Inspection on 25/07/07 for Sunnymede Nursing Home

This inspection was carried out on 25th July 2007.

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 19/01/07

Sunnymede Nursing Home 08/06/06

Sunnymede Nursing Home 15/10/05

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 Andrew Pollard Key Unannounced Inspection 25th July 2007 10:00 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 Sunnymede Nursing Home DS0000060331.V338465.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. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunnymede Nursing Home Address 4 Vandyke Avenue Keynsham Bath & N E Somerset BS31 2UH 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 9863157 0117 9862232 bernice@charltoncare.com Charlton Care Homes Ltd Bernice Currey Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Staffing Notice dated 8th April 2002 applies. Manager must be a RN on parts 1 or 12 of the NMC register. Date of last inspection February 2007 Brief Description of the Service: Sunnymede is registered to provide nursing care for up to 41 older people. At present the home exercises a voluntary limit of 31 residents. The home is a converted older property partially extended and set in wellmaintained gardens with a pleasant location. The home offers accommodation over 3 floors, access being provided by stair lift and shaft lift. The home is situated within ¼ mile of the centre of Keynsham and many local amenities. Local venues are best accessed by car because of the gradient of local roads. The cost per week to reside at Sunnymede Nursing Home ranges between £471.00 and £609.00. Fees are reviewed annually and if care needs increase. This weekly fee does not include provision for items such as hairdressing, chiropody, dental, ophthalmic, or audiology services. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process. The inspection lasted one day. Following the previous inspection several requirements were made concerning the environment and issues related to the health and safety of residents, there are no outstanding requirements. The following methods of evidence gathering has been used in the production of this report; observation, discussion with residents, relatives and staff, tour of the home and sampling policies, records, care plans and a meals. 26 surveys were returned from residents and relatives and five from health professionals. Information from these has been collated and are detailed throughout the report. Staff and resident interactions were seen to be friendly and caring upholding the dignity of the residents. Members of staff were observed on duty and several were consulted individually. General feedback was given to the manager on the day of inspection. What the service does well: What has improved since the last inspection? Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 6 The staffing levels are adequate for the current needs of the residents. There have been major improvements in the upkeep and décor within the home. A system has been put in place so that residents and their relatives have the opportunity to discuss any issues, views and level of satisfaction about the service they are receiving. 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. The summary of this inspection report can be made available in other formats on request. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 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 Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients and their families are given relevant information in written or verbal form about the home. Contracts and terms and conditions of services are provided to all clients. The assessment procedure is clearly written and a thorough assessment of prospective residents needs is carried out. EVIDENCE: A statement of purpose and a home guide is made available at the initial stage of enquiry to prospective residents/families. This provides useful information of the services available and includes the terms and conditions. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 9 All the residents’ surveys returned stated that they had received adequate information to help them decide if Sunnymede was somewhere they would like to live. They also confirmed that they had received a contract on admission to the home. Visits to the home are encouraged either for the day or perhaps for lunch dependent on their wishes. The home operates a robust admission procedure and maintains a checklist to ensure the smooth running of this first initial period within their new home. The pre-admission assessments are comprehensive; covering activities of daily living, a full health screen and personal history background. The information gathered pre-admission details the resident’s ability and state of health prior to admission. The prospective resident/relative are involved in the pre-assessment and all information is used to determine the suitability of the placement. Where possible the manager had obtained assessments and care plans from other professionals involved for example, social workers and hospital staff. A month’s trial period on both sides is usually undertaken to ensure that everyone is happy with the arrangements and to ensure that the placement is suitable. Residents are referred to the Primary Care Trust for assessment of funding under the Registered Nurse Contribution (RNC) or Continuing Health Care (CHC). Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans detail residents care needs and are clearly written and give clear directions to staff. The staff provide appropriate personal and nursing care to maintains residents’ health and well being and dignity. Proper arrangements are in place for residents to access primary healthcare services. The staff properly store, administer and record medication on behalf of residents. