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Inspection on 17/11/05 for Sunnyside Nursing Home

Also see our care home review for Sunnyside Nursing Home for more information

This inspection was carried out on 17th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Individuals are encouraged to personalise their rooms with their own furniture and personal belongings. Meals are of a good standard and presented in an appealing way. Many staff are undertaking relevant training and working towards their National Vocational Qualifications. All mandatory training is being updated for all staff. There are adequate levels of staff on duty who endeavour to meet the personal and healthcare needs of service users. The staff team are motivated, committed and respond to service users in a respectful and appropriate manner. Service users spoken to said that the staff were "very helpful and kind" and " nothing was too much trouble ". There is good support for the home by the provider organisation, with effective monitoring and quality assurance systems in place. Medication is well managed in the home with relevant procedures in place for the administration of medicines. There is an effective complaints procedure with all complaints and concerns being acted upon promptly, within stated time scales.

What has improved since the last inspection?

Care plans have been improved and these set out the action, which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. The medication systems in the home have improved since the previous announced inspection. Service users medication charts were found to be accurate and legible with no omissions seen. There is a recruitment policy in place and all staff files were found to be accurate and contain all relevant documentation. A requirement was made during the previous announced inspection to ensure that door wedges are not used to hold open fire doors and that serious consideration is given to alternative ways to keep doors open. It is pleasing to see that this has been complied with.

What the care home could do better:

The environment in its present condition is not adequate for its present purpose. However, there are plans to improve the home and extensive refurbishment plans are in place. This work will greatly improve most areas of the home and will provide extra bed capacity and eliminate the three-bedded bedrooms. The registered provider is required to undertake Regulation 26 visits and send the reports to the Commission. This was a requirement of the previous announced inspection and has been made a requirement of this report.

CARE HOMES FOR OLDER PEOPLE Sunnyside Nursing Home 140 High Street Iver Buckinghamshire SL09QA Lead Inspector Barbara Mulligan and Christine Sidwell Announced Inspection 17th November 2005 10:00 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 Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 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. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sunnyside Nursing Home Address 140 High Street Iver Buckinghamshire SL09QA 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) 01753 653920 Mr Arshad Gamiet Mrs Mariam Gamiet Mrs Wendy Marsh Care Home 32 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (32) of places Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Elderly Physically Frail Elderly Mentally Infirm Date of last inspection 6th July 2005 Brief Description of the Service: Sunnyside Nursing home is a privately owned home registered to provide accommodation and 24hr nursing care for up to thirty-two elderly persons who may be physically or mentally frail. The home offers a respite care service when vacant beds are available. The home is a detached large Victorian style building with a modern extension to the rear of the property. It has pleasant gardens and there is car parking to the front. The home is situated close to the local amenities within the village of Iver. Available communal space consists of three lounge areas on the ground floor and another lounge on the first floor. There is also a small dining area on the ground floor. The home has nine double rooms, five single rooms and three triple rooms. All rooms are wellappointed and provided with separate furnishings and privacy screens. However there are plans in place for development of the home and to reduce the number of shared rooms to bring the home in line with the current Care Standards. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on the 17th November 2005. The visit consisted of discussions with the manager and proprietor, care staff and a tour of the home. Records, policies and procedures were also examined. A preinspection questionnaire was sent to the home prior to the inspection with comment cards to distribute to service users, relatives and health care professionals. The inspection officers were Barbara Mulligan and Christine Sidwell. The registered manager is Wendy Marsh. What the service does well: What has improved since the last inspection? Care plans have been improved and these set out the action, which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. The medication systems in the home have improved since the previous announced inspection. Service users medication charts were found to be accurate and legible with no omissions seen. There is a recruitment policy in place and all staff files were found to be accurate and contain all relevant documentation. A requirement was made during the previous announced inspection to ensure that door wedges are not Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 6 used to hold open fire doors and that serious consideration is given to alternative ways to keep doors open. It is pleasing to see that this has been complied with. 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. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 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 Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 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. The homes Statement of Purpose and Service Users Guide provide service users and prospective service users with details of the services the home provides. Each service user has an individual written statement of terms and conditions that is signed by service users or relative or relevant third party and the registered manager. Service users needs are thoroughly assessed prior to admission ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. Service users receive care services from staff who have the skills and competencies to meet their care needs. Prospective service users have the opportunity to visit the home on an introductory basis, before making a decision to move there, ensuring that service users are able to make an informed choice about where they live. EVIDENCE: Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 9 The Statement of Purpose contains all the necessary information as detailed in Schedule 1. The Service Users Guide has been completed since the following announced inspection and is informative, detailed and contains all the necessary information detailed in Standard 1. All service users are given a contract that details the terms and conditions of occupancy. It is the responsibility of the manager or the senior nurse to carry out the initial assessment of need. The manager stated that they will visit a potential service user either in the hospital or occasionally in their home to undertake the initial assessment of needs. On some occasions potential service users are invited into the home for the day where the initial assessment can take place. The home use an assessment tool that covers, present medical history, past medical history, medication, mobility, allergies, pressure area care, nutritional status, personal hygiene needs, continence needs, mental health, and a section for any other significant information. Potential service users are then invited to visit the home. This procedure is used for individuals referred through care management arrangements and for individuals who are self funding. Prospective service users and family members or representatives are included in the assessment process. There is evidence from the care notes that the care-plans are working documents. Extensive refurbishment work is due to be undertaken to the environment that will meet the requirements of service users who have physical needs and will improve individual and communal living facilities for all service users. Specialist equipment is in place around the home. The home employs three permanent registered nurses and a bank of regular relief registered nurses who are able to meet the health needs of service users. The home has catered for service users from different social, cultural and religious back-grounds, and the manager felt that this had been successful. The manager informed the inspector that the home had worked closely with families to ascertain the service users preferences and needs and to ensure these were understood and met by the home. The prospective service user is invited to spend time at Sunnyside Nursing Home. If the visit is successful then an admission is planned. It is at this time that a key-worker is allocated. The potential service user has a review after the first 4 – 6 weeks to assess their stay in the home. Emergency admissions have taken place occasionally, and the manager said that the home would inform the service user within 48 hours about the key aspects rules and routines of Sunnyside Nursing Home. The home has an admission policy and service users and relatives are encouraged to visit the home prior to admission. The home does not admit service users for intermediate care so this standard was not assessed during the inspection. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 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, 10 and 11. Clear and consistent care planning systems are in place to provide staff with adequate information they need to satisfactorily meet service users needs. The health care needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication policies and procedures are clear and there is consistent implementation resulting in safe working practices that ensures that service users are not put at risk. The manner in which personal care is delivered ensures service users are treated with respect and dignity and that their right to privacy is upheld. Service users and their families are treated with respect and sensitivity at the time of their death. EVIDENCE: The manager or the senior nurse completes the initial assessment for potential service users and from this a plan of care is developed. Following the first four Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 11 weeks stay at the home a review is held and the care plan is discussed and reviewed. A random selection of care plans were looked at during the inspection. These show that a variety of health care needs have been identified. There is evidence of preferred daily living routines and all care plans looked at contained the individual’s likes and dislikes. Risk assessments are in place for pressure area care, prevention of falls, manual handling and smoking. The registered manager is to be commended for the work she has undertaken regarding the prevention of falls and this has been implemented into the care plans. A requirement was made following the previous announced inspection for each care plan to contain a detailed action plan. It is pleasing to see that this has been complied with. There is evidence in care plans that service users are involved in drawing up the care plan and that they agreed with its contents. All care plans are stored in safe and secure areas and there is documentation to demonstrate that care plans are reviewed monthly. All service users are registered with a local GP Practice who visits the home weekly and as needed. Service users can register with their own GP if this is practical and agreeable to both parties. All have access to local NHS Services. Training has been undertaken by the registered manager and two senior members of staff that enables them to complete continence assessments for