CARE HOMES FOR OLDER PEOPLE
Sunnyside Residential Home Crewkerne Road Chard Somerset TA20 1EZ Lead Inspector
Ms Sue Hale Unannounced Inspection 09:05 3 January 2007
rd 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 Residential Home DS0000057862.V317693.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 Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Sunnyside Residential Home Address Crewkerne Road Chard Somerset TA20 1EZ 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) 01460 61623 Mrs Shirley Ann Pontefract Mrs Shirley Ann Pontefract Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd March 2006 Brief Description of the Service: Sunnyside provides services for up to 14 residents under the registration category of Older People. The registered provider and manager is Mrs Ann Pontefract. The home is close to the centre of Chard. There is a large supermarket nearby and the amenities of the town centre are within walking distance for those physically fit and who have awareness of dangers from traffic. The home provides residential services on two floors. The first floor is accessed by a passenger lift. The registered manager lives on the floor above. Outside there is a drive leading to the front door and car parking area. There is a small garden area with a patio at the end of the drive. This area is protected from the main road by a high hedge. The main garden is at the back of the property with access on both sides. Side paths have been made safe with gates because of the busy road. Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the first key inspection of Sunnyside Residential Home using the Inspecting for Better Lives methodology introduced by the Commission for Social Care Inspection in April 2006. The inspection methodology used by the Commission for Social Care Inspection enables the inspector to make a judgement on the quality of the service delivery based on the outcomes for residents. Selected staff and residents files were looked at and other documents relevant to the running of the home such as policies and procedures. A tour of the premises was undertaken and the inspector took lunch with the residents and watched the karaoke sing-along. Surveys were sent out to relatives/visitors to the home, care staff and residents. Eight were returned from relatives/visitors, three from staff and ten from residents. The comments made are incorporated into this report. The inspector spoke to all members of staff on duty on the day of the inspection, several residents, the owners/registered providers Mr and Mrs Pontefract. The current fee levels are from £360 to £400 per week. What the service does well:
The home produces a statement of purpose/service user guide that is readily available in the home. All residents are given terms and conditions of residency which are clear and written in plain English. A copy of the latest CSCI inspection report is kept in the entrance hall and is readily available for residents and visitors to the home. The needs of prospective residents are fully assessed before they move into the home. The home encourages and supports them to visit and spend time at the home before they make a decision about residency. Care plans are detailed and clear and cover all aspects of residents’ health, social care needs. Residents and their relatives/representatives are fully involved if they wish to be in the care planning of review process. Risks were managed well and took into account residents’ aspirations for independence and choice. The home works to an efficient medication policy supported by procedures, training and practice guidance.
Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 6 Residents are treated with respect and their right to privacy is a key principle of the homes aims and objectives, this is detailed in the service user guide. The home supports and encourages residents to maintain their independence and to make their own decisions about what they do each day. A resident said that the home offered ‘quality care and support’ to them and another resident commented that they were ‘very lucky to be here and well looked after’. The routines of the home are usually very flexible and planned around the residents’ needs and wishes. A good range of activities inside the home and within the local community available and tailored to suit the residents’ choices and needs The home has a clear complaints procedure that is clearly written and easy to understand. Residents are confident of their right to raise any problems or complaints and those will be listened to and action taken. The home has adult protection policies and procedures that safeguard residents. Contact with residents relatives/representatives is encouraged and all visitors made welcome. The overwhelming majority of responses from relatives/visitors to the home were very positive. One relative/visitor to the home said that they felt that ‘Sunnyside is an excellent home where the owner and staff make the place feel like home’. Another said that the home provides ‘excellent quality care and support’. Residents are very satisfied with the quality and variety of meals served at the home. Residents were very pleased with the special celebrations that had taken place at Christmas and appreciated efforts made by Mr and Mrs Pontefract and staff. They had all received a ‘lovely’ present and mealtimes had been special with a ‘lovely Christmas dinner and chocolate log’, and wine and spirits of their own choice. The home is very well maintained and provides a homely, safe and comfortable environment for the residents. Residents are very satisfied with the standards of their rooms and are encouraged to personalise it in line with their own choices and preferences. They are able to bring in small items of furniture and personal belongings within the space constraints of the room. Aids and adaptations are provided in line with individuals needs. Appropriate laundry facilities are provided and infection control procedures to protect residents are in place. Staff surveyed and spoken to were very positive about working at the home and staff were confident that they were offered the training they needed to do their job well. Residents have confidence in the staff that looks after them. Sufficient numbers of staff are employed to meet residents’ needs. Staff are
Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 7 paid to attend training courses and the home pays the course fees. Staff have completed several training course via distance learning since the last inspection. The home benefits from the strong, positive leadership of Mrs Pontefract and both staff and the residents are confident in the way the home is managed. Financial procedures protect and safeguard residents. The health and safety of residents and staff were safeguarded by the homes policies and procedures. All necessary checks and servicing of equipment were in place, What has improved since the last inspection? What they could do better:
The statement of purpose must include all the matters listed in schedule 1. (This refers to the size of rooms available, the number of staff qualified to NVQ level, the type of needs that the home is registered for i.e. older people with personal care needs only) .The terms and conditions of residency should make clear the fees payable and by whom and that complainants are able to contact the CSCI at any stage of a complaint. The home should consider obtaining a nutritional risk assessment tool and using this for all residents on admission and as necessary thereafter. Consideration should be given to obtaining sit on scales so that all residents’ weights can be monitored. The complaints procedure should make clear the complainants are able to contact the Commission for Social Care Inspection at any stage of a complaint. It should also be updated in the service user guide information and the contract.
Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 8 The finance policy should make it clear that staff should not assist with or benefit from residents wills. Recruitment checks must be improved to safeguard the residents. New staff must not start work unless two references have been received and a satisfactory POVA first check has been received. The home should continue their efforts toward proving staff competence through NVQ training or its equivalent and have a system to check their competence in the mean time. 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. Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 9 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 Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 10 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides information to prospective residents, their relatives and funding authorities about the services it offers. All residents are given a terms and conditions of residency that is clearly written in plain English. The needs of prospective residents are fully assessed before they move into the home. The home encourages and supports them to visit and spend time at the home before they make a decision about residency. Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 11 EVIDENCE: The home produces a joint statement of purpose/service user guide that gives prospective residents, their relatives, representatives and funding authorities information about the home. Whilst is was reviewed and updated in October 2006 it requires further minor review to include all the information required and recommended in the national minimum standards. All residents are given a contract of the terms and conditions of occupancy. The contract is clearly written in plain English. This does not make clear the fees payable and by whom. The information about complaints in the contract should make clear that complainants are able to contact the CSCI at any stage of a complaint. The home considers carefully the needs assessment for each prospective resident before agreeing admission. Mrs Pontefract visits prospective residents in hospital or wherever they are staying to undertake a pre admission assessment and make sure that the home can is suitable for the individual. Prospective residents and their family, always have the opportunity to visit and spend time in the home before they make a decision about moving in. A copy of the funding authorities assessment and care plan is always obtained and taken into account in care planning The manager stated that enquires and admissions were welcome from all members of the local community and that individuals needs would be assessed and met. Opportunities for residents to share rooms if they chose to was respected and supported by the staff team. Staff were described by a residents as ‘very good’ and ‘very efficient’. Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 12 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are detailed and clear and cover all aspects of residents’ health, social care needs. Residents and their relatives/representatives are fully involved if they wish to be in the care planning of review process. Risks were managed well and took into account residents’ aspirations for independence and choice. The home works to an efficient medication policy supported by procedures, training and practice guidance. Residents are treated with respect and their right to privacy is a key principle of the homes aims and objectives. Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 13 EVIDENCE: All residents have a care plans that is clearly written and gives detailed instructions to staff on how residents health, social and care needs are to be met. Management of risk takes into account the needs of residents balanced with their aspirations for independence and choice. Records showed that care plans were reviewed monthly and updated as necessary. Residents’ weights were recorded if they were able to stand on normal scales. The home did not have a nutritional risk assessment tool available. Staff actively promote the residents right of access to the health or remedial services that they need, both within the home and in the community. Records showed that the home arranges for health professionals to visit frail residents in the home and that staff keep a regular check on health aids, making sure they are working effectively and each resident has the necessary aids to improve their quality of life. Residents spoken to and surveyed confirmed that they were able to access medical and healthcare as needed. The home takes residents to see their G.P.s or district nurse at the health centre if at all possible. Equipment to reduce the risk of pressure sores was in place Residents have choice over their personal care and are encouraged to be independent and responsible for their own personal hygiene where possible, although support is always available when required. The need to respect resident’s privacy and dignity when delivering health and personal care is an important principle of the homes care practice. Record showed that care plans had been signed by residents and their relatives to confirm their agreement. Residents are supported to look after their own medication if they wish to. The home takes this responsibility if they choose not to or are unable to do so safely. Medicines are handled in a safe way, and records demonstrate an understanding of safe practice. Staff receive training in how to administer and handle medication and there was evidence of GP review as appropriate. Residents confirmed that staff are polite, knock before entering their room, they are treated with respect and that their privacy is upheld. Contact between residents and staff was friendly and unhurried. Sunnyside Residential Home DS0000057862.V317693.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Activities inside the home and in the community are tailored to residents’ choices and preferences. The routines of the home are usually very flexible and planned around the residents’ needs and wishes. Contact with residents relatives/representatives is encouraged and all visitors made welcome. The home supports and encourages residents to maintain their independence and to make their own decisions about what they do each day. Residents are very satisfied with the quality and variety of meals served at the home. Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 15 EVIDENCE: Residents were generally very satisfied with the home, confirming that they are able to make daily lifestyle choices. Staff work hard to meet individual tastes and needs. They were observed assisting and supporting residents to live as they wish. Some residents told the inspector that they were woken early in the morning (6am) when a particular member of staff was on night duty. This was confirmed by checking the records in the kitchen of when cups of tea were taken around. Mrs Pontefract was unaware of this practice and assured the inspector that residents would only be taken early drinks if that was their wish and it was recorded in the care plan. The home provides a programme of activities including arts, crafts and entertainment and the sitting room is very homely. The ‘sun lounge’ provides a more private space if preferred. Residents confirmed that the garden is well used in the warmer weather, and spoke of activities enjoyed out side of the home. Visitors are made welcome, work closely with the staff in the best interest of residents, and there are no visiting restrictions. One resident said that they ‘liked the days out with the other residents’. Another resident confirmed that they were always asked if they wanted to go out on the trips. Some residents had been to the theatre before Christmas to a concert. Residents’ religious choices were respected and the vicar was in the home on the day of the inspection to offer communion to those who wanted to take part. Residents spoken to were very pleased with the activities and arrangements over Christmas and were very pleased with the celebrations organised by Mr and Mrs Pontefract. On the day of the inspection several residents were enjoying a karaoke sing-along with Mr Pontefract. Food is considered to be highly important and mealtimes considered as a social occasion. Mealtimes were seen to be relaxed, and staff were patient and helpful allowing residents the time they needed to finish their meal comfortably. The menu was varied, balanced and nutritious and took into account residents likes and dislikes. Residents spoken to were very satisfied with the standard of food served at the home. It was described as ‘very good at all times’. The inspector took lunch with the residents and condiments were available and residents were offered ‘seconds’. A visitor who had observed the food served at the home described it as ‘excellent’ and said that the home often ‘smelt of home baking’ when they visited. Residents are able to take their meals in the dining room or in their room. Relatives/visitors to the home confirmed that they are encouraged to visit and one person said that Sunnyside was ‘very, very welcoming to relatives and friends, it feels like home from home’.
Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 16 Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 17 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. The home has a clear complaints procedure that is clearly written and easy to understand, it needs minor review to meet the national minimum standards. Residents are confident of their right to raise any problems or complaints and that they will be listened to and action taken. The home has adult protection policies and procedures that safeguard residents. Greater vigilance is needed in the recruitment process to make sure the necessary checks are done before new staff starts work. EVIDENCE: The home nor CSCI have received any complaints since the last inspection. The home has a complaints policy that is included in the statement of purpose/service user guide and available to residents, their relatives and representatives. The complaints policy does not make clear the complainants are able to contact the Commission for Social Care Inspection at any stage of an investigation. Residents spoken to and surveyed were very clear that they could complain or raise any concerns with Mrs Pontefract or other staff and
Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 18 that they would be listened to. All residents confirmed that they felt safe and well looked after in the home. Since the last inspection Mrs Pontefract has attended training on the protection of vulnerable adults and this training has been passed on to all staff using a video and by staff undertaking written work, which is verified by the manager. A recommendation from the last inspection report that the policies on the prevention of abuse and whistle blowing should contain the contact details of the local authority vulnerable adults team has been addressed. The homes finance policy makers are clear that staff should not accept gifts from residents but does not make clear that staff should not assist with or benefit from residents wills. Mrs Pontefract stated that new staff were not employed at the home unless a satisfactory POVA First and CRB disclosure was received. However, on checking staff files it was clear whilst an application had been made, one member of staff had been working in the home before the POVA First check had been received. Mrs Pontefract was unaware that the regulations had changed and that CRB disclosures were no longer portable from previous employment. Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 19 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, 23, 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 home is very well maintained and provides a homely, safe and comfortable environment for the residents. Residents are very satisfied with the standards of their rooms and are encouraged to personalise it in line with their own choices and preferences. Aids and adaptations are provided in line with individuals needs. Appropriate laundry facilities are provided and infection control procedures to protect residents are in place. Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 20 EVIDENCE: Sunnyside provides a very well maintained, safe, comfortable, attractive home, which has all the specialist equipment and adaptations needed to meet individual residents needs. The home is furnished and decorated to a good standard and Mr and Mrs Pontefract and the staff work hard to promote a homely atmosphere for residents and their visitors. Residents are encouraged to bring their own possessions and small items of furniture into the home and to personalise their private rooms to their own choice. The home was clean and tidy on the day the inspection and there were no unpleasant odours. Residents spoken to confirmed that their bedrooms were regularly tidied and cleaned by staff but that staff respected the individual way that they want their rooms maintained. A visitor to the home described that home as ‘always spotlessly clean’ The garden includes a pond, apple tree, seating, shrubs and a bird table and residents said that it is well used and enjoyed in the warmer weather. The home has level access throughout; the manager confirmed that staff are always available when residents choose to use the garden. One resident spoken to was a keen gardener and birdwatcher before moving into the home and she had been supported to use the conservatory and to take responsibility for putting out food for the birds. There is a choice of bathing facilities and a number of toilets strategically placed around the home. Laundry facilities are provided in outbuilding at the rear of the home. The home has an infection control policy that is up-to-date and accessible to all staff. All residents spoken to him said that their clothes were returned promptly and in good condition from the laundry. The temperature of the water in all outlets is regularly checked and recorded. Fire safety is correctly managed through staff training and the provision, maintenance and testing of fire safety equipment. Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 21 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, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have confidence in the staff that looks after them. Sufficient numbers of staff are employed to meet residents’ needs. Recruitment procedures need to be improved to safeguard residents. The number of qualified staff is low although plans are in place to resolve this. EVIDENCE: A weekly staff rota was in place that showed each members of staff job. Mrs Pontefract acknowledged that on some occasions at weekends there had been a minimum number of staff available due to long-term sickness and current vacancies. Vacancies had been advertised for a cleaner and weekend and evening care staff. All staff were aged 18 or over and all senior staff were aged 21 or over. All residents spoken to were very positive about the staff and the care they receive. The files of the three new members of staff were checked. All files contained a photograph of the employee. One file contained a reference supplied by the applicant that had not been verified by the manager. One member of staff had started work in the several days before the POVA first check had been received
Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 22 and the same file contained only one reference. The development of a checklist for in staff files was discussed with Mrs Pontefract. The home employs nine care staff, only one of which is qualified to NVQ level 2.However, four staff are currently registered on NVQ level 2 courses and the manager stated that she felt progress was being made within the staff team and that they were committed to obtaining qualifications and new skills. All new staff completes a detailed induction programme. All staff surveyed was very positive about working at the home and confirmed that they were encouraged and supported by the Mrs Pontefract to go on training courses. One member of staff said that they were doing NVQ 2’ training something I didn’t think was possible for me’. Staff are paid to attend training courses and the fees are paid by they home. Staff have completed several distance learning courses since the last inspection. Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 23 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): 31,32,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides leadership, knowledge and an approach that promotes residents’ wellbeing. Residents’ financial interests are safeguarded by practices at the home. Health and safety policies and practise safeguarded residents and staff. Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 24 EVIDENCE: Residents’ benefit from a caring and very experienced manager who has a Diploma in Management Studies and is committed to the provision of a quality life for residents. Staff spoken to and surveyed was very positive about Mrs Pontefract and the support and encouragement that was offered to them. One member of staff said that they had never been asked to do anything they weren’t confident about. All staff spoken said that Mrs Pontefract was always available for advice and support. All but one survey response from relatives/visitors to the home was positive about the way that the home is managed and run by Mrs Pontefract and the staff. Those residents able to look after their own financial affairs are supported to do so. Some ask the home to keep money and valuables for them. The arrangements for this were secure, with records kept of all transactions Whilst there are no formal quality assurance systems in place residents confirmed that their views are sought and listened to. Referrals have been made to the home by stakeholders such as G.P.s and nurses who have confidence in the quality of care provided. Regular meetings are held with staff and records kept. Advice was given by the inspector in relation to the Data Protection Act 1998 and how information discussed in the meetings should be recorded. Ways of improving quality assurance systems were discussed with Mrs Pontefract. Certificates and documentation was seen in relation to maintaining the equipment and health and safety of residents and staff. An accident book was kept and records checked were correctly recorded. Sunnyside Residential Home DS0000057862.V317693.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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 17 18 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 3 3 X 3 Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP1 Regulation 4(1)(c) Requirement Timescale for action 30/04/07 2 OP27 The statement of purpose must include all the matters listed in schedule 1. (This refers to the size of rooms available, the number of staff qualified to NVQ level, the type of needs that the home is registered for i.e. older people with personal care needs only) 01/02/07 Regulation The registered person shall not 19 (1) (b) employ a person to work at the (i) (5) care home unless they have (d)(i) obtained the information and Schedule documents required. (This refers to (7) to the member of staff who started work before the POVA First check had been received and one staff file that only contained one reference, and a reference that have been supplied by the applicant and not verified). Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 27 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 Refer to Standard OP2 OP8 OP16 Good Practice Recommendations The terms and conditions of occupancy should be reviewed to make clear the fees payable and by whom (i.e. the resident or local authority). The home should consider obtaining a nutritional risk assessment tool and using this for all residents on admission and as necessary thereafter. The complaints procedure should make clear the complainants are able to contact the Commission for Social Care Inspection at any stage of their complaint. This should also be reviewed in the statement of purpose/service user guide and the residents contract. It is recommended that the home consider purchasing sit on scales so that all residents weight can be monitored. The finance policy should make it clear that staff should not assist with or benefit from residents wills. The home must continue to work towards achieving the minimum ratio of 50 members of care staff qualified to NVQ level 2 (or equivalent) at the earliest opportunity. Consideration should be given to introducing formal quality assurance systems to evaluate the services provided by the home. 4 5 6 7 OP8 OP18 OP28 OP33 Sunnyside Residential Home DS0000057862.V317693.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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
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