Inspection on 27/06/06 for Sunnyside Nursing Home

This inspection was carried out on 27th June 2006.

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

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

Other inspections for this house

Sunnyside Nursing Home 27/08/08

Sunnyside Nursing Home 30/11/07

Sunnyside Nursing Home 15/05/07

Sunnyside Nursing Home 17/01/06

Sunnyside Nursing Home 01/09/05

Sunnyside Nursing Home 31/03/05

Sunnyside Nursing Home 08/11/04

Sunnyside Nursing Home 10/08/04

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

CARE HOMES FOR OLDER PEOPLE Sunnyside Nursing Home 6-8 Oxford Road Dewsbury West Yorkshire WF13 4LN Lead Inspector Tracey South Unannounced Inspection 27th June 2006 08:20 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 DS0000045066.V293588.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. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunnyside Nursing Home Address 6-8 Oxford Road Dewsbury West Yorkshire WF13 4LN 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) 01924 462951 01924 457870 northfields@leedscare.co.uk Northfields Care Homes Ltd Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Can accommodate two named service users under 65 years of age category DE. Can accommodate one named service user aged under 65 years of age category - DE MD PD. 17th January 2006 Date of last inspection Brief Description of the Service: Sunnyside is owned by Northfield Care Homes Ltd and provides nursing and accommodation for up to 30 people with dementia related care needs. The home is situated on the outskirts of Dewsbury, within easy access to the town centre. The home consists of a large detached building made up of two Victorian semi detached houses and a modern extension. There are single and double bedrooms available. There are four lounges, a dining room and a sun lounge. There is a passenger lift, which serves the ground and first floor. There are attractive gardens to the front of the house and car parking facilities for visitors. There is a separate unit within the home, which accommodates up to 6 residents with challenging behaviour. The unit is staffed separately to that of the main house with 3 care staff on duty during the day and 2 at night. The current charges at the home range from £347.00 to £1,700.00 per week. Additional charges are made for transport, physiotherapy, dentistry, ophthalmology, personal shopping services, dry cleaning and laundering outdoor clothing, bookshop services, private telephone and television, clinic appointments, telephone in room, cost of external outings, hairdressing, chiropody and toiletries. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006, the company, Northfield Care Homes Ltd, was bought out by new owners. The company status of Northfield Care Homes Ltd remains the same. Since the last key inspection on 17th January 2006 a further visit to the home was carried out on 22nd May 2006. The purpose of the visit was to follow up issues raised by the contracts compliance team at Kirklees Metropolitan Council. As a result of the visit, requirements were made in respect of care plans and staff training. Two inspectors carried out this inspection and spent approximately 8½ hours in the home. Alongside this, the staff at the home also completed a preinspection questionnaire, which was returned to the Commission before the inspection as requested. Information from this questionnaire was also used for this report. This inspection was carried out to assess the home against a pre-determined selection of the National Minimum Standards for Older People and to check if progress had been made on meeting the requirements from previous inspection visits. Residents were not able to comment directly about their care and support because of their level of dementia. Care practice was observed throughout the day. Inspectors spoke to management, care staff and ancillary staff. Records were examined and a tour of the home was also undertaken. Surveys were sent to residents, their relatives, visiting professionals and GPs. Ten surveys were sent out to residents, three responses were returned (all were completed by the resident’s relatives). Nine surveys were sent out to relatives, seven responses were returned. Seven surveys were sent to GP’s, two were returned. What the service does well: Information gathered at the pre-admission stage is thorough and enables staff to make an informed decision as to whether or not they will be able to meet the persons needs. Comments made in relatives ‘ surveys included, “I am very happy with Sunnyside, and the carers and all staff”, “I think they do a very good job in looking after my wife, thank you”. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 6 Staff were observed attending to residents in a kind and respectful manner. There was a good atmosphere at the home. Residents were seen walking around the home, one resident was playing the organ. There was a good “banter” between residents and staff. What has improved since the last inspection? What they could do better: Care plans and associated health care assessments must be reviewed more thoroughly. Any changes highlighted as part of that review must be reflected within the care plan and the appropriate action must be taken. Health care assessments in respect of oral hygiene and nutrition as well as manual handling and risk assessments must be completed in full. There are a number of areas within the home in need of redecoration. The owners have been requested to provide a redecoration programme including the timescales for completion. One relatives’ survey included the comment, “The fabric of the building (e.g. windows, gutters) appear to be in need of maintenance”. New staff must receive their induction training within the first 6 weeks of their employment. All staff should receive mandatory training with regular updates to help them look after vulnerable people. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 3. 6 does not apply. Residents are admitted on the basis that the home is able to meet their needs. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There was no evidence in the case files examined that residents received a contract at the point of moving into the home. One out of the 3 resident surveys returned indicated that they had received a contract. The new owners of Northfield Care Homes Ltd will implement their own contracts in respect of any new residents admitted to the home. A copy of the contract/terms of conditions was examined during the inspection. The contract outlines the services and facilities included in the fee and those that are not. The group manager was advised of a couple of items included in the contract that may need slight amendments to ensure there is no confusion between the paying resident and the company. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 10 Residents were asked as part of the surveys whether or not they received enough information about the home before they moved in. Two said yes they had, whilst one person said, “would like to have been put in the picture more before going in”. Prospective residents are assessed prior to them moving into the home. This is usually carried out either by the manager or a senior member of the team. The prospective resident is visited at their home or in hospital whichever applies. A pre-admission assessment is completed in respect of the prospective resident. This document is used to detail the person’s current needs and assist staff in making the decision as to whether or not they will be able to meet the person’s needs at the home. The pre-admission assessments examined were detailed and gave a good account of the person’s needs, including their likes and dislikes. There was evidence within the pre-admission documents that relatives had visited the home prior to the resident moving in. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The home must decide on the care plan format to be adopted. Residents have access to health care services. The medication systems in place have improved. Residents are treated with respect. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: As part of the surveys, residents were asked if they received the care and support they needed. Three responses were received which included, “always”, “usually” and “sometimes”. From the seven relatives’ surveys returned, five said they were satisfied with the overall care provided, two said no they were not and one relative replied “sometimes no, mostly yes”. Additional comments made included, “I am very happy with Sunnyside, and the carers and all staff”, “I think they do a very good job in looking after my wife, thank you”. There has been much debate about the standard of care plans at Sunnyside over the past 6 months. The Commission for Social Care Inspection has made requirements in previous inspection reports about the need to include the Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 12 social care needs of residents within the care plan. The contracts compliance team at Kirklees Metropolitan Council have also raised their concerns about the content of the care plans and the review process undertaken by staff. Lengthy discussions took place on the day of the inspection between the inspectors, the acting manager and the group manager. Whilst the Commission for Social Care Inspection does not dictate the format to be used by the home there is an expectation that the care plan reflects the resident’s health, personal and social care needs. The care plan including associated health care assessments must be reviewed on a regular basis, that is, at least monthly. Four resident’s case files were examined in detail. One resident’s care plan had been completed on a newly introduced format that resembled a “communal” type of care plan. There was no specific or individual needs included. It referred to the “service user” rather than the named individual. There was no clear indication when looking at the care plan of the level of support the person required in order for their needs to be met. A further three care plans were examined. Two of the three care plans were of a good standard and provided the reader with a detailed account of the resident’s needs and the level of support they required. The third care plan did not include enough detailed information. It was evident after speaking with staff and examining other documentation about the resident’s welfare and health care needs that specific issues had not been included in the care plan. The acting manager is developing the care plans to include the social care needs of residents, and there was evidence of this within at least two of the care plans examined. Progress in this area needs to continue. Although health care assessments are being reviewed on a regular basis, the actual review itself is not as thorough as it could be. The tissue viability nurse visiting the home at the time of the inspection pointed out that one Waterlow assessment (used to identify those people who are prone to developing pressure sores) was incorrect. It had identified the resident’s skin as healthy and intact when in fact the skin had broken down and a pressure sore had developed. The nursing staff had continued to fill in incorrect information on each review from April to June 2006. There was also evidence in one resident’s case file that the health care assessments had not been completed in full, certain sections had been left blank. A risk assessment in respect of one resident had not been reviewed for over 3 months when it was clear from reading the daily records that the situation had altered. Residents have access to health care services. Visits by GP’s and other health care professionals are recorded in the resident’s case file. The tissue viability nurse visiting the home spoke positively about Sunnyside. She feels that Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 13 improvements have been made in the way that nursing staff meet the needs of those residents who develop pressure sores. She explained how the home could be more proactive regarding preventative measures such as when to implement the use specialist equipment. It was also felt that the home would benefit from having its own alternating overlay mattresses used in the prevention and treatment of pressure sores. All three residents who returned their surveys said they always received the medical support they needed. The medication systems at the home have improved. Medical records examined were well maintained and easy to follow. All stocks of medication were correct in accordance with the records kept. All medication is accounted for when it is received in the home and surplus medication is accounted for and destroyed in accordance with health authority guidelines. The group manager explained how weekly audits of medication are now taking place to ensure medical records are kept up to date and well maintained. Staff were observed attending to residents in a kind and respectful manner. Two members of the care staff were clear about the importance of maintaining the privacy and dignity of residents. They were able to give examples of their understanding of respecting residents privacy and dignity. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 14 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 & 15 Residents are able to take part in organised activities. Residents are able to make their own choices about how they spend their time. Friends and family are made to feel welcome at the home and know that they can visit the home at any time. Residents receive a well balanced diet. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Two of the care staff are allocated 12 hours a week to organise and undertake activities in the home. Both staff had a good insight into the importance of undertaking meaningful activities with residents. The staff explained how they have been speaking with residents to try and establish any past hobbies as well as things they are interested in doing now. It was clear from the examples that were given that these staff had spent time with residents to get to know their interests, and activities have been tailored around this. One resident who is fond of animals was recently taken to a local pet shop, which she thoroughly enjoyed. Another resident was taken for a bar meal and enjoyed a pint of beer. Other outings have included a trip to the ice cream parlour. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 15 One resident was observed playing the organ in one of the communal lounges. The group manager explained how he used to play in a club and enjoys the opportunity to play from time to time. Staff explained that residents are able to choose when they get up and go to bed. Evidence of this was seen on the day, as during the morning handover there were a number of residents reported as in bed at 9am. Relatives are able to visit the home as they wish. Although the group manager said the home receives very little visitors. The reason why is not entirely clear. As part of the surveys relatives were asked if the staff/owners welcome you in the home at any time. All seven said yes they did. Relatives were also asked if they are kept informed of important matters affecting their relative/friend. Six relatives said they were kept informed whilst one relative replied “no not really”. Good progress has been made to ensure mealtimes are considered as a social event. It was encouraging to see both table covers and table decorations in place. Four staff were observed sitting down with residents supporting and assisting with feeding in a sensitive manner. The meal on offer was savoury mince cobbler, or scampi, served with salad, chips and vegetables, with cherry sponge and custard for dessert. Residents appeared to enjoy their meal, which was served in generous portions and well presented. Resident’s surveys indicated that they were happy with the meals at the home. Specialist diets are catered for. One resident follows a Kosher diet, instructions for staff referring to types of appropriate foods and how particular food items should be prepared was available in the kitchen. Sunnyside Nursing Home DS0000045066.V293588.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The complaints procedure does not reflect the current status of the company. This may confuse those people wishing to make a complaint. Residents are protected from abuse. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The complaints procedure was displayed in the foyer of the home. The procedure refers to the previous owner and manager. This may mislead people who wish to make a complaint. This needs to be addressed. The home must ensure that all complaints/concerns are recorded. A complaints/concerns log should be introduced which includes details of the complaint, any investigation that takes place, the outcome and any action taken. Such information must be made available for the purpose of inspections. Following requirements made as part of a visit to the home in May 2006, the majority of staff have now completed adult protection training. Three sessions took place during April, May and June 2006. Those staff spoken to had a good understanding of adult protection issues. The policies and procedures regarding protection of residents are in place. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Improvements to the décor of the home need to take place. Unpleasant odours are apparent in various parts of the home. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A number of the fixtures and fittings need replacing and the décor requires upgrading. A number of carpets within the home are heavily marked and need replacing. As the new owners have not been in situ for very long the Commission for Social Care Inspection feel it only fair to request that a maintenance programme be introduced. A copy of which should be made available to the Commission for Social Care Inspection. The programme should include timescales for completion. In the short time the new owners have been in place they have made a positive start to redecorating areas within the home. Two toilets have been Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 18 redecorated and the flooring has been replaced. Redecoration to the sun lounge is currently taking place. Resident surveys asked residents, is the home fresh and clean. Two residents said yes and one resident said it usually was. Unpleasant odours were noted in certain parts of the home. The group manager explained how the domestic staff do try to keep on top of this although it is difficult as some residents have continence problems. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 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): 26, 28, 29, 30 There are adequate numbers of staff employed at the home to meet the needs of the residents. The home’s recruitment procedures are robust. Not all staff have received the mandatory training they require to do their job, this has affected the quality rating for this outcome area. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Relatives’ surveys asked if there were always sufficient staff on duty. Four relatives said yes, two said no and one said they were unsure. There are currently 27 residents living at the home, 6 of which are accommodated on the challenging behaviour unit. The staffing levels are 1 trained nurse and 4 care staff on the morning shift, 1 trained nurse and 2 care staff on the afternoon shift. The night shift is consists of 1 trained nurse and 2 care staff. In addition to these staffing levels on the challenging behaviour unit are 3 staff during the day and 2 staff at night. There are 30 care staff employed at the home including bank staff, 13 (43 ) of which have a qualification at NVQ level 2 or above. The personnel files of three recently recruited staff were examined. The files were disorganised which made it difficult to find the relevant documents Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 20 required for inspection. However, there was evidence that employment checks had been carried out prior to the new person starting work in the home. It is recommended that the reference requests include the facility for the referee to date and sign the request, as there were some references that had not been dated or signed by the person completing it. Induction training is provided to all new staff. The records relating to two new staff were examined and there was very little evidence that the member of staff had received a thorough induction. A number of sections within the induction booklet remained blank. All new staff must receive induction training that meets National Training Organisation specification within the first 6 weeks of employment or within the first 12 weeks as from 30th September 2006 when the new Common Induction Standards are introduced. The management at the home have recently undertaken a training audit. The findings were that a number of staff have not received the mandatory training they need to carry out their jobs. The group manager explained that by October 2006 all staff will have received the appropriate training they need. Such training includes, health and safety, fire training, manual handling, food hygiene, first aid, infection control and adult protection. This will be monitored as part of future inspections at the home. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The home is run in the best interest of the residents who live there. Residents’ financial interests are safeguarded. There are good health and safety systems in place. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home does not have a registered manager in post. Since the last key inspection an acting manager has been appointed at the home. He is a Registered General Nurse and a Registered Mental Nurse who has worked in hospital settings, nursing a wide range of people, for over 15 years. He has also worked in nursing homes as an agency nurse whilst continuing his further education and personal development. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 22 It was clear from speaking to staff and the group manager that the acting manager is a well-respected individual. Staff spoke positively about him and said he was a caring person who had made changes in the home, which were for the better. The acting manager is resident focused with the intention of providing quality care at Sunnyside. He has recently spent a considerable amount of time implementing new care plans and although there is still some confusion about the format to be used, the Commission for Social Care Inspection do acknowledge the amount of time and effort he has spent on this. The group manager is responsible for carrying out visits to the home to form an opinion of the standard of care provided. A report is then produced, a copy of which is sent to the Commission for Social Care Inspection. The group manager spoke of how quality assurance systems will be introduced within the next 6-9 months. This will be looked into as part of the next key inspection at the home. Records of residents’ monies held in the home are kept and receipts for any purchases made on the residents’ behalf are available. Two residents’ monies were checked against the records kept, both of which were correct. There are good health and safety systems in place and regular checks such as fire alarm tests, fire drills, gas safety checks and the servicing of equipment are carried out. COSHH (Control of Substances Hazardous to Health) assessments were seen in place although they had not been reviewed for a considerable amount of time. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 23 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 1 X X X X X X 2 STAFFING Standard No Score 27 X 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Timescale for action The care plan format needs to be 30/08/06 decided but more importantly each resident must have a care plan in place, which includes their health, personal and social care needs. The care plan must be kept under regular review. The reviews must be thorough and changes in the resident’s needs must be recorded and acted upon. Associated assessments must also be kept under regular review. A redecoration programme needs to be implemented. The programme must include timescales for completion. All staff must receive training appropriate to the work they are to perform. All new staff must receive induction training that meets National Training Organisation DS0000045066.V293588.R01.S.doc Requirement 2. OP19 23 30/08/06 3. OP30 18 30/08/06 4. OP30 18 30/08/06 Sunnyside Nursing Home Version 5.2 Page 25 5. OP33 24 specification within the first 6 weeks of employment or within the first 12 weeks as from 30th September 2006 with the introduction of the new Common Induction Standards in accordance with Skills for Care. A quality assurance tool used to seek the views of residents, relatives and any other professionals must be introduced within the next 6-9 months. 30/04/07 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. 3. 4. 5 Refer to Standard OP19 OP28 OP29 OP29 OP38 Good Practice Recommendations A copy of the redecoration programme should be made available to the CSCI. The home should continue working towards achieving 50 of the workforce qualified at NVQ level 2 or above. Staff personnel files should be better organised to enable easy access to relevant documents required for the purpose of inspection. The reference request forms should be amended to include the date and signature of the referee. COSHH (Control of Substances Hazardous to Health) assessments currently in place should be reviewed to ensure they are still relevant. Sunnyside Nursing Home DS0000045066.V293588.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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. 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