service users. Tissue viability assessments are in place for each service user. There are no service users with pressure sores at the time if the visit. There is a policy/statement regarding pressure area care that gives clinical guidelines for staff to follow. Other risk assessments seen are for moving and handling needs, the use of bed rails, and nutritional status. A domiciliary optical service visits the home on a six monthly basis. Referrals for a hearing test go through the service users G.P. or the home can contact the King Edward hospital directly. The home works closely with the dietician and nutritional risk assessments are in the care plans of service users. Weight monitoring is undertaken monthly and recorded in care plans. Chiropody services visit the home on a six weekly basis and the home pay for this service. Dental services are accessed in the local village and they will visit service users in the home. There are no service users who are able to administer their own medication. Medication is kept in two secure trolleys, one on the ground level that is kept in the clinical room. The second medication trolley is kept on the first floor and is securely attached to a wall just outside the matron’s office. There is a fridge in the clinical room for the storage of certain medicines and regular temperature records are kept for this. Photographs of service users, on medication charts, are used for identification. Qualified nurses administer all medications in the home. Several N.M.C. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 12 booklets are in place regarding the administration of medicines. There is a medication policy in place and this covers all areas detailed in standard 9. Following the previous announced inspection a requirement was made that that staff provide a signature for all medicines administered and the date that they were administered and it is pleasing to note that this has been complied with. Records of all medication received and returned are entered in a hardback book and when the medicines are returned the pharmacist signs stamps the book to verify the return. The home uses controlled drugs, and the controlled drugs register was looked at. This is completed with two signatures, is legible and up to date. All controlled drugs are stored in a metal cupboard, which complies with the Misuse of Drugs Regulations 1973.The home use oxygen cylinders and there is a separate policy and procedure for this. The manager is aware of the need to retain medication for a period of seven days after a service user has died. Service users receive care from staff and health care professionals in complete privacy. Adequate screening observed ensures complete privacy for the service users. Staff were observed during the inspection to knock on service users bedroom doors before entering. The homes Statement of Purpose includes information about maintaining the privacy of service user’s. Service users can have a key to their rooms if they wish. Preferred terms of address are recorded in service users care plans and likes and dislikes are recorded in most service users plans. The home has a policy and procedure for the care of the dying and death. It includes procedures for the expected and unexpected death of a service user. The manager has a training pack that she uses to undertake in-house training for care staff. Every effort is made to ensure that service users stay in the home, and importance is placed upon the comfort and care of a service user who is dying. The home involves the service users and their families, if appropriate, when trying to ascertain an individuals wishes regarding dying and death. This information is gathered as soon as is feasible. Staff are made aware of the needs of a service user who is dying during their induction period. The homes qualified nurses following an assessment by the G.P administer appropriate pain relief. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 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 Systems in the home ensure that where appropriate service users are supported to exercise choice and control over their lives. Service users are able to receive visitors at the home and there are no restrictions imposed on visiting unless requested by the service user. Service users are encouraged to bring personal possessions in with them allowing personal space to reflect the character and interests of its occupant. The presentation and standard of food is good and meets the nutritional needs of service users. EVIDENCE: Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 14 Care plans show routines of daily living and include bathing, rising and retiring times. Religious observance are recorded in care plans and service users interests are recorded in the initial assessment. Examples given of social activities that take pace in the home are a monthly church service, music sessions and the hairdresser visits regularly. One service user visits her local church weekly and family and staff support her to do his. Service users are able to receive visitors in the privacy of their own rooms and are able to choose whom they see and do not see. There are no restrictions on visiting, and this is documented in the Service Users Guide. Involvement by local community groups includes the local church, scouts group, regular visits by the hairdressers and barbers and various visiting entertainers. The home has no volunteers at the time of the inspection. Service users and/or their families are encouraged to look after their own financial affairs whenever possible. If this is not practicable a chosen solicitor will be responsible for an individuals financial dealings. An invitation to bring in personal items of furniture and other belongings is included in the service users guide and this was evident during a tour of the premises. When questioned about service users having access to their personal records, the manager said that this could be facilitated if it was requested. The menu’s demonstrate a choice of main meal and is based on a four weekly rotating menu. Service users are informed daily about the meal for the day. The main meal is served at lunchtime and the inspector sampled a lunchtime meal. The meal was tasty and well presented. Discussions with service users confirm that all meals are always of the same standard. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 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, 17 AND 18 The home has effective complaints procedures to ensure that service users or their representatives are listened to. The legal rights of service users are protected by the homes policies, procedures and protocols. Staff have a good knowledge and understanding of Adult Protection issues which protect service users from abuse. EVIDENCE: Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 16 The home has a complaints procedure. This includes timescales for responding to complaints and includes information regarding contacting the Commission for Social Care Inspection. The home has received four complaints since April 2005. These are well recorded and responded to within timescales. A summary of the complaints procedure is included in the Statement of Purpose and Service Users Guide. Voting can be facilitated for any service user that requests to do so. Postal votes are arranged and individuals can be taken to the polling stations by car if they wish to vote that way. The manager is aware of the POVA register and stated that she would submit staff for inclusion if it became necessary. Policies for whistle blowing and adult abuse are in place and observed to be reviewed regularly. Copies of both policies are kept in the nurse’s office for all staff to have access to. Adult Abuse Awareness training is covered in the homes induction policy. The inspector also looked at a policy regarding aggression towards staff from service users and was informed that this is covered during induction. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 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. Standards of cleanliness at the home are good ensuring that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. The home in its present condition is not adequate for its present purpose. However, there are plans to improve the home and extensive refurbishment plans are in place. This work will greatly improve most areas of the home providing service users with a comfortable, homely and safe environment for those living there and visiting. EVIDENCE: Sunnyside is a family run Nursing Home providing 24hr-nursing care for frail elderly people. The home offers thirty two beds, nine of these are double rooms and three are triple rooms. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 18 Sunnyside is situated in the village of Iver, close to shops and other amenities. The fabric of the home incorporates both new and old buildings. Bedrooms are situated on the ground and first floor and access to the upper floor is via a stair lift. This can provide moving and handling problems at the top of the stairs. However, with the proposed re-development of the home the stair lift will be replaced with a passenger lift. The internal decoration of the home is mainly in good repair, however some redecoration is needed in certain areas. Extensive refurbishment plans are due to take place in the near future. This work will provide extra bed capacity and eliminate the three-bedded bedrooms. The kitchen is clean, spacious and well looked after. The home has a large garden that is well-maintained and accessible to service users. There are no CCTV cameras in use within the home at the time of the inspection. There is one small dining room. This caters for approximately eight service users. Other service users eat their meals either in their rooms or in the lounges where they have been sitting throughout the day. Small tables are brought into the lounges at lunchtime for service users to eat their meals from. Refurbishment work will provide more appropriate dining space. The lounges are adequately decorated and there are personal touches around the home such as flowers, plants, books and pictures. Lighting in communal areas is domestic in character and sufficient to facilitate reading and other activities. There are quiet areas around the home where service users can meet visitors in private. A church service is held in the home on a monthly basis. The furnishings observed in communal areas are of good quality and suitable for the range of interests and activities preferred by service users. There are accessible toilets available for service users throughout the home and several are close to the lounges and dining area. All radiators have low temperature surface covers and are thermostatically controlled. Emergency lighting is provided throughout the home. Hot water control valves are fitted to all hot water outlets accessible to service users. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The laundry floor finishes are impermeable and these and the wall finishes are readily cleanable. The home has an infection control policy and the inspector observed this. Instructions are in place for the washing of soiled linen. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 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. Staffing numbers are adequate to ensure that the assessed needs of the service users are met. Service users benefit from a staff team who are up to date with their training, to ensure that staff are competent to do their jobs. There are effective recruitment procedures in place to ensure service users are protected from harm. Service users benefit from clarity of staff roles and responsibilities that results in a good quality care service being delivered. EVIDENCE: The duty rotas for the home were looked at. A mixture of full time permanent and regular relief registered nurses are employed in the home during the day and night. The home has just recruited a deputy manager, which is much needed. The home employs one senior carer and twelve care assistants. The morning shift consist of two RGN`S and five care assistants. The afternoon shift consists of one RGN and four care assistants. The night shift consists of one RGN`S and two care assistants. The home employs eight ancillary staff. This includes one full time cook and one weekend cook, one kitchen assistant, domestic staff and one handyman. There are no staff working in the home who are aged under 18 years of age. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 20 Progress is being made with NVQ training with care staff undertaking this training following the completion of the TOPPS Training. A random selection of staff files were made available for inspection purposes. All files looked at contained the necessary documentation as detailed in schedule 2. There is evidence that all staff CRB checks had been obtained. The home do not employ any volunteers. There is a policy regarding staff recruitment and this was found to cover all areas as detailed in standard 29. All new staff receive the TOPPS training within the first six weeks of appointment. There is evidence to demonstrate that all staff undertake mandatory training and this is updated as needed. Other training made evident includes Dementia Training, Continence Training, Nutritional Training and Diabetes Training. All staff receive a minimum of three paid days training per year. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 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, 32, 33, 34, 35, 36, 37 and 38. The manager is supported well by the staff team in providing clear leadership and demonstrating an awareness of their roles and responsibilities to the benefit of service users. The registered manager has a good understanding of the areas in which the unit need to improve. Health and Safety procedures are in place ensuring the safety of service users, staff and visitors to the home. The home operates a consistent approach to quality assurance resulting in the home being proactive in identifying issues that may effect the well being of services users. Policies and procedures are consistently implemented and monitored, thereby safeguarding the service users rights, health and best interests. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 22 EVIDENCE: The manager is a Registered General Nurse and has been the manager at Sunnyside Nursing Home for approx 2 years. The registered is in the process of completing her Registered Managers Award. Examples of further training include falls prevention, CPR and First Aid, wound care and nutrition. The manager is not responsible for any other registered establishment. The home operates regular monthly staff meetings for all staff. The manager tries to meet and talk to all service users on a daily basis. There is an equal opportunities policy in place and this was looked at during the inspection. The registered manager stated that a service users satisfaction questionnaire is sent out on an annual basis. Accidents, pressure sores and complaints are monitored regularly and there is evidence of this. There is a folder containing compliments and thank you letters, mainly from the relatives of service users. Notices were observed about the announced inspection. The homes policies and procedures files are extensive and evidence was seen of policies being updated. Regulation 26 visits by the proprietor are not received monthly by the Commission and this is a requirement of the report. Insurance certificates for the home are on display in the main reception area. Four service users receive personal money from family and this is looked after by the home. An administrator employed by the home undertakes all financial transactions. The manager does not undertake the role of appointee for any service users. Secure facilities are available for the safekeeping of valuables if required. There is evidence to demonstrate that staff receive formal supervision at least six times a year. Staff spoken to confirm that annual appraisals take place. Service users can have access to their records if they wish to. The care plans are informative and user friendly. The records maintained for health and safety are in good order. The homes policies and procedures are comprehensive and cover a wide range of issues. All confidential information is kept in secure areas of the home. Records were seen for fire safety. These are very comprehensive and up to date. A fire manual covers the homes fire procedures, practice fire drills, fire prevention, maintenance of escape routes, fire alarm testing, emergency lighting testing and door maintenance. There is a fire equipment log-book which is up to date. A generic fire risk assessment for the home is in place and there is evidence that this has been agreed with the fire officer. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 23 Service reports are in place for the maintenance of the lifts, hoists and electrical appliances and inspection and testing reports are in place for gas safety, water chlorination and kitchen hygiene. COSHH sheets are up to date and accurate. Risk assessments for the use of cot sides and service users who smoke are in place and observed by the inspector. The inspector looked at Infection Control guidelines that are available for all staff. The homes incident and accident book is completed legibly and a three monthly audit is undertaken of all accidents/incidents. Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 3 3 1 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 3 3 3 3 Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 1 33 26 2 19 23 The registered provider is required to undertake monthly Regulation 26 visits to Sunnyside 30/12/05 Nursing Home and send a copy of the report to the commission. (present timescale of 30/02/2005 not met.) The registered provider is required to ensure that all 30/03/07 previous requirements made regarding the environment are complied with when refurbishment work commences. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Sunnyside Nursing Home DS0000019254.V267167.R01.S.doc Version 5.0 Page 27 - 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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