individual carrying out the required monthly visits. They will then be able to make a judgement of the standard of care provided in the home. EVIDENCE: The inspector took the opportunity to check the personal finances for the residents that were subject to ‘case tracking’. All balances checked were correct at the time of inspection. It was noted that there was no formal audit of finances apart from that carried out by an appointed staff member. The manager said this would be looked at as part of the quality audits carried out by the company. It is a requirement that the appropriate monthly visits take place by the registered provider and a report sent to the CSCI. These visits Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 21 must be unannounced and include interviews with staff and residents to ascertain the quality of care provided. The home’s records were generally satisfactory. There is an annual appraisal process, which ties in with the supervision arrangements. The manager has established a formal recorded supervision procedure for all staff, who attend a minimum of 6 supervision sessions annually. One of the regular agency staff on duty said, “this is a lovely home, I love coming here, the manager and staff team are good”. The fire logbook evidenced compliance to the weekly, monthly and annual checks alongside records of staff training and drills completed. There was a comprehensive risk assessment in place. As previously mentioned some of the bedroom doors were propped open with furniture or wedges. This practice must cease and equipment recommended by the Fire Brigade must be sought. All records evidencing the regular routine maintenance of equipment, electrical and gas safety were in order. The inspector was informed that all windows above ground floor level were restricted; those randomly checked by the inspector further evidenced this. The manager said some of the windows were due to be replaced due to a problem with condensation. The inspector viewed the kitchen area, this was generally clean, tidy and well organised. Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 22 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 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 1 3 3 3 3 3 2 x STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 x x x 3 3 3 2 Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 23 no 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 29 Regulation schedule 2 (7) Requirement Timescale for action 15/10/05 2. 3. 27 19 18(1)(a) 23(2)(a)( b) 13(4) there must be a robust employment procedure. potential staff will not be employed at the home without a current CRB and POVA first check. A risk assessment must be put in place and the staff member without a CRB must be adequately supervised. the qualified nurse staffing hours 1/11/05 must be reassessed. the following maintenance and 1/11/05 improvement work must be carried out and unless specified as ‘immediate’ send an action plan to the CSCI detailing timescales and priority areas. 1. Refurbishment of the remaining bathrooms and toilets 2. Provide adequate storage space in residents’ bedrooms 3. Make safe hot water in individual bedrooms - immediate 4. Make safe radiators throughout - immediate 5. Replace the worn carpet on the first floor 6. Remove the continence aids from the hallways and store appropriately – immediate Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 24 4. 31 26 5. 38 23(4)(a) 13(4)(a) 6. 9 13(2) 7. Ensure the COSSH cupboard remains locked when unattended - immediate 8. Ensure footrests are in place and used at all times the appropriate monthly visits must take place by the registered provider and a report sent to the CSCI. cease the use of wedges or furniture used for propping open bedroom doors. provide suitable equipment as recommended by the fire brigade. all medication must be signed as administered including creams. 1/11/05 15/10/05 15/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 27 Good Practice Recommendations Remove the manager from the staffing numbers providing care and allow her to become supernumery thus maintaining her managerial presence and being available to cover emergencies and absences. When a downstairs room becomes available utilise the space for the storage of wheelchairs and equipment and reduce the risk of trips and falls. A comments’ book to be made available and kept by the visitors book to enable visitors to make positive comments as well as record their concerns. 2. 3. 19 16 Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 25 Commission for Social Care Inspection 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 Sunnymede Nursing Home D56_D05_S60331_Sunnymede_V247534_050905_Stage4.doc Version 1.40 Page 26 - 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. 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