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 11 EVIDENCE: From the pre admission assessments the manager and the registered nurses are able to develop a set of care plans based on identified needs. During the first months trial period the residents’ plans are reviewed weekly and updated. The manager has developed system in the home whereby a care review meeting will be arranged every six months for each resident, involving their relatives and key worker. The meeting will be used to discuss and evaluate the residents’ care plans and will give the opportunity to raise any issues or concerns. Several residents files were looked at in detail, including assessments, care plans personal history profiles and risk assessments. The records showed consistency and were comprehensive and up to date. Intermittent care plans were available when short-term needs had been identified. Regular evaluation of resident’s care plans were taking place. Risk assessments were in place with detailed information to ensure safe procedures for example, manual handling, the correct use of bed rails and how to reduce the risk of falls. Health Care needs in files and included continence, nutritional, waterlow and pain assessments. In discussion with the manager it was agreed that after the initial assessments are made it is a matter of clinical judgement how of ten they are repeated. The assessments should be done where there is a clinical indication for doing so rather than routinely for everyone every month. Each resident was referred to a GP on admission to the home and an initial first visit was then set up. Although the GP does not conduct weekly visits to the home, good working relationships with the GP have been formed and the GP will visit on request. General Practitioner (GP) and Para-medical visits and their outcomes were well documented. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 12 There GPs returned comment cards that indicated their satisfaction with the home with comments such as, ”The staff have always looked after my patients well” and “I think this is a good home where the residents are well cared for, all the staff are extremely caring towards the residents”. A mental health practioner said,” The service provides a caring environment with a high degree of professionalism and the emphasis on Sunnymeade being a home, they are particularly skilled at assisting clients with mental health needs”. The residents surveys evidenced that they receive the care and support they need Comments from received were very satisfactory and complimentary of the staff and the care they provided. All the residents spoken with said, “They were satisfied with the overall level of care being provided”. They spoke highly of the staff saying they were, “Friendly and caring”. Policies and procedures for receiving, storing, administering and disposing of medications are in place. There were photographs of each resident on their medication charts to help ensure that medication was dispensed to the correct person. The administration charts were legible up to date and in order. Proper arrangements are in place for the storage and recording of controlled drugs and drug disposal. The manager and deputy are link nurses with the Dorothy House Hospice and oversee end of life care planning. The staff make every effort to establish resident’s wishes concerning palliative care and any provision residents and their families would wish for when developing end of life plans. The plans are sensitively completed with residents and their families/significant others. Some families had chosen to take private time together to discuss their wishes and then pass the information on to the home so that a care plan could be devised. The home has adopted The Liverpool Integrated Care Pathway using a comprehensive assessment tool for people who require palliative care. A care pathway is intended as a guide to treatment and an aid to documenting residents’ progress. Sunnymede Nursing Home DS0000060331.V338465.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): 12,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of social and recreational activities is arranged that seek to enhance the quality of life for the residents. Resident’s families are involved and informed of issues related to their relatives and are able to maintain close contact with families and friends. The food is of a high standard and provides a balanced diet for residents. EVIDENCE: Personal history profiles of the residents are usually completed with them and the activities coordinator; information obtained included details of the residents’ work history hobbies or interests and younger and adult memories. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 14 The profiles enable staff to recognise the person as an individual and gives them a better understanding of them. It also creates topics of conversation, encouraging life review and reminiscence, which will have meaning to the individual resident. The activities coordinator continues to provide a varied programme of activities for the residents. She is a well-established member of staff who is knowledgeable of the residents’ needs and wishes. The coordinator is responsible for documenting a record of any activities the residents have taken part in. In conjunction with the residents the activities coordinator develops a monthly timetable of activities and forthcoming events. A copy of this is placed in communal areas throughout the home, to ensure that all residents and visitors are aware of the planned activities. Individuals have records of their social and activity choices and record of participation in their files. A recent summer fete and garden party were a great success according to several residents spoken to and as recorded by photos on display. There are annual fund raising events that Sunnymede organise and all proceeds go to the residents’ funds. The grounds staff have done a good job in the gardens, a new garden project has just been completed and the flower boarders were pretty and well stocked and the lawns had been cut. The Pool Activity Level (PAL) assessment and activity process is in operation to enhance the quality of life for residents with dementia. An aroma therapist visits the home to offer simple massage to residents paid for by the home. This service is being well received by the residents. A music therapist visits the home every month. The session is tailored for all residents to participate in but has been particularly engaging for residents with dementia. Residents are given musical instruments to play with to music. After the session they perform a mini concert for staff and any residents who chose to participate. Residents continue to enjoy trips to the local Brass Mill for lunch and out shopping in the local high street Or various events at the local Fry’s Chocolate Factory. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 15 Residents are supported to satisfy their religious preferences. Several denominations visit the home for individual communion and every four weeks an interdenominational group visits the home to provide a service that represents various individual faiths. One resident told the inspector “I always enjoy the service and the different hymns we sing”. There are no residents with other faith backgrounds. The level of privacy in the residents lounge when visiting can be restricted due to the television and general activity within it. A “quiet” room had been allocated to ensure that residents could receive guests without having to go to their bedrooms. The home is welcoming to families and friends and relatives are invited to many social activities and their view and opinions valued. In a survey a mental health care co-ordinator said,” Sunnymeade has always worked hard to consider the views of clients and their families”. Two relatives spoken with said they were made welcome and felt they were kept in touch with what was going on. The home has devised three weekly menu rotas. The menus consist of a varied, well-balanced choice of traditional home cooked meals. Each day residents have a choice of two meals and in addition to this omelette; fish or ham is also made available on a daily basis. The menu includes alternative choices for residents who are diabetics or those requiring a pureed diet. No resident currently requires any culturally specific diet. The cook’s visits each resident regularly to gain feedback on the food served the previous day and take requests from the menu plan for the day ahead. Residents’ surveys expressed that “The food is always very good” and “we have plenty of choice”. The kitchen is very small and not well laid out but was clean and organised. A new extraction fan has been installed to help reduce high temperatures experienced on sunny days. Food hygiene training is up to date for all staff. Records are made to show that required temperature checks were being carried out on fridges and freezers and that food was also being probed after being cooked before serving. Risk assessments were in place and up to date. An Environmental Health Officer inspection is expected this summer. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 16 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are robust and comprehensive policies in place to protect residents investigate complaints or manage allegations of abuse. There are good arrangements in place for staff training and awareness of Protection Of Vulnerable Adults matters. EVIDENCE: A copy of the complaints procedure is on display in the main foyer and is part of the information provided to people on admission resident and relative surveys indicated people knew how to complain. The complaints policy and procedure is detailed and contains all the required information. There have been no complaints received since the last inspection. A ‘comments’ book is kept by the visitors’ book to enable visitors to make positive comments as well as record their concerns if any there were none recorded. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 17 All residents who completed a survey indicated that they knew who to talk if they were not happy and how to make a complaint. Comments included, “I’ve never had cause to complain “. Residents also said they would speak to their key workers or the manager to discuss any concerns they may have. The home has written procedures for adult protection, whistle blowing, management of aggression, abuse, bullying and management of money/valuables. The Local Authority ‘No Secrets’ document was available. The manager and 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. The operations manager is a protection trainer and the manager is expecting update sessions to be run in the near future. All staff are instructed in adult protection and prevention of abuse as part of heir induction. There have been no allegations of abuse. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 18 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): 19,20,22,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of furnishing and décor is good to the benefit of residents. The home provides a safe and well-maintained environment for the residents. The bedrooms and communal rooms and facilities are suitable and well presented for their purpose and meet the resident’s needs. The standard of cleanliness is high. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 19 EVIDENCE: There is ongoing redecoration of rooms and replacement of bedroom furniture, including profiling beds. Replacement of flooring in specified corridors and carpets in some residents’ bedrooms. All of the work completed was of a good standard. Residents had been involved in the process by choosing colours for their walls and carpets for their rooms. The bedrooms looked homely and had evidence of personalisation. Suitable screening has been provided in bedrooms, which respects the privacy and dignity of the residents. Bedrooms have been provided with net curtains, roller blinds and curtains. The manager and housekeeping staff have developed a programme of rota cleaning in the home to maintain higher standards of cleanliness and ensure continuity of cleaning throughout all areas of the home. The home was very clean and smelt fresh. The housekeeping staff confirmed that standards have greatly improved and in addition domestic staff had been deployed on the weekends, which had enabled more continuity in cleaning over a seven-day period. Corridors, landings and stairwells had been decorated and were bright and fresh. All of the bathrooms and toilets were in good order, clean and fresh. Baths have thermostatic mixer valves and the monitoring hot water temperatures takes place. Mobile and fixed hoists are provided. There is one shaft lift a wheelchair lift and a stair lift, which together give level access to all parts of the home. A room has been refurbished to enable residents to receive their visitors in private other than in their rooms if they wish. Suitable dining room seating and table facilities are provided so that residents can enjoy their meal times comfortably and in a congenial setting. The dining room has been redecorated and the flooring replaced. All lounge/recliner chairs have been replaced and are of good quality, comfortable and are suitable for the residents. Residents’ surveys confirmed that the home is now and clean and one resident stated, “That things have got a lot better now and the decoration is nice”. Sunnymede Nursing Home DS0000060331.V338465.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): 27,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment procedures and records are in good order. The home is well staffed with appropriately trained and experienced staff for the number of residents. Proper training arrangements and clinical updating for RN’s are in place. Good progress is being made training care staff for the benefit of residents. EVIDENCE: The staffing levels are in accord with or exceed the staffing notice for 31 residents The staffing levels are indicative of the needs and level of care required by the residents. An additional carer works a twilight shift from 6.30pm-9.30pm to assist the night staff to manage more effectively when putting residents to bed. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 21 Residents’ surveys agreed that staff were always or usually available when they needed them and always listened and acted upon what the residents had to say. There is no administrator post thus the manager is supernumerary to deal with the high level of ad ministerial and management duties. At present there are no Nurse or carer vacancies. The home has a small bank of staff and agency use is minimal. The domestic, catering, admin and laundry staffing levels are satisfactory. The induction programme is comprehensive and based on the Skills for Care standards. After completion of the commence foundation training care staff enrol on the National Vocational Qualification (NVQ) programme level 2 run by Norton Radstock college. Three of the Registered nurses (RN’s) are NVQ assessors. A health care professional commented in a survey that,” I admire their (staff) dedication, skill and patience, I recommend this home to many of my local clients”. A training matrix has been developed to show that all mandatory training including fire safety, food hygiene, first aid, load handling and adult protection was undertaken and course dates had been organised for staff. The manager has done additional training to train staff in load handling and Ms Harding in general Health and Safety matters, both felt they were in need of updating. The manager and other nurses are conscientious in attending training relevant to the care needs of the residents, which was evident in their personnel files. The Registered Nurse training records checked showed evidence of learning and updating both internal and external. A robust recruitment policy and procedure is in place and the manager has applied to the CRB to become a counter signatory, enabling her to apply for staff CRB’s directly. The staff files inspected showed all the appropriate documents and checks were in evidence. In future CRB’s will be retained until the inspector has signed them off. Registered Nurse verification of registrations has been validated with the Nursing and Midwifery Council (NMC). A monthly electronic check of the NMC list of struck off or suspended staff is carried out. Residents’ surveys stated that, “the staff work hard to please everyone” Visitors’ comments included, “The whole team are of a caring nature” and “Staff are friendly, approachable and respectful”. Sunnymede Nursing Home DS0000060331.V338465.