Inspection on 13/08/09 for Sunrise Operations Bassett Ltd

This inspection was carried out on 13th August 2009.

CQC found this care home to be providing an Adequate service.

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

Sunrise Operations Bassett Ltd 16/02/09

Sunrise Operations Bassett Ltd 29/02/08

Sunrise Operations Bassett Ltd 27/03/07

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Sunrise Operations Bassett Ltd 111 Burgess Road Southampton Hampshire SO16 7AG Lead Inspector Nick Morrison Key Unannounced Inspection 13th August 2009 09:30 DS0000068064.V377345.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunrise Operations Bassett Ltd Address 111 Burgess Road Southampton Hampshire SO16 7AG 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) 02380 706050 02380 706051 Sunrise Operations Bassett Ltd Manager post vacant Care Home 29 Category(ies) of Dementia (0) registration, with number of places Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia (DE). The maximum number of service users to be accommodated is 29. Date of last inspection 21st April 2009 Brief Description of the Service: Sunrise Operations Bassett Ltd is a residential home registered to provided care and accommodation for up to twenty-nine older people with Dementia. The home is situated on the second floor of a large complex, the lower three floors (terrace, ground and first) being a registered care home with nursing for up to seventy-five older people. Bedrooms are predominately single although some twin rooms are available. Open plan communal rooms and a relaxation room are provided, as is an enclosed roof terrace. Access to the unit is achievable via the stairs or alternatively the passenger lift and the facilities of the entire ‘community’ are available to the ‘reminiscence’ clients, although this is reliant on sufficient staff being available to accompany people outside of the ‘reminiscence’ environment. The Provider is Sunrise Operations Bassett Ltd and at the time of the inspection visit the home did not have a registered manager. Additional charges are made for hairdressing, chiropody, manicure, newspapers and some other services. Full information about current fees is available from the home. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection of this service took place at the same time as the inspection of the other registered service that is in the same building. The two registrations were inspected separately by different Inspectors. However, some aspects of the two services such as meals, staff recruitment and training, some management issues and maintenance were managed centrally for both registered services. These were inspected for both services by one Inspector. The Manager of the two services informed us that the organisation is planning to register both current services as one single service in the near future. At present there is one Manager for both services, however she is not yet registered. One member of staff has responsibility for managing the service upstairs, to which this report relates. She is referred to in this report as the Assistant Manager. This report represents a review of all the evidence and information gathered about the service since the previous inspection. This included a site visit that occurred on 13th August 2009 and lasted six hours. During this time we looked around the premises, looked at the files of four service users, spoke with two of them and observed the support they were receiving. We also met the Assistant Manager, spoke with two members of staff and one relative and observed interaction between staff and service users. All records and relevant documentation referred to in the report was seen on the day of the inspection visit. What the service does well: The service provides very good facilities in a homely, comfortable, wellmaintained and clean home. Staffing levels reflect the needs of people living in the home and staff seen on the day of the inspection visit were energetic and focussed on providing a stimulating environment for people living in the home. Service users are treated with respect, their right to privacy is upheld and their healthcare needs are met. The food provided in the home is good and takes account of individual needs and wishes. There is an effective quality assurance in place in the home that takes account of the views of service users and their families and develops an improvement plan based on those. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from having their needs assessed prior to moving into the home and have the information they need about the service. EVIDENCE: We looked at the files of four people who use the service, including the two most recent admissions. The home requires full assessment for all service users prior to deciding whether or not they can meet the person’s needs in the home. Service users’ files showed that these assessments were in place and had been completed prior to the person moving in. Assessments were comprehensive and contained details of all needs. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 9 Clear information about the service was available to all people moving into the home and was also available in the entrance to the home. The home does not provide intermediate care. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are treated with respect and their right to privacy is upheld. Their healthcare needs are met. Care plans and risk assessments were not reviewed and kept up to date. There were no specific guidelines in place for some ‘as required’ medication. EVIDENCE: We looked at the care plans of four people living in the home and observed the service they were receiving. We also looked at the records of their care and spoke with service users, staff and one relative about the service people received. Care plans did contain information on people’s likes and dislikes and also set out care needs in a clear way. Individual goals and outcomes for people were Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 11 set out and it was clear what action staff needed to take in order to meet people’s needs. However, they were not reviewed as often as they should be. There was a sheet in each person’s file to record the monthly review for each person. One person’s records showed that their care plan was reviewed on 22 September 2008 and then on 4 June 2009. Where care plans are not reviewed and kept up to date it may lead to people not getting the support they require. Risk assessments were also not reviewed as often as they should be and this may result in risks to people’s well-being not being managed effectively. The Assistant Manager informed us that the person in the organisation whose role it was to review and update care plans and risk assessments had spent a lot of time doing this for the other registered service in the building, but had not yet had time to complete this work for this service. Some of the people living in the home were born abroad and English was not their first language. One of those people has begun to lose a lot of the English they used and now has reverted to their first language. Their care plan acknowledges this and makes it clear that they now speak almost entirely in their own first language. The care plan also states that the person gets very frustrated when staff do not understand her and that this can lead to behaviour that causes problems for other people living in the home. The care plan also states that the person prefers to speak in their own first language but should be encouraged to speak English. From observation of the person on the day of the inspection and from talking to staff, it is clear that this person now speaks almost entirely in their own first language. The care plan also states that this person is given sedative medication, on an ‘as required’ basis, when they become anxious and also that they suffer with blood pressure when anxious. The Assistant Manager told us that none of the staff are able to speak in this person’s first language. Daily records showed that there are clear occasions where the person gets anxious and frustrated, which may affect their blood pressure. These occasions also sometimes result in the sedative medication being administered. As the care plan identifies, this is sometimes due to the fact that staff are unable to understand what the person is saying. The Assistant Manager is aware that there are other people in the home for whom English is a second language and that Dementia may result in them losing their ability to speak it. The failure of the service to have strategies in place to ensure that staff are able to communicate with service users places people at risk of having their needs not met. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 12 There had been a previous requirement that the responsible person must ensure that the home is conducted so as to make proper provision for people’s health and welfare. The fact that staff are unable to understand this person and the resulting difficulties show that this requirement has not been met. Care plans and records on service users’ files showed that individual health needs were monitored on a regular basis and this included regular checks of all vital signs. Records also showed that people were supported to access healthcare services when they needed to and this was confirmed in discussion with people living in the home. There had been three requirements from the previous inspection concerning medication. The first was that the home should have policies and procedures relating to medicines that are relevant and specific to the service. Examination of the policies and procedures showed that this requirement had been met. The second was that the responsible must ensure that staff handling medicines have ongoing training which focus on keeping accurate records including Controlled drugs records. Training files and discussion with staff involved in administering medication demonstrated that this requirement had been met and that training was occurring. Observation of the medication records showed that they were up-to-date and accurate. The third medication requirement was that the responsible person must ensure that the Controlled Drugs cupboard complies with the requirements of the relevant law. It did not previously comply because it was not secured to a solid wall. At this inspection we found that the medication cupboard was still not attached to the wall. We spoke with the Assistant Manager and the Maintenance person about this. The Maintenance person told us he had secured the cupboard to a steel frame which was in turn secured to the concrete floor. One person whose file we looked at showed that they had been prescribed ‘as required’ Paracetemol for pain relief. However, the care plan did not specify how the person might communicate pain and therefore when the medication would be necessary. This means that each member of staff has to decide for themselves when the medication is required and this may result in the person not getting the medication when they need it or getting it when they do not need it. Observation throughout the inspection showed that service users were treated with respect by staff. This was also confirmed in discussion with a relative. Peoples care plans were also written in a way which emphasised the need to demonstrate respect for people at all times. An example of this was the need Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 13 to stand in front of a particular service user when speaking with them because their vision was poor and they may otherwise get disorientated. Sunrise Operations Bassett Ltd DS0000068064.V377345.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users have access to a range of stimulating activities and are able to exercise choice and control over their own lives. The food in the home is good and takes account of individual needs and wishes. EVIDENCE: The home is well equipped to ensure that people living there have access to a wide range of activities, either planned activities they could join in with or equipment that they could make use of either on their own or with other people living there. Planned activities took place in the open plan lounge/dining area and this enabled people to come and join in with activities as they chose. There were not individual records of activities, so it was not possible to identify who had taken part in activities and to what extent they had enjoyed them. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 15 The Assistant Manager told us they used to keep such records and were aiming to re-introduce them. On the day of the inspection we saw different planned activities taking place throughout the day and being led by staff. Staff observed were energetic and thoughtful in the activities they led in order to ensure that they were stimulating and relevant to the people living in the home. Service users appeared to enjoy the activities they were involved with on the day off the inspection. People living in the home were supported to exercise control over their own lives through close liaison with families about what the person enjoys and what they do not like. There was also good information about people on their preadmission assessment about their preferences and choices. Staff spoken with were aware of this information and took time to ensure that people were offered choices and had the opportunity to express their preferences. We spoke with kitchen staff, service users and a relative about the food in the home, looked at individual records and observed the support people received during the lunchtime period. The home has set menus demonstrating a range of nutritious alternatives available at each mealtime. Kitchen staff were aware of the need to ensure that people’s food was presentable as well as being suited to individual needs. Fresh ingredients were used as far as possible and there was a demonstrable emphasis on good nutrition and individual choice. Service users spoken with said they enjoyed the food in the home and that they always got enough to eat. During the lunchtime we observed that staff support was available for each person who needed some help with eating with their food. The mealtime was a relaxed time and staff spoken with were aware of the need to make it an enjoyable time. Time was given to people who took longer to eat their food and they were offered additional food if they wanted it. Care plans showed that individual likes and dislikes were recorded and this information was also shared with kitchen staff. In the kitchen there were photographs of service users with individual diets, along with their individual requirements so that kitchen staff were fully aware of individual needs and choices. The home also has a monthly Residents Dining Committee where people get the chance to discuss the menus and other food issues with the chef. Care plans also showed that, where needs had been identified, individual service users had their food and/or fluid intake monitored. Everyone living in the home has a nutritional risk assessment on admission in order to identify any risks they may have. Sunrise Operations Bassett Ltd DS0000068064.V377345.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from a clear complaints policy and are protected by the services safeguarding policies and procedures. EVIDENCE: The home has a clear and effective complaints policy in place. The policy is made available to service users and their families on admission and a copy is also available in the front entrance of the building. There had been no complaints since the previous inspection. The Assistant Manager told us she thought the lack of complaints was due to the service being responsive to peoples needs, thus decreasing the need for people to complain. This was acknowledged by a relative we spoke with who told us they had never yet needed to make a complaint, but knew how to should the situation arise. The home has clear adult protection policies and procedures in place and the Manager was clear that people living in the home needed to be protected from any form of abuse. Examination of training records showed that staff had received training in adult protection issues. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 17 The manager was clear about the reporting procedures and the service had demonstrated in the past that they will report issues through the correct channel should the need arise. A relative told us that there had been some difficulties because another service user had been going into her mother’s room and taking things. She said this is being resolved with support from staff in the home. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from living in a clean, safe and homely environment. EVIDENCE: The service is in the upstairs part of the building housing the two registered services. Individual bedrooms are well equipped and staff have been working on individual items of reference for people that are kept in a small glass box on the outside of their room in order that they can identify their own room. Room signs were also in Braille throughout the building. There are also photographs of staff with their names underneath. The Communal areas consist of a lounge area, a dining area and a main, multipurpose area. In addition there is a large outside balcony which has been made safe so that people can wander outside whenever they wish. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 19 The home is well-maintained by the in-house maintenance staff. Regular checks of the building take place and are recorded. Records showed that maintenance issues were responded to very soon after they were identified. There are four cleaners working in the home and there are clear cleaning schedules in place. The Maintenance Manager does regular spot checks of the building to ensure that cleaning standards are maintained. On the day of the inspection the building was very clean throughout. On 14 January 2009 the home had an Environmental Health office inspection and was rated as highly satisfactory. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from being supported by adequate numbers of staff and are protected by the home’s recruitment practices. Staff are not trained to communicate with all the people who use the service. EVIDENCE: On the day of the inspection visit it appeared that there were sufficient staff on duty to meet the needs of people living in the home. Staff spoken with said they felt the staffing was adequate, as did the relative we spoke with. Staffing levels on the day matched the rota and the rota for the rest of the week showed that staffing levels were the same throughout the week. We looked at the recruitment and training files for four staff working in the home. The recruitment records showed that all necessary pre-employment checks were undertaken prior to people beginning work in the home. Staff observed on the day of the inspection visit were focussed on meeting the needs of service users and their daily routines were arranged around providing support to people throughout the day. There were separate staff for cleaning, Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 21 laundry and the kitchen, so care staff were employed just to support people living in the home. Support and supervision sessions for staff had not been taking place regularly over the last six months. The Assistant Manager told us that this had restarted recently. A visit to the service by a representative of the Provider in June 2009 acknowledged that support and supervision had started again. There had been a requirement from the previous inspection that the responsible person must ensure that staff receive all mandatory and other training relevant to the needs of the people who live at the home. Training records showed that mandatory training was now taking place for all staff in the service. As described in the personal and Healthcare section of this report, staff do not have the skills to support and communicate with one person who does speak English. Staff need to have the skills to be able to communicate with service users in order to ensure that their needs are met. Although in most of this section the service ensures good outcomes for service users, we have rated this section adequate due to the effect of staff not having the skills to communicate with particular service users. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users’ financial interests are protected and the home is run in their best interests. Health and safety issues are well managed. The Manager is not yet registered. EVIDENCE: The Manager of the two different registered services in the building had been in post for eight weeks at the time of our inspection. She is not yet registered as the Manager. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 23 She informed us that the organisation was planning to register the two services as one registered service. We have yet to receive an application to this effect. The organisation has comprehensive quality monitoring processes in place. These include monthly visits by a representative of the Provider, regular staff meetings, service user meetings, service user dining committee meetings and management team meetings. The views of people using the service (and their families) are sought through satisfaction surveys. This is contracted out to a professional survey organisation who produce and collect all the surveys. They also provide the service with a written and statistical report on the outcomes of the surveys. This gives service users and their families reassurance that they can provide their views anonymously and that those views will form part of the feedback the service receives. The service develops an action plan based on the feedback received through this process. There was evidence that action had been taken to address issues highlighted through the quality assurance process. We looked at the financial records for five people living in the home. There was a comprehensive system in place to record any transactions the home was involved in with service users’ money. Receipts of transactions were kept and records of how much money each person should have matched with the actual amount they did have. Access to service users’ money was restricted to two members of staff to decrease the likelihood of mistakes being made. The management of maintenance and health and safety in the building was thorough. The Maintenance Manager undertook daily checks of the building and kept comprehensive records. All issues identified were responded to and rectified without delay. Good records were kept of all servicing of equipment throughout the home ad these demonstrated that regular servicing took place on a planned basis. People living in the home were able to access support from the maintenance team directly, either by telephoning the maintenance department or by speaking to them over breakfast. Direct requests from service users included things such as having pictures hung in their room and having their television set tuned. Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 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 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The responsible person must ensure that work on reviewing all risk assessments and care plans is completed so that they fully reflect all people’s current health, personal and social care needs and are kept under regular review. This is to ensure that information about peoples needs is current and that their needs are met. The responsible person must ensure that where people are prescribed ‘as required’ medication there must be clear guidelines in place for staff to describe the circumstances under which the medication may be administered. This is to ensure that there is consistency in the administration of the medication and that the person receives the medication at the time they need it. The responsible person must ensure that staff receive training in communicating with all the people who live in the home. This is to ensure that the needs DS0000068064.V377345.R01.S.doc Timescale for action 07/10/09 2. OP9 12 07/10/09 3. OP30 18 30/10/09 Sunrise Operations Bassett Ltd Version 5.2 Page 26 and wishes of service users can be understood and that service users feel reassured that they are being understood by the people who support them. 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 Sunrise Operations Bassett Ltd DS0000068064.V377345.R01.S.doc Version 5.2 Page 27 Care Quality Commission South East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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