Inspection on 06/10/05 for Sunridge Court

This inspection was carried out on 6th October 2005.

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

Sunridge Court 10/05/06

Sunridge Court 21/06/05

Sunridge Court 04/11/04

Sunridge Court 25/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Sunridge Court 76 The Ridgeway Golders Green London NW11 8PT Lead Inspector Tom McKervey Unannounced Inspection 6th October 2005 10:15 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 Sunridge Court DS0000010526.V251136.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. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sunridge Court Address 76 The Ridgeway Golders Green London NW11 8PT 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) 020 8458 3389 020 8455 0902 Sunridge Housing Association Mrs Pamela Venita Darroux Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Eight specified service users who are diagnosed with dementia may remain accommodated in the home for so long as the home is able to meet their needs. The home must advise the registering authority at such times as any of the specified service users vacates the home. 21st June 2005 Date of last inspection Brief Description of the Service: Sunridge Court, which is owned by Sunridge Housing Association, provides care and support for up to 46 older people, male and female, from the Progressive Jewish Community. The building has three storeys, with accommodation on the first and second floors for the more independent service users. All rooms have en-suite facilities. The majority of this group of service users live quite independently and have a very active lifestyle. Some of these service users still drive their own cars. There is a ten-bedded area, referred to as “the care unit”, on the lower ground floor of the home, which accommodates service users who are more frail, and require more support. Some of these service users have dementia. There is a separate small dining area provided for this group. There is a large dining room, a lounge and conservatory, on the ground floor. The administration area and an office are situated on the third floor. There is a large attractive garden at the rear, and a car park at the front of the premises. The home is situated in a pleasant area of Golders Green, and shops, restaurants and other amenities are a short distance away. The home is easily accessible by public transport. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of five hours and fifteen minutes. The registered manager was present throughout the inspection and gave fully assisted in the process. The inspection consisted of a tour of the premises, including visiting some residents in their bedrooms. In all, some ten residents were spoken to at length about their experience of living in the home. Four relatives and six staff were also spoken to. These interviews were conducted independently of the management. In addition, residents’ records and other documents relating to the efficient running of the home were examined. What the service does well: What has improved since the last inspection? A post of domestic supervisor has been created to ensure the high standard of cleanliness and hygiene in the home. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 6 Residents’ care plans are now reviewed on a monthly basis, and some maintenance requirements from the last inspection have been addressed. Staff recruitment and screening procedures have improved. 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. Sunridge Court DS0000010526.V251136.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 Sunridge Court DS0000010526.V251136.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): 4 & 5. Standard 6 does not apply to this home. The home provides a culturally sensitive service that fully meets the particular needs and expectations of the residents. EVIDENCE: The home only admits people from the Jewish community, which meets the expectations of the residents. Their religious and cultural needs are met by the provision of appropriate meals and religious services. For example, there is a synagogue provided within the home. A separate area in the home is provided for the care of more frail residents, some of whom have dementia. However, these residents also have access to all parts of the home. The home also admits married couples and has provided double rooms for this purpose. The home enjoys a very good reputation in the Jewish community, and several residents and relatives who were spoken to, said that they had learned of the home by word of mouth. They also said that they were able to visit the home prior to moving in. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 9 Sunridge Court DS0000010526.V251136.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 Residents’ individual needs are assessed and met through good care plans that are kept under review. The healthcare of residents is safeguarded and they are treated with respect and dignity. The administration of medicines EVIDENCE: Four care plans were sampled. The plans were well structured and provided advice for staff about how to meet assessed needs. The care plans were being reviewed on a monthly basis as required by this standard. Residents’ blood pressure is monitored monthly and there are records of hospital appointments and visits by the G.P and district nurse. Residents said that they were well cared for by the staff, but there were some concerns expressed about the G.P, which is addressed under the complaints section of this report. Several service users self-administer their medication, and there were appropriate documents in place from the G.P to support this practice. There are still problems in the records of the administration of medicines. In some cases, when a medication was not given, the code was either not entered Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 11 in the MAR sheet or it was the wrong code. This was a particular problem in the care unit. A requirement is made to address this issue. Residents said that they were always treated with respect and dignity, especially when personal care was being given. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 12 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 & 15 The residents enjoy a very good quality of life in the home, and their cultural, social and religious needs are being met. The food provided is of a high standard, and the range of choice available to residents is excellent. EVIDENCE: A varied activities programme was in evidence, which included weekly musical movement, topical discussion groups and keep fit sessions. Outside entertainers are also employed and trips are organised to places of interest. There is a strong emphasis on observance of Jewish religious and other holidays, and there is a synagogue in the home. The visitors’ book records visits by friends and relatives, some of whom the inspector met during the inspection. They said that the staff always treated them cordially. Many residents described their experience as, “like living in a hotel”. Another comment from a relative; “I don’t know what I would do without this place”. The menus showed a good variety of meals with plenty of choice. There were forms available each day in the dining room, for residents to indicate their choice of meals. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 13 The dining room provides a pleasant environment, with side tables containing condiments to supplement the meals. A fridge in the dining room contained residents’ personal items of food. Separate meetings are held between the chef and residents to discuss the catering and sort out any concerns about the food. All of these elements contribute to this standard being exceeded. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 14 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 Residents’ complaints about the home are addressed properly and resolved within appropriate timescales. However, problems with the G.P service need to be raised with the appropriate authorities. However, residents’ welfare and best interests are not being properly protected because disciplinary procedures about allegations against staff are not being properly followed. EVIDENCE: The complaints book contained minor complaints, which had been appropriately addressed and resolved by the manager through the complaints procedure. However, some residents and a relative said that they were not happy with the service provided by the G.P, who was described as abrupt, always in a rush and insensitive to the residents. The manager informed the inspector that these criticisms had been made before and she had raised them with the practice. A requirement is made for this issue to be brought to the attention of the Primary Care Trust on behalf of the residents as a complaint. The manager informed the inspector about a serious matter, which concerned allegations about theft of property from the home by a member of staff who had since left. Although an investigation had been carried out, the inspector was concerned that the home’s disciplinary procedure had not been followed thoroughly and a requirement is made about this issue. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 15 In addition, these allegations had not been reported to the police, and an immediate requirement was made for this to be done by the day after the inspection. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 16 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 Residents live in a home that is very clean and generally well maintained, and enjoy a comfortable and pleasant environment. A survey needs to be carried out into the cracked paving around the building. EVIDENCE: A tour of the premises was carried out. The home was well maintained and there was a good standard of décor throughout the home. It was noted that there were several large and deep cracks in the paving around the side and rear of the building. A requirement is made for a surveyor to assess this problem and for the home to implement any actions identified in the surveyor’s report. At the time of the inspection, there was a high standard of cleanliness and there were no offensive odours. A new post of domestic supervisor had been created. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 17 Staff were seen to be wearing disposable gloves and aprons appropriate to the tasks they were performing. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 & 30 There are always sufficient numbers of staff on duty to meet residents’ needs and residents are protected by thorough recruitment practices. EVIDENCE: The staff rotas showed that there is normally five staff on in the morning, three in the evening and three waking night staff plus a senior carer on each shift during the week. The rotas indicated that this level of staffing is maintained at the weekends. In addition, there are cleaning staff, a cook, a maintenance person and an administrator. At the time of the inspection, eleven staff had attained National Vocational Qualification level 2, three had level 3 and one had level 4. The records of a new member of staff showed that proper recruitment procedures had been used and appropriate checks had been carried out. There is a staff development plan, which identifies training courses for the year; for example, induction and foundation in care, and dementia care. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 19 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 & 36 The home is well managed and residents’ care is provided by a dedicated group of staff that are regularly supervised. EVIDENCE: There was a relaxed and cordial atmosphere in the home during the inspection. The registered manager has been in charge of the home for approximately three years and has attained the Registered Managers Award at NVQ level 4. Residents, relatives and staff who were spoken to, were very complimentary about the manager and her ability in running the home. She was described as very caring and approachable. Various management responsibilities are delegated to senior carers. The manager demonstrates diligence and competence in addressing performance issues with staff. All staff receive regular supervision by the manager or senior carers. Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 20 Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 21 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 X X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 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 3 3 X X X 3 X X Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 22 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 OP9 Regulation 13(2) Requirement The registered person must ensure that the correct codes are entered in the MAR sheets when medication is not given. This requirement is restated. The previous timescale was 31/8/05 The registered person must raise residents’ concerns about the G.P service with the appropriate authorities. The registered person must inform the police about the alleged theft of property from the home. This is an immediate requirement. The registered person must ensure that the home’s disciplinary procedure is adhered to at all times. The registered person must have a survey of the paving around the building and implement any recommendations of the surveyor. Timescale for action 30/11/05 2 OP16 22(3) 31/12/05 3 OP18 13(6) 07/10/05 4 OP18 13(6) 30/11/05 5 OP19 23(2)(b) 31/12/05 Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 23 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 Sunridge Court DS0000010526.V251136.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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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