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): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run taking into account the views and wishes of the relatives and residents and as they are able. There are good arrangements in place to maintain and service the equipment and facilities in the home. The Home protects the health and safety of residents and staff. The staff supervision and appraisal arrangements are good. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 23 EVIDENCE: Mrs Currey is a registered general nurse who was able to demonstrate an understanding of the needs of the individuals living in the home. Mrs Currey has a good team who work with her to ensure that the highest standards of care are achieved and maintained. A care co-ordinator said in a survey, “The manager is always extremely professional and caring”. The Area Manager works closely with Mrs Currey and makes regular visits to the home. Monthly visits to the home (Regulation 26 visits) and reports sent to CSCI. These visits include interviews with staff and residents and an audit of the premises and quality of care provided. Residents meetings are held every 6-8 weeks And the first relative forum was held in June, which was well attended, and it is hoped to repeat this every quarter. There was a high degree of satisfaction expressed by all of the residents spoken with. Based on the comments received from residents surveys and visitors comment cards and through observation it is evident that residents feel the home is run in their best interests and to ensure their needs are being met. Residents meetings are held 6-8 weekly and are well attended. Minutes are taken and circulated to residents and their families on the notice boards throughout the home. Staff will ask residents prior to the meeting if they have any issues they would like to discuss and any information they would like to share with the group. The manager conducts an annual audit to assess the satisfaction of residents with regards to the service that the home provides. This information is obtained through questionnaires and completed by residents and relatives. The comments from the surveys included “I feel that my views are always listened to” and “Everyone is very caring”. The procedure for safekeeping of residents money was examined and three individual accounts were checked which were in order. Each person has a ledger sheet, which accounts for all transactions and receipts for purchases are kept. However the record keeping for valuables and unclaimed items need to be improved by recording all items deposited in a ledger and signing and sealing the envelopes. A policy for the disposal of unclaimed property needs to be written. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 24 The manager has established a formal recorded supervision procedure for all staff. The annual appraisal process ties in with the supervision arrangements. It was agreed that each person would receive a minimum of quarterly supervision the fourth quarter being the appraisal. The outcomes of the supervision are recorded and learning needs identified. Regular staff meetings take place and the RN’s meet separately which in part is for the process of peer review. Staff have carried out residents risk assessments and made appropriate provision to protect residents from injury. Padded bed rails are used to reduce the risk of falls where there is an assessed need and consent in place. There are restricted openings on windows. There are radiator covers in areas of identified risk. Accident records are fully completed and the manager makes a detailed analysis of them on a regular basis. The home has keypad security on the external door. There is a formal fire risk assessment and fire plan. The fire logbook was up to date and in order. Drills, checks and maintenance have taken place. Fire safety training for staff is given on induction and then at the recommended given intervals, as recommended by the Fire Prevention Officer. All night staff undertake this on a three-monthly basis, and day staff sixmonthly. There was a system for monitoring the risk of Legionella disease. A record of hot water outlet temperatures is maintained. The gas appliances have been serviced but no safety certificate was available. The electrical installation safety certificate inspection has been booked. The various types of lifts had been serviced and there were load test certificates for the hoists. Monthly equipment checks, including bed rails, wheelchairs, beds and commodes are being conducted and recorded; any repairs carried out are also documented. New sluicing/ disinfector facilities have been installed on the top floor. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 25 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 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 26 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 OP38 Regulation 13 Requirement Arrange for a gas safety inspection and issuing of the relevant certificate. Timescale for action 30/08/07 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. Refer to Standard OP38 OP18 Good Practice Recommendations The manager and Ms Harding need to attend update sessions in load handling and general Health and Safety matters respectively. All resident valuables and unclaimed property should be recorded in a ledger and envelopes signed and sealed. A policy for the disposal of unclaimed property needs to be written. Sunnymede Nursing Home DS0000060331.V338465.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colston 33 33 Colston Avenue Bristol BS1 4UA 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. Extracts may not be used or reproduced without the express permission of CSCI